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Quality Report

Summary of Accreditation Quality Information
Mercy Medical Center Mt. Shasta
Org ID: 2841
914 Pine Street
Mount Shasta, CA  96067
(530)926-6111
www.mercymtshasta.org

Accreditation
Programs		 Accreditation
Decision		 Effective
Date		 Last Full Survey Date Last On-Site Survey Date  
Critical Access Hospital
Accredited 7/15/2009 7/14/2009 7/14/2009  
Home Care
Accredited 7/15/2009 7/14/2009 7/14/2009  
Medicare/Medicaid Certification-Based Long Term Care
Accredited 7/16/2009 7/15/2009 7/15/2009  
Pathology and Clinical Laboratory
Accredited 1/30/2010 1/29/2010 1/29/2010  


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  Symbol Key
This organization achieved the best possible results
This organization’s performance is above the target range/value.
This organization’s performance is similar to the target range/value.
This organization’s performance is below the target range/value.
This measure is not applicable for this organization.
Not displayed
  Footnote Key
1. The measure or measure set was not reported.
2. The measure set does not have an overall result.
3. The number of patients 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.
National Patient Safety Goals and National Quality Improvement Goals
    Compared to other Joint Commission Accredited Organizations
    Nationwide Statewide
Critical Access Hospital
2009 National Patient Safety Goals See Detail
This organization’s performance is similar to the target range/value.
This Goal is not applicable for this organization.
*
National Quality Improvement Goals:    
Reporting Period:
Jan  2009 -
Dec  2009
Heart Failure Care See Detail
Not displayed.
3
Not displayed.
3
Pneumonia Care See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
Pregnancy Care See Detail
Not displayed.
2
Not displayed.
2
Surgical Care Improvement Project (SCIP)    
SCIP - Cardiac See Detail
   
SCIP - Infection Prevention
For All Reported Procedures:
 See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
  • Colon/Large Intestine Surgery
 See Detail
Not displayed.
3
Not displayed.
3
  • Hip Joint Replacement
 See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
  • Hysterectomy
 See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
  • Knee Replacement
 See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
SCIP – Venous Thromboembolism (VTE) See Detail
   
  30 Day Risk Adjusted Mortality Rates (see details)
  30 Day Hospital Readmission Rates (see details)
  Survey of Patients' Hospital Experiences (see details)
Home Care
2010 National Patient Safety Goals See Detail
This organization’s performance is similar to the target range/value.
This Goal is not applicable for this organization.
*
Medicare/Medicaid Certification-Based Long Term Care
2009 National Patient Safety Goals See Detail
This organization’s performance is similar to the target range/value.
This Goal is not applicable for this organization.
*
Pathology and Clinical Laboratory
2010 National Patient Safety Goals See Detail
This organization’s performance is similar to the target range/value.
This Goal is not applicable for this organization.
*
 
Hospitals voluntarily participate in the Survey of Patients' Hospital Experiences(HCAHPS).
Pediatric and psychiatric hospitals are not eligible to participate in the HCAHPS survey based on their patient population.
National Quality Forum The Joint Commission only reports measures endorsed by the National Quality Forum.
 
* State results are not calculated for the National Patient Safety Goals.

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Sites and Services
* Primary Location

An organization may provide services not listed here. For more information refer to the Quality Report User Guide .

Locations of Care Available Services
Catholic Healthcare West  *
914 Pine Street
Mount Shasta, CA  96067
  • Acute Care
  • CT Scanner (Inpatient, Outpatient)
  • Dentistry (Inpatient)
  • EEG/EKG/EMG Lab (Inpatient, Outpatient)
  • Emergency Room (Outpatient)
  • Family Practice (Inpatient, Outpatient)
  • Gastroenterology (Inpatient, Outpatient)
  • General Laboratory Tests
  • General Medical Services (Inpatient, Outpatient)
  • General Surgery (Inpatient, Outpatient)
  • GI or Endoscopy Lab (Inpatient, Outpatient)
  • Gynecology (Inpatient, Outpatient)
  • Hematology/Blood Treatment (Inpatient, Outpatient)
  • Hospice Care
  • Imaging/Radiology (Inpatient, Outpatient)
  • Infectious Diseases (Inpatient, Outpatient)
  • Intensive Care Unit (Inpatient)
  • Internal Medicine (Inpatient, Outpatient)
  • Labor & Delivery (Inpatient)
  • Long Term Care
  • Magnetic Resonance Imaging (Inpatient, Outpatient)
  • Nuclear Medicine (Outpatient)
  • Nursery (Inpatient)
  • Obstetrics (Inpatient, Outpatient)
  • Operating Room (Inpatient, Outpatient)
  • Ophthalmology/Eye Surgery (Outpatient)
  • Oral Maxillofacial Surgery (Outpatient)
  • Orthopedic Surgery (Inpatient, Outpatient)
  • Otolaryngology/Ear, Nose, and Throat (Outpatient)
  • Outpatient Surgery (Outpatient)
  • Pain Management (Inpatient, Outpatient)
  • Pediatric Care (Inpatient, Outpatient)
  • Podiatry (Inpatient, Outpatient)
  • Pulmonary Function Lab (Inpatient, Outpatient)
  • Radiation Oncology (Outpatient)
  • Rehabilitation and Physical Medicine (Inpatient, Outpatient)
  • Respiratory Care (Ventilator) (Inpatient)
  • Respite Care (Inpatient)
  • Skilled Nursing Care
  • Skilled Nursing Facility (Inpatient)
  • Telemetry (Inpatient)
  • Thoracic Surgery (Inpatient, Outpatient)
  • Toxicology
  • Ultrasound (Inpatient, Outpatient)
  • Urgent Care/Emergency Medicine (Outpatient)
  • Urology (Inpatient, Outpatient)
  • Vascular Surgery (Inpatient, Outpatient)
Mercy Medical Center Nuclear Medicine
635 Lassen Lane
Mount Shasta, CA  96067
  • General Outpatient Services (Outpatient)
Mercy Medical Center Regional Cancer Center-Radiation
914 Pine Street
Mount Shasta, CA  96067
  • General Outpatient Services (Outpatient)
Mercy Outpatient Services of Weed
100 Alamo Road
Weed, CA  96094
  • General Outpatient Services (Outpatient)
Mercy Physical Therapy/Lake Shastina Medical Services
16337 Everhart Drive
Weed, CA  96094
  • General Outpatient Services (Outpatient)

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