QualityReport

Accreditation Quality Report
>	Summary of Accreditation Quality Information
>	Accredited Programs
>	Accreditation National Patient Safety Goals
>	Sites and Services
>	Accreditation History
>	Download Accreditation PDF Report
>	Download Accreditation PDF Report - Include Quarterly Data
>	Accreditation Quality Report User Guide

Quality Report

Summary of Accreditation Quality Information

Avera Marshall Regional Medical Center
Org ID: 4198
300 South Bruce Street
Marshall, MN 56258
(507)532-9661
www.averamarshall.org

Accreditation
Programs

Accreditation
Decision

Effective
Date

Last Full Survey Date

Last On-Site Survey Date

Critical Access Hospital

Accredited

4/20/2007

6/2/2010

Pathology and Clinical Laboratory

Accredited

6/10/2009

6/9/2009

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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

2007 National Patient Safety Goals

See Detail

National Quality Improvement Goals:

Reporting Period:
Jan 2009 -
Dec 2009

Heart Attack Care

See Detail

Heart Failure Care

See Detail

Pneumonia Care

See Detail

30 Day Risk Adjusted Mortality Rates (see details)

30 Day Hospital Readmission Rates (see details)

Survey of Patients' Hospital Experiences (see details)

Pathology and Clinical Laboratory

2009 National Patient Safety Goals

See Detail

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.
	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

Avera Marshall Regional Medical Center *
300 South Bruce Street
Marshall, MN 56258

Acute Care
Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult)
CT Scanner (Inpatient, Outpatient)
EEG/EKG/EMG Lab (Inpatient, Outpatient)
Emergency Room (Outpatient)
General Laboratory Tests
General Medical Services (Inpatient, Outpatient)
General Surgery (Inpatient, Outpatient)
GI or Endoscopy Lab (Inpatient, Outpatient)
Gynecology (Inpatient, Outpatient)
Imaging/Radiology (Inpatient, Outpatient)
Infusion Therapy (Inpatient, Outpatient)
Inpatient Intake (Inpatient)
Intensive Care Unit (Inpatient)
Labor & Delivery (Inpatient)
Magnetic Resonance Imaging (Inpatient, Outpatient)
Nuclear Medicine (Inpatient, Outpatient)
Nursery (Inpatient)
Obstetrics (Inpatient, Outpatient)

Operating Room (Inpatient, Outpatient)
Ophthalmology/Eye Surgery (Outpatient)
Orthopedic Surgery (Inpatient)
Outpatient Surgery (Outpatient)
Pain Management (Inpatient, Outpatient)
Pediatric Care (Inpatient, Outpatient)
Post Anesthesia Care Unit (PACU) (Inpatient, Outpatient)
Psychiatric Unit
Pulmonary Function Lab (Inpatient, Outpatient)
Rehabilitation and Physical Medicine (Inpatient, Outpatient)
Respiratory Care (Ventilator) (Inpatient)
Respite Care (Inpatient)
Skilled Nursing Facility (Inpatient)
Sleep Center (Outpatient)
Telemetry (Inpatient)
Toxicology
Ultrasound (Inpatient, Outpatient)
Urology (Inpatient, Outpatient)
Wound Care (Inpatient, Outpatient)

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