Quality Report


Quality Report

University of California San Diego Medical Center
HCO ID: 10071
200 West Arbor Drive
San Diego, CA, 92103-8949
(619) 543-3957
https://health.ucsd.edu
Summary of Quality Information

Accreditation Programs

Gold Seal
Behavioral Health Care and Human Services
Accreditation Decision
Effective Date
10/9/2019
Last Full Survey Date
10/8/2019
Last On-Site Survey Date
10/8/2019
Gold Seal
Home Care
Accreditation Decision
Effective Date
10/11/2019
Last Full Survey Date
10/10/2019
Last On-Site Survey Date
10/10/2019
Gold Seal
Hospital
Accreditation Decision
Effective Date
10/12/2019
Last Full Survey Date
10/11/2019
Last On-Site Survey Date
11/25/2019

Advanced Certification Programs

Gold Seal
Certification Decision
Effective Date
9/21/2019
Last Full Survey Date
9/20/2019
Last On-Site Survey Date
9/20/2019
Gold Seal
Certification Decision
Effective Date
6/18/2019
Last Full Survey Date
6/17/2019
Last On-Site Survey Date
6/17/2019
Gold Seal
Certification Decision
Effective Date
12/18/2019
Last Full Survey Date
12/17/2019
Last On-Site Survey Date
12/17/2019

Sites

Koman Family Outpatient Pavilion
9400 Campus Point Drive
La Jolla, CA, 92037

Available Services

  • Administration of Blood Product (Outpatient )
  • Administration of High Risk Medications (Outpatient )
  • Anesthesia (Outpatient )
  • Hazardous Medication Compounding (Outpatient )
  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Outpatient Services - Maternal Fetal Care at Sorrento Valley
DBA: UC San Diego Maternal - Fetal Care and Genetics
4910 Directors Place, Suite 200
San Diego, CA, 92121

Available Services

  • Administration of Blood Product (Outpatient )
  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Other Clinics/Practices Located at This Site:

  • Sorrento Valley Maternal Fetal Care and Genetics

Radiation Oncology and PET/CT Scanner Center
3960 Health Sciences Drive
La Jolla, CA, 92093

Available Services

  • Outpatient Clinics (Outpatient )

The Rebecca and John Moores UCSD Cancer Center
3855 Health Sciences Drive
La Jolla, CA, 92037

Available Services

  • Administration of Blood Product (Outpatient )
  • Administration of High Risk Medications (Outpatient )
  • Anesthesia (Outpatient )
  • Hazardous Medication Compounding (Outpatient )
  • High Risk Sterile Medication Compounding (Outpatient )
  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

UC San Diego Health Eating Disorders Center for Treatment Re
4510 Executive Drive, Suite 315
San Diego, CA, 92121

Available Services

  • Eating Disorders
  • Eating Disorders
  • Eating Disorders (Day Programs - Adult )
  • Eating Disorders (Day Programs - Child/Youth )
  • Eating Disorders (Partial Hospitalization - Adult )
  • Eating Disorders (Partial Hospitalization - Child/Youth )
  • Family Support (Non 24 Hour Care )
  • Peer Support (Non 24 Hour Care )

UC San Diego Health System - Encinitas Cancer Services
1200 Garden View Road, Suite 200/210
Encinitas, CA, 92024

Available Services

  • Administration of Blood Product (Outpatient )
  • Administration of High Risk Medications (Outpatient )
  • Hazardous Medication Compounding (Outpatient )
  • Outpatient Clinics (Outpatient )

UCSD Home Infusion and Specialty Pharmacy
9610 Ridgehaven Court, Suite A
San Diego, CA, 92123

Available Services

  • Durable Medical Equipment
  • Enteral Equipment and/or Supplies
  • Enteral Nutrients
  • External Infusion Pump Supplies
  • External Infusion Pumps
  • Freestanding Ambulatory Infusion Services
  • Hazardous Medication Compounding
  • Home Health, Non-Hospice Services
  • Infusion Nursing
  • Infusion Pharmacy
  • Parenteral Equipment and/or Supplies
  • Parenteral Nutrients
  • Pharmacy, Clinical Consulting Services
  • Pharmacy/Dispensary,General Services
  • Specialty Pharmacy
  • Sterile Medication Compounding
  • Supplies

UCSD Hyperbaric Medicine and Wound Healing Center
477 North El Camino Real, D-204
Encinitas, CA, 92024

Available Services

  • Outpatient Clinics (Outpatient )

UCSD Medical Center - Hillcrest
200 West Arbor Drive
San Diego, CA, 92103-8949

Available Services

  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult )
  • Burn Unit (Inpatient )
  • Cardiac Catheterization Lab (Surgical Services )
  • Cardiac Surgery (Surgical Services )
  • Cardiothoracic Surgery (Surgical Services )
  • Coronary Care Unit (Inpatient )
  • CT Scanner (Imaging/Diagnostic Services )
  • Dialysis Unit (Inpatient )
  • Ear/Nose/Throat Surgery (Surgical Services )
  • EEG/EKG/EMG Lab (Imaging/Diagnostic Services )
  • Gastroenterology (Surgical Services )
  • GI or Endoscopy Lab (Imaging/Diagnostic Services )
  • Gynecological Surgery (Surgical Services )
  • Gynecology (Inpatient )
  • Hazardous Medication Compounding (Inpatient )
  • Inpatient Unit (Inpatient )
  • Interventional Radiology (Imaging/Diagnostic Services )
  • Labor & Delivery (Inpatient )
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services )
  • Medical /Surgical Unit (Inpatient )
  • Medical ICU (Intensive Care Unit )
  • Neuro/Spine ICU (Intensive Care Unit )
  • Neuro/Spine Unit (Inpatient )
  • Neurosurgery (Surgical Services )
  • Non-Sterile Medication Compounding (Inpatient )
  • Normal Newborn Nursery (Inpatient )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Ophthalmology (Surgical Services )
  • Orthopedic Surgery (Surgical Services )
  • Orthopedic/Spine Unit (Inpatient )
  • Outpatient Clinics (Outpatient )
  • Peer Support (Non 24 Hour Care )
  • Plastic Surgery (Surgical Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Sterile Medication Compounding (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Surgical Unit (Inpatient )
  • Teleradiology (Imaging/Diagnostic Services )
  • Thoracic Surgery (Surgical Services )
  • Transplant Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Advanced Comprehensive Stroke Center

UCSD Medical Center - La Jolla
DBA: Jacobs Medical Center and Sulpizio Cardiovascular Center
9300 Campus Point Drive
La Jolla, CA, 92037

Available Services

  • Cardiac Catheterization Lab (Surgical Services )
  • Cardiac Surgery (Surgical Services )
  • Cardiothoracic Surgery (Surgical Services )
  • Cardiovascular Unit (Inpatient )
  • Coronary Care Unit (Inpatient )
  • CT Scanner (Imaging/Diagnostic Services )
  • Ear/Nose/Throat Surgery (Surgical Services )
  • EEG/EKG/EMG Lab (Imaging/Diagnostic Services )
  • Gastroenterology (Surgical Services )
  • GI or Endoscopy Lab (Imaging/Diagnostic Services )
  • Gynecological Surgery (Surgical Services )
  • Gynecology (Inpatient )
  • Hazardous Medication Compounding (Inpatient )
  • Hematology/Oncology Unit (Inpatient )
  • Inpatient Unit (Inpatient )
  • Interventional Radiology (Imaging/Diagnostic Services )
  • Labor & Delivery (Inpatient )
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services )
  • Medical /Surgical Unit (Inpatient )
  • Medical ICU (Intensive Care Unit )
  • Neuro/Spine ICU (Intensive Care Unit )
  • Neurosurgery (Surgical Services )
  • Non-Sterile Medication Compounding (Inpatient )
  • Normal Newborn Nursery (Inpatient )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Orthopedic Surgery (Surgical Services )
  • Outpatient Clinics (Outpatient )
  • Plastic Surgery (Surgical Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Sterile Medication Compounding (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Surgical Unit (Inpatient )
  • Teleradiology (Imaging/Diagnostic Services )
  • Thoracic Surgery (Surgical Services )
  • Transplant Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Advanced Comprehensive Stroke Center
  • Ventricular Assist Device

UCSD Medical Offices South
4168 Front Street
San Diego, CA, 92103

Available Services

  • Outpatient Clinics (Outpatient )

Certification Programs

  • Chronic Kidney Disease

UCSD Senior Behavioral Health Intensive Outpatient Program
DBA: UCSD Senior Behavioral Health Intensive Outpatient Program
410 Dickinson Street, Ste. 100
San Diego, CA, 92103

Available Services

  • Behavioral Health (Non 24 Hour Care - Adult )
  • Community Integration (Non 24 Hour Care )
  • Family Support (Non 24 Hour Care )

University of California Shiley Eye Center
9415 Campus Point Drive, 3rd Floor
La Jolla, CA, 92037

Available Services

  • Ambulatory Surgery Center (Outpatient )
  • Anesthesia (Outpatient )

Special Quality Awards

   Due to our commitment to accurate data reporting, The Joint Commission is suspending the practice of updating Special Quality Awards until
  further notice
  • 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program
  • 2012 Silver - The Medal of Honor for Organ Donation
  • 2010 Silver - The Medal of Honor for Organ Donation

National Patient Safety Goals and National Quality Improvement Goals

Symbol Key

  • starThis organization achieved the best possible results
  • plusThis organization's performance is above the target range/value
  • checkThis organization's performance is similar to the target range/value
  • minusThis organization's performance is below the target range/value
  • naThis measure is not applicable for this organization
  • ndNot displayed

Measures Footnote Key

  1. The measure or measure set was not reported.
  2. The measure set does not have an overall result.
  3. The number is not enough for comparison purposes.
  4. The measure meets the Privacy Disclosure Threshold rule.
  5. The organization scored above 90% but was below most other organizations.
  6. The measure results are not statistically valid.
  7. The measure results are based on a sample of patients.
  8. The number of months with measure data is below the reporting requirement.
  9. The measure results are temporarily suppressed pending resubmission of updated data.
  10. Test Measure: a measure being evaluated for reliability of the individual data elements or awaiting National Quality Forum Endorsement.
  11. There were no eligible patients that met the denominator criteria.

Symbol Key

  • starThis organization achieved the best possible results
  • plusThis organization's performance is above the target range/value
  • checkThis organization's performance is similar to the target range/value
  • minusThis organization's performance is below the target range/value
  • naThis measure is not applicable for this organization
  • ndNot displayed

Measures Footnote Key

  1. The measure or measure set was not reported.
  2. The measure set does not have an overall result.
  3. The number is not enough for comparison purposes.
  4. The measure meets the Privacy Disclosure Threshold rule.
  5. The organization scored above 90% but was below most other organizations.
  6. The measure results are not statistically valid.
  7. The measure results are based on a sample of patients.
  8. The number of months with measure data is below the reporting requirement.
  9. The measure results are temporarily suppressed pending resubmission of updated data.
  10. Test Measure: a measure being evaluated for reliability of the individual data elements or awaiting National Quality Forum Endorsement.
  11. There were no eligible patients that met the denominator criteria.

The Joint Commission only reports measures endorsed by the National Quality Forum.
* This information can also be viewed at Hospital Compare.

**      Indicates per 1000 hours of patient care.
***   The measure was not in effect for this quarter.
----   Null value or data not displayed.

Hospital 2019 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Behavioral Health Care and Human Services 2019 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Home Care 2019 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Reporting Period: January 2019 - December 2019
Emergency Department National Comparison: nd 2 Statewide Comparison: nd 2
Perinatal Care National Comparison: nd 2 Statewide Comparison: nd 2

New Changes to Quarterly Measure

Download Quarterly Measure Results

The Joint Commission only reports measures endorsed by the National Quality Forum.
* State results are not calculated for the National Patient Safety Goals.