Compare Facilities
The Leapfrog Group 2025 Survey Results
Scroll to compare these 2 selected facilities...
...in all Safety Areas:
Billing Ethics
Southwest Healthcare Rancho Springs Hospital
This hospital provides a detailed bill within 30 days of receiving insurance payments: Yes
This hospital provides access to a representative who can quickly investigate billing errors and establish payment plans: Yes
This hospital sues patients: No
Billing Ethics
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
This hospital provides a detailed bill within 30 days of receiving insurance payments: Yes
This hospital provides access to a representative who can quickly investigate billing errors and establish payment plans: Yes
This hospital sues patients: No
Informed Consent
Southwest Healthcare Rancho Springs Hospital
This hospital ensures that all staff involved in the informed consent process achieve the appropriate training: Yes
This hospital ensures doctors explain expected difficulties and recovery time and allow patients to ask questions: Yes
This hospital lists all doctors involved in the procedure on the consent form, and notifies patients if a doctor will be absent and if trainees will be involved: Yes
This hospital provides consent forms written at a 6th grade reading level: Yes
This hospital asks patients about their preferred language for decision-making and makes a trained medical interpreter available if appropriate: Yes
This hospital ensures doctors use the “teach back method” to ensure patients understand what will be performed and the associated risks: Yes
Informed Consent
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
This hospital ensures that all staff involved in the informed consent process achieve the appropriate training: No
This hospital ensures doctors explain expected difficulties and recovery time and allow patients to ask questions: Yes
This hospital lists all doctors involved in the procedure on the consent form, and notifies patients if a doctor will be absent and if trainees will be involved: Yes
This hospital provides consent forms written at a 6th grade reading level: No
This hospital asks patients about their preferred language for decision-making and makes a trained medical interpreter available if appropriate: Yes
This hospital ensures doctors use the “teach back method” to ensure patients understand what will be performed and the associated risks: No
Responding to Never Events
Southwest Healthcare Rancho Springs Hospital
The hospital apologizes to the patient and/or family following a Never Event: Yes
The hospital reports the Never Event to an external agency: Yes
The hospital conducts an analysis of how the why the event occurred: Yes
The hospital interviews patient and/or family involved in the event to gather evidence for the event analysis: Yes
The hospital informs patient and/or family of the action(s) taken to prevent future events: Yes
The hospital waives all costs directly associated with the event: Yes
The hospital supports caregivers involved in the event: Yes
The hospital makes a copy of this policy available to patients and payors upon request: Yes
The hospital performs an annual review to ensure compliance after all Never Events: Yes
Responding to Never Events
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
The hospital apologizes to the patient and/or family following a Never Event: Yes
The hospital reports the Never Event to an external agency: Yes
The hospital conducts an analysis of how the why the event occurred: Yes
The hospital interviews patient and/or family involved in the event to gather evidence for the event analysis: Yes
The hospital informs patient and/or family of the action(s) taken to prevent future events: Yes
The hospital waives all costs directly associated with the event: Yes
The hospital supports caregivers involved in the event: Yes
The hospital makes a copy of this policy available to patients and payors upon request: Yes
The hospital performs an annual review to ensure compliance after all Never Events: Yes
Patient and Family Caregiver Initiated Rapid Response Team
Southwest Healthcare Rancho Springs Hospital
Patient and Family Caregiver Initiated Rapid Response Team
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
Protocol to collect and respond to patient-reported concerns about care
Southwest Healthcare Rancho Springs Hospital
Protocol to collect and respond to patient-reported concerns about care
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
Nursing and Bedside Care for Patients
Southwest Healthcare Rancho Springs Hospital
This hospital's total number of nursing hours per patient day is: 10.20
Nursing and Bedside Care for Patients
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
This hospital's total number of nursing hours per patient day is: 9.65
This hospital achieved Magnet status, nationally recognized for nursing excellence.
Nursing Care for Patients
Southwest Healthcare Rancho Springs Hospital
This hospital's total number of RN nursing hours per patient day is: 7.81
Nursing Care for Patients
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
This hospital's total number of RN nursing hours per patient day is: 8.16
Percentage of Nursing Staff who are Registered Nurses (RNs)
Southwest Healthcare Rancho Springs Hospital
This hospital's proportion of RN nursing hours per patient day to total nursing hours per patient day is: 76.52% (where a higher percentage is better).
Percentage of Nursing Staff who are Registered Nurses (RNs)
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
This hospital's proportion of RN nursing hours per patient day to total nursing hours per patient day is: 84.54% (where a higher percentage is better).
Effective Leadership to Prevent Errors
Southwest Healthcare Rancho Springs Hospital
This hospital scored 120.00 out of 120.00 possible points.
Effective Leadership to Prevent Errors
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
This hospital scored 120.00 out of 120.00 possible points.
Staff Work Together to Prevent Errors
Southwest Healthcare Rancho Springs Hospital
This hospital scored 120.00 out of 120.00 possible points.
Staff Work Together to Prevent Errors
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
This hospital scored 120.00 out of 120.00 possible points.
Handwashing
Southwest Healthcare Rancho Springs Hospital
| Hand Hygiene Domain | Performance |
|---|---|
| Hospital regularly monitors hand hygiene practices | Met the requirement to monitor 200 hand hygiene opportunities monthly using direct observation only. |
| Feedback provided to ensure compliance with hand hygiene | Met |
| Appropriate training and education provided | Met |
| Access to paper towels, soap dispensers, and hand sanitizer maintained | Met |
| Culture of good hand hygiene emphasized | Met |
Handwashing
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
| Hand Hygiene Domain | Performance |
|---|---|
| Hospital regularly monitors hand hygiene practices | Met the requirement to monitor 100 hand hygiene opportunities monthly using direct observation only. |
| Feedback provided to ensure compliance with hand hygiene | Did Not Meet |
| Appropriate training and education provided | Did Not Meet |
| Access to paper towels, soap dispensers, and hand sanitizer maintained | Met |
| Culture of good hand hygiene emphasized | Met |
Safe Medication Ordering
Southwest Healthcare Rancho Springs Hospital
This hospital's percentage of inpatient medication orders entered electronically: 85% or greater
This hospital's score on the CPOE Evaluation Tool: Full Demonstration of National Safety Standard for Decision Support
Safe Medication Ordering
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
This hospital's percentage of inpatient medication orders entered electronically: 85% or greater
This hospital's score on the CPOE Evaluation Tool: Full Demonstration of National Safety Standard for Decision Support
Medication Reconciliation
Southwest Healthcare Rancho Springs Hospital
This hospital's rate of unintentional discrepancies per medication is: 0.196
Medication Reconciliation
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
This hospital's rate of unintentional discrepancies per medication is: 0.352
Safe Medication Administration
Southwest Healthcare Rancho Springs Hospital
| Implementation | Performance |
|---|---|
| The extent of BCMA implementation throughout the hospital with a focus on medical and/or surgical units (adult and pediatric), labor and delivery units, intensive care units (adult, pediatric, and neonatal), and pre-operative and post-anesthesia care units (adult and pediatric) | 100% |
| Compliance with both patient and medication scans at the bedside prior to administering medications | 96% |
| The types of decision support that the BCMA system offers | 5 out of 5 |
| Structures to monitor and reduce workarounds | 8 out of 8 |
Safe Medication Administration
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
| Implementation | Performance |
|---|---|
| The extent of BCMA implementation throughout the hospital with a focus on medical and/or surgical units (adult and pediatric), labor and delivery units, intensive care units (adult, pediatric, and neonatal), and pre-operative and post-anesthesia care units (adult and pediatric) | 100% |
| Compliance with both patient and medication scans at the bedside prior to administering medications | 95% |
| The types of decision support that the BCMA system offers | 5 out of 5 |
| Structures to monitor and reduce workarounds | 8 out of 8 |
Medication Documentation for Elective Outpatient Surgery Patients
Southwest Healthcare Rancho Springs Hospital
| Documentation | Rate |
|---|---|
| Medications the patient was taking at home | 100% |
| Medications the patient was administered and prescribed during their visit | 97% |
| Allergies and adverse reactions | 100% |
Medication Documentation for Elective Outpatient Surgery Patients
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
| Documentation | Rate |
|---|---|
| Medications the patient was taking at home | 33% |
| Medications the patient was administered and prescribed during their visit | 97% |
| Allergies and adverse reactions | 90% |
C. difficile Infection
Southwest Healthcare Rancho Springs Hospital
This hospital’s standardized infection ratio (SIR) is: 0.238
C. difficile Infection
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
This hospital’s standardized infection ratio (SIR) is: 0.409
Infection in the Blood
Southwest Healthcare Rancho Springs Hospital
This hospital’s standardized infection ratio (SIR) is: 1.459
Infection in the Blood
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
This hospital’s standardized infection ratio (SIR) is: 0.480
Infection in the Urinary Tract
Southwest Healthcare Rancho Springs Hospital
This hospital’s standardized infection ratio (SIR) is: 0.000
Infection in the Urinary Tract
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
This hospital’s standardized infection ratio (SIR) is: 0.804
MRSA Infection
Southwest Healthcare Rancho Springs Hospital
This hospital’s standardized infection ratio (SIR) is: 1.081
MRSA Infection
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
This hospital’s standardized infection ratio (SIR) is: 0.452
Surgical Site Infection After Colon Surgery
Southwest Healthcare Rancho Springs Hospital
This hospital’s standardized infection ratio (SIR) is: 0.795
Surgical Site Infection After Colon Surgery
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
This hospital’s standardized infection ratio (SIR) is: 0.288
Specially Trained Doctors Care for Adult Critical Care Patients
Southwest Healthcare Rancho Springs Hospital
This hospital achieved the standard using on-site intensivist coverage.
Specially Trained Doctors Care for Adult Critical Care Patients
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
This hospital achieved the standard using on-site intensivist coverage.
Delivery of Very Low Birth-Weight Babies
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
Cesarean Sections
Southwest Healthcare Rancho Springs Hospital
This hospital's rate of Cesarean sections is 19.6%
Cesarean Sections
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
This hospital's rate of Cesarean sections is 21.1%
Episiotomies
Southwest Healthcare Rancho Springs Hospital
This hospital's rate of episiotomies is 1.9%
Episiotomies
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
This hospital's rate of episiotomies is 0.8%
Screening Newborns for Jaundice Before Discharge
Southwest Healthcare Rancho Springs Hospital
This hospital's rate of screening newborns for jaundice before discharge is 100.0%
Screening Newborns for Jaundice Before Discharge
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
This hospital's rate of screening newborns for jaundice before discharge is 100.0%
Preventing Blood Clots in Women Undergoing Cesarean Section
Southwest Healthcare Rancho Springs Hospital
This hospital's rate of preventing blood clots in women undergoing cesarean section is 99.0%
Preventing Blood Clots in Women Undergoing Cesarean Section
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
This hospital's rate of preventing blood clots in women undergoing cesarean section is 97.3%
Number of Live Births
Southwest Healthcare Rancho Springs Hospital
Number of Live Births
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
Midwives
Southwest Healthcare Rancho Springs Hospital
Midwives
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
Doulas
Southwest Healthcare Rancho Springs Hospital
Doulas
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
Lactation Services
Southwest Healthcare Rancho Springs Hospital
Lactation Services
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
Vaginal Delivery After Cesarean Section (VBAC)
Southwest Healthcare Rancho Springs Hospital
Vaginal Delivery After Cesarean Section (VBAC)
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
Tubal Ligation
Southwest Healthcare Rancho Springs Hospital
Tubal Ligation
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
Policy to Prevent Early Elective Deliveries
Southwest Healthcare Rancho Springs Hospital
This hospital does have a policy to prevent early elective deliveries.
Policy to Prevent Early Elective Deliveries
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
This hospital does have a policy to prevent early elective deliveries.
Carotid Endarterectomy
Southwest Healthcare Rancho Springs Hospital
This hospital performed 5 carotid artery surgeries compared to Leapfrog’s standard of 20 procedures annually.
As part of their process for privileging surgeons, this hospital does ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 10 procedures annually for carotid artery surgery.
Carotid Endarterectomy
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
This hospital performed 22 carotid artery surgeries compared to Leapfrog’s standard of 20 procedures annually.
As part of their process for privileging surgeons, this hospital does ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 10 procedures annually for carotid artery surgery.
Mitral Valve Repair and Replacement
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
This hospital performed 79 mitral valve repairs and replacements compared to Leapfrog’s standard of 40 procedures annually.
As part of their process for privileging surgeons, this hospital does ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 20 procedures annually for mitral valve repair and replacement.
This hospital does participate in the Society of Thoracic's Surgeons Adult Cardiac Surgery Database.
This hospital's outcome (absence of mortality and major morbidity) for mitral valve repairs and replacements is: As Expected.
Open Aortic Procedures
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
This hospital performed 79 open aortic procedures compared to Leapfrog’s standard of 10 procedures annually.
As part of their process for privileging surgeons, this hospital does ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 7 procedures annually for open aortic procedures.
Bariatric Surgery for Weight Loss
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
This hospital performed 179 bariatric surgeries for weight loss compared to Leapfrog’s standard of 50 procedures annually.
As part of their process for privileging surgeons, this hospital does ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 20 procedures annually for bariatric surgeries for weight loss.
Esophageal Resection for Cancer
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
This hospital performed 21 esophageal resections for cancer compared to Leapfrog’s standard of 20 procedures annually.
As part of their process for privileging surgeons, this hospital does ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 7 procedures annually for esophageal resection for cancer.
Lung Resection for Cancer
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
This hospital performed 104 lung resections for cancer compared to Leapfrog’s standard of 40 procedures annually.
As part of their process for privileging surgeons, this hospital does ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 15 procedures annually for lung resection for cancer.
Pancreatic Resection for Cancer
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
This hospital performed 51 pancreatic resections for cancer compared to Leapfrog’s standard of 20 procedures annually.
As part of their process for privileging surgeons, this hospital does ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 10 procedures annually for pancreatic resection for cancer.
Rectal Cancer Surgery
Southwest Healthcare Rancho Springs Hospital
This hospital performed 4 rectal cancer surgeries compared to Leapfrog’s standard of 16 procedures annually.
As part of their process for privileging surgeons, this hospital does not ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 6 procedures annually for rectal cancer surgery.
Rectal Cancer Surgery
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
This hospital performed 78 rectal cancer surgeries compared to Leapfrog’s standard of 16 procedures annually.
As part of their process for privileging surgeons, this hospital does ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 6 procedures annually for rectal cancer surgery.
Total Knee Replacement Surgery
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
This hospital performed 611 total knee replacement surgeries compared to Leapfrog’s standard of 50 procedures annually.
As part of their process for privileging surgeons, this hospital does ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 25 procedures annually for total knee replacement surgeries.
Total Hip Replacement Surgery
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
This hospital performed 630 total hip replacement surgeries compared to Leapfrog’s standard of 50 procedures annually.
As part of their process for privileging surgeons, this hospital does ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 25 procedures annually for total hip replacement surgeries.
Experience of Patients Undergoing Elective Outpatient Surgery
Southwest Healthcare Rancho Springs Hospital
Performance on the following four domains of the Outpatient and Ambulatory Surgery (OAS) CAHPS Survey make up a hospital’s score on Leapfrog’s “Experience of Patients Undergoing Elective Outpatient Surgery” measure. “Top Box Score” represents the percentage of respondents who gave the most favorable response.
| OAS CAHPS Survey Domain | Top Box Score |
|---|---|
| Facilities and staff | 96% |
| Communication about the procedure | 93% |
| Patients’ overall rating of the facility | 88% |
| Patients willingness to recommend the facility | 85% |
Experience of Patients Undergoing Elective Outpatient Surgery
UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center
Performance on the following four domains of the Outpatient and Ambulatory Surgery (OAS) CAHPS Survey make up a hospital’s score on Leapfrog’s “Experience of Patients Undergoing Elective Outpatient Surgery” measure. “Top Box Score” represents the percentage of respondents who gave the most favorable response.
| OAS CAHPS Survey Domain | Top Box Score |
|---|---|
| Facilities and staff | 96% |
| Communication about the procedure | 92% |
| Patients’ overall rating of the facility | 89% |
| Patients willingness to recommend the facility | 89% |
Compare Facilities
Patient Rights and Ethics
This hospital provides a detailed bill within 30 days of receiving insurance payments: Yes
This hospital provides access to a representative who can quickly investigate billing errors and establish payment plans: Yes
This hospital sues patients: No
This hospital provides a detailed bill within 30 days of receiving insurance payments: Yes
This hospital provides access to a representative who can quickly investigate billing errors and establish payment plans: Yes
This hospital sues patients: No
ACHIEVED THE STANDARD
ACHIEVED THE STANDARD
This hospital ensures that all staff involved in the informed consent process achieve the appropriate training: Yes
This hospital ensures doctors explain expected difficulties and recovery time and allow patients to ask questions: Yes
This hospital lists all doctors involved in the procedure on the consent form, and notifies patients if a doctor will be absent and if trainees will be involved: Yes
This hospital provides consent forms written at a 6th grade reading level: Yes
This hospital asks patients about their preferred language for decision-making and makes a trained medical interpreter available if appropriate: Yes
This hospital ensures doctors use the “teach back method” to ensure patients understand what will be performed and the associated risks: Yes
This hospital ensures that all staff involved in the informed consent process achieve the appropriate training: No
This hospital ensures doctors explain expected difficulties and recovery time and allow patients to ask questions: Yes
This hospital lists all doctors involved in the procedure on the consent form, and notifies patients if a doctor will be absent and if trainees will be involved: Yes
This hospital provides consent forms written at a 6th grade reading level: No
This hospital asks patients about their preferred language for decision-making and makes a trained medical interpreter available if appropriate: Yes
This hospital ensures doctors use the “teach back method” to ensure patients understand what will be performed and the associated risks: No
The hospital apologizes to the patient and/or family following a Never Event: Yes
The hospital reports the Never Event to an external agency: Yes
The hospital conducts an analysis of how the why the event occurred: Yes
The hospital interviews patient and/or family involved in the event to gather evidence for the event analysis: Yes
The hospital informs patient and/or family of the action(s) taken to prevent future events: Yes
The hospital waives all costs directly associated with the event: Yes
The hospital supports caregivers involved in the event: Yes
The hospital makes a copy of this policy available to patients and payors upon request: Yes
The hospital performs an annual review to ensure compliance after all Never Events: Yes
The hospital apologizes to the patient and/or family following a Never Event: Yes
The hospital reports the Never Event to an external agency: Yes
The hospital conducts an analysis of how the why the event occurred: Yes
The hospital interviews patient and/or family involved in the event to gather evidence for the event analysis: Yes
The hospital informs patient and/or family of the action(s) taken to prevent future events: Yes
The hospital waives all costs directly associated with the event: Yes
The hospital supports caregivers involved in the event: Yes
The hospital makes a copy of this policy available to patients and payors upon request: Yes
The hospital performs an annual review to ensure compliance after all Never Events: Yes
More Information
Preventing Patient Harm
This hospital's total number of nursing hours per patient day is: 10.20
This hospital's total number of nursing hours per patient day is: 9.65
This hospital achieved Magnet status, nationally recognized for nursing excellence.
This hospital's total number of RN nursing hours per patient day is: 7.81
This hospital's total number of RN nursing hours per patient day is: 8.16
This hospital's proportion of RN nursing hours per patient day to total nursing hours per patient day is: 76.52% (where a higher percentage is better).
This hospital's proportion of RN nursing hours per patient day to total nursing hours per patient day is: 84.54% (where a higher percentage is better).
CONSIDERABLE ACHIEVEMENT
ACHIEVED THE STANDARD
This hospital scored 120.00 out of 120.00 possible points.
This hospital scored 120.00 out of 120.00 possible points.
This hospital scored 120.00 out of 120.00 possible points.
This hospital scored 120.00 out of 120.00 possible points.
| Hand Hygiene Domain | Performance |
|---|---|
| Hospital regularly monitors hand hygiene practices | Met the requirement to monitor 200 hand hygiene opportunities monthly using direct observation only. |
| Feedback provided to ensure compliance with hand hygiene | Met |
| Appropriate training and education provided | Met |
| Access to paper towels, soap dispensers, and hand sanitizer maintained | Met |
| Culture of good hand hygiene emphasized | Met |
| Hand Hygiene Domain | Performance |
|---|---|
| Hospital regularly monitors hand hygiene practices | Met the requirement to monitor 100 hand hygiene opportunities monthly using direct observation only. |
| Feedback provided to ensure compliance with hand hygiene | Did Not Meet |
| Appropriate training and education provided | Did Not Meet |
| Access to paper towels, soap dispensers, and hand sanitizer maintained | Met |
| Culture of good hand hygiene emphasized | Met |
Medication Safety
This hospital's percentage of inpatient medication orders entered electronically: 85% or greater
This hospital's score on the CPOE Evaluation Tool: Full Demonstration of National Safety Standard for Decision Support
This hospital's percentage of inpatient medication orders entered electronically: 85% or greater
This hospital's score on the CPOE Evaluation Tool: Full Demonstration of National Safety Standard for Decision Support
This hospital's rate of unintentional discrepancies per medication is: 0.196
This hospital's rate of unintentional discrepancies per medication is: 0.352
| Implementation | Performance |
|---|---|
| The extent of BCMA implementation throughout the hospital with a focus on medical and/or surgical units (adult and pediatric), labor and delivery units, intensive care units (adult, pediatric, and neonatal), and pre-operative and post-anesthesia care units (adult and pediatric) | 100% |
| Compliance with both patient and medication scans at the bedside prior to administering medications | 96% |
| The types of decision support that the BCMA system offers | 5 out of 5 |
| Structures to monitor and reduce workarounds | 8 out of 8 |
| Implementation | Performance |
|---|---|
| The extent of BCMA implementation throughout the hospital with a focus on medical and/or surgical units (adult and pediatric), labor and delivery units, intensive care units (adult, pediatric, and neonatal), and pre-operative and post-anesthesia care units (adult and pediatric) | 100% |
| Compliance with both patient and medication scans at the bedside prior to administering medications | 95% |
| The types of decision support that the BCMA system offers | 5 out of 5 |
| Structures to monitor and reduce workarounds | 8 out of 8 |
| Documentation | Rate |
|---|---|
| Medications the patient was taking at home | 100% |
| Medications the patient was administered and prescribed during their visit | 97% |
| Allergies and adverse reactions | 100% |
| Documentation | Rate |
|---|---|
| Medications the patient was taking at home | 33% |
| Medications the patient was administered and prescribed during their visit | 97% |
| Allergies and adverse reactions | 90% |
Healthcare-Associated Infections
This hospital’s standardized infection ratio (SIR) is: 0.238
This hospital’s standardized infection ratio (SIR) is: 0.409
This hospital’s standardized infection ratio (SIR) is: 1.459
This hospital’s standardized infection ratio (SIR) is: 0.480
This hospital’s standardized infection ratio (SIR) is: 0.000
This hospital’s standardized infection ratio (SIR) is: 0.804
This hospital’s standardized infection ratio (SIR) is: 1.081
This hospital’s standardized infection ratio (SIR) is: 0.452
This hospital’s standardized infection ratio (SIR) is: 0.795
This hospital’s standardized infection ratio (SIR) is: 0.288
Critical Care
This hospital achieved the standard using on-site intensivist coverage.
This hospital achieved the standard using on-site intensivist coverage.
Pediatric Care
ACHIEVED THE STANDARD
CONSIDERABLE ACHIEVEMENT
ACHIEVED THE STANDARD
CONSIDERABLE ACHIEVEMENT
Maternity Care
This hospital's rate of Cesarean sections is 19.6%
This hospital's rate of Cesarean sections is 21.1%
This hospital's rate of episiotomies is 1.9%
This hospital's rate of episiotomies is 0.8%
This hospital's rate of screening newborns for jaundice before discharge is 100.0%
This hospital's rate of screening newborns for jaundice before discharge is 100.0%
This hospital's rate of preventing blood clots in women undergoing cesarean section is 99.0%
This hospital's rate of preventing blood clots in women undergoing cesarean section is 97.3%
More Information
Complex Adult Surgery
This hospital performed 5 carotid artery surgeries compared to Leapfrog’s standard of 20 procedures annually.
As part of their process for privileging surgeons, this hospital does ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 10 procedures annually for carotid artery surgery.
This hospital performed 22 carotid artery surgeries compared to Leapfrog’s standard of 20 procedures annually.
As part of their process for privileging surgeons, this hospital does ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 10 procedures annually for carotid artery surgery.
This hospital performed 79 mitral valve repairs and replacements compared to Leapfrog’s standard of 40 procedures annually.
As part of their process for privileging surgeons, this hospital does ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 20 procedures annually for mitral valve repair and replacement.
This hospital does participate in the Society of Thoracic's Surgeons Adult Cardiac Surgery Database.
This hospital's outcome (absence of mortality and major morbidity) for mitral valve repairs and replacements is: As Expected.
This hospital performed 79 open aortic procedures compared to Leapfrog’s standard of 10 procedures annually.
As part of their process for privileging surgeons, this hospital does ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 7 procedures annually for open aortic procedures.
This hospital performed 179 bariatric surgeries for weight loss compared to Leapfrog’s standard of 50 procedures annually.
As part of their process for privileging surgeons, this hospital does ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 20 procedures annually for bariatric surgeries for weight loss.
This hospital performed 21 esophageal resections for cancer compared to Leapfrog’s standard of 20 procedures annually.
As part of their process for privileging surgeons, this hospital does ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 7 procedures annually for esophageal resection for cancer.
This hospital performed 104 lung resections for cancer compared to Leapfrog’s standard of 40 procedures annually.
As part of their process for privileging surgeons, this hospital does ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 15 procedures annually for lung resection for cancer.
This hospital performed 51 pancreatic resections for cancer compared to Leapfrog’s standard of 20 procedures annually.
As part of their process for privileging surgeons, this hospital does ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 10 procedures annually for pancreatic resection for cancer.
This hospital performed 4 rectal cancer surgeries compared to Leapfrog’s standard of 16 procedures annually.
As part of their process for privileging surgeons, this hospital does not ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 6 procedures annually for rectal cancer surgery.
This hospital performed 78 rectal cancer surgeries compared to Leapfrog’s standard of 16 procedures annually.
As part of their process for privileging surgeons, this hospital does ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 6 procedures annually for rectal cancer surgery.
This hospital performed 611 total knee replacement surgeries compared to Leapfrog’s standard of 50 procedures annually.
As part of their process for privileging surgeons, this hospital does ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 25 procedures annually for total knee replacement surgeries.
This hospital performed 630 total hip replacement surgeries compared to Leapfrog’s standard of 50 procedures annually.
As part of their process for privileging surgeons, this hospital does ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 25 procedures annually for total hip replacement surgeries.
LIMITED ACHIEVEMENT
ACHIEVED THE STANDARD
Elective Outpatient Surgery - Adult
Gastroenterology (Stomach and Digestive)
General Surgery
Neurosurgery
Obstetrics and Gynecology
Ophthalmology (Eyes)
Orthopedic (Bones and Joints)
Otolaryngology (Ear, Nose, Mouth, and Throat)
Plastic and Reconstructive Surgery
Urology (Urinary Tract, Male Reproductive)
Elective Outpatient Surgery - Pediatric
Ophthalmology (Eyes)
Orthopedic (Bones and Joints)
Otolaryngology (Ear, Nose, Mouth, and Throat)
Care for Elective Outpatient Surgery Patients
ACHIEVED THE STANDARD
ACHIEVED THE STANDARD
ACHIEVED THE STANDARD
ACHIEVED THE STANDARD
ACHIEVED THE STANDARD
ACHIEVED THE STANDARD
Performance on the following four domains of the Outpatient and Ambulatory Surgery (OAS) CAHPS Survey make up a hospital’s score on Leapfrog’s “Experience of Patients Undergoing Elective Outpatient Surgery” measure. “Top Box Score” represents the percentage of respondents who gave the most favorable response.
| OAS CAHPS Survey Domain | Top Box Score |
|---|---|
| Facilities and staff | 96% |
| Communication about the procedure | 93% |
| Patients’ overall rating of the facility | 88% |
| Patients willingness to recommend the facility | 85% |
Performance on the following four domains of the Outpatient and Ambulatory Surgery (OAS) CAHPS Survey make up a hospital’s score on Leapfrog’s “Experience of Patients Undergoing Elective Outpatient Surgery” measure. “Top Box Score” represents the percentage of respondents who gave the most favorable response.
| OAS CAHPS Survey Domain | Top Box Score |
|---|---|
| Facilities and staff | 96% |
| Communication about the procedure | 92% |
| Patients’ overall rating of the facility | 89% |
| Patients willingness to recommend the facility | 89% |
CONSIDERABLE ACHIEVEMENT
ACHIEVED THE STANDARD
25500 Medical Center Drive
Murrieta, California 92562-5965
9300 Campus Point Drive
La Jolla, California 92037
