The Joint Commission
Quality Check
Quality Report

Summary of Accreditation Quality Information
Mercy Health - Defiance Hospital LLC
DBA: Mercy Health - Defiance Hospital
Org ID: 420146
1404 East Second Street
Defiance, OH  43512
(419)785-3951
Mercyweb.org


Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full Survey Date Last On-Site Survey Date
Hospital
Accredited 12/2/2011 12/1/2011   12/1/2011  


Accreditation programs recognized by the Centers for Medicare and Medicaid Services (CMS)
Hospital






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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 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.
National Patient Safety Goals and National Quality Improvement Goals
    Compared to other Joint Commission Accredited Organizations
    Nationwide Statewide
Hospital
2011 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:
Oct  2012 -
Sep  2013
Heart Attack Care See Detail
Not displayed.
3
Not displayed.
3
Heart Failure Care See Detail
Not displayed.
3
Not displayed.
3
Pneumonia Care See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
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
Not displayed.
3
Not displayed.
3
  • Hysterectomy
See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above 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
   
 
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
Mercy Health - Defiance Hospital LLC  *
DBA:  Mercy Health - Defiance Hospital
1404 E. Second St
Defiance, OH  43512
    Services:
    • Medical /Surgical Unit (Inpatient)
    • Teleradiology (Imaging/Diagnostic Services)
    • Ultrasound (Imaging/Diagnostic Services)
    Mercy Hospital of Defiance Surgery Suite
    1400 E. Second Street
    Defiance, OH  43512
      Services:
      • Ambulatory Surgery Center (Outpatient)
      Mercy Hospital of Defiance, Sleep Center
      1404 E. Second Street
      Defiance, OH  43512
        Services:
        • Outpatient Clinics (Outpatient)

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