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Quality Report

Summary of Quality Information
California Pacific Medical Center
Org ID: 5152
2333 Buchanan Street
San Francisco, CA  94115
(415)600-6000
www.cpmc.org

Accreditation
Programs		 Accreditation
Decision		 Effective
Date		 Last Full Survey Date Last On-Site Survey Date  
Hospital
Accredited 7/28/2007 7/27/2007 7/7/2008  

Advanced Certification
Programs		 Certification
Decision		 Effective
Date		 Last Full
Review Date		 Last On-Site
Review Date
Primary Stroke Center
Certification 10/29/2008  10/28/2008  10/28/2008 
Ventricular Assist Device
Certification 12/9/2009  12/8/2009  12/8/2009 


Other Accredited Programs / Services
Laboratory  -  Accredited by College of American Pathologists
Hospital  -  Accredited by American College of Surgeons/Commission on Cancer


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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
Hospital
2008 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:
Jul  2008 -
Jun  2009
Children's Asthma 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.
Heart Attack Care See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
Heart Failure Care See Detail
This organization’s performance is below the target range/value.
This organization’s performance is below the target range/value.
Pneumonia Care See Detail
This organization’s performance is below the target range/value.
This organization’s performance is below 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.
  • Blood Vessel Surgery
 See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
  • Colon/Large Intestine Surgery
 See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
  • Coronary Artery Bypass Graft
 See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
  • 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.
  • Open Heart Surgery
 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)
 
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
California Pacific Medical Center - Davies Campus
Castro and Duboce Street
San Francisco, CA  94114
Joint Commission Advanced Certification Programs:
  • Primary Stroke Center
Services:
  • Audiology (Inpatient, Outpatient)
  • Cardiac Unit/Cardiology (Inpatient)
  • CT Scanner (Inpatient, Outpatient)
  • Dentistry (Inpatient, Outpatient)
  • Dermatology (Inpatient)
  • Dialysis (Inpatient, Outpatient)
  • EEG/EKG/EMG Lab (Inpatient, Outpatient)
  • Emergency Room (Outpatient)
  • Endocrinology (Inpatient)
  • Family Practice (Inpatient)
  • Gastroenterology (Inpatient, Outpatient)
  • General Medical Services (Inpatient)
  • General Surgery (Inpatient, Outpatient)
  • Gynecology (Inpatient, Outpatient)
  • Hematology/Blood Treatment (Inpatient, Outpatient)
  • Imaging/Radiology (Inpatient, Outpatient)
  • Infectious Diseases (Inpatient)
  • Infusion Services (Inpatient, Outpatient)
  • Intensive Care Unit (Inpatient)
  • Internal Medicine (Inpatient)
  • Lithotripsy/Kidney Stone Treatment (Inpatient, Outpatient)
  • Magnetic Resonance Imaging (Inpatient, Outpatient)
  • Nephrology (Inpatient, Outpatient)
  • Neurology (Inpatient)
  • Neurosurgery (Inpatient)
  • Nuclear Medicine (Inpatient, Outpatient)
  • Occupational Health (Outpatient)
  • Operating Room (Inpatient, Outpatient)
  • Ophthalmology/Eye Surgery (Inpatient, Outpatient)
  • Oral Maxillofacial Surgery (Inpatient, Outpatient)
  • Orthopedic Surgery (Inpatient, Outpatient)
  • Otolaryngology/Ear, Nose, and Throat (Inpatient, Outpatient)
  • Outpatient Surgery (Outpatient)
  • Pain Management (Inpatient, Outpatient)
  • Plastic Surgery (Inpatient, Outpatient)
  • Podiatry (Inpatient, Outpatient)
  • Post Anesthesia Care Unit (PACU) (Inpatient, Outpatient)
  • Rehabilitation (Inpatient, Outpatient)
  • Respiratory Care (Ventilator) (Inpatient)
  • Rheumatology (Inpatient)
  • Skilled Nursing Facility (Inpatient)
  • Telemetry (Inpatient)
  • Thoracic Surgery (Inpatient, Outpatient)
  • Ultrasound (Inpatient, Outpatient)
  • Urology (Inpatient, Outpatient)
  • Vascular Surgery (Inpatient, Outpatient)
California Pacific Medical Center - California Campus
3700 California Street
San Francisco, CA  94118
  • Audiology (Outpatient)
  • Cancer Center/Oncology (Inpatient)
  • Cardiac Surgery (Inpatient)
  • CT Scanner (Inpatient, Outpatient)
  • Dentistry (Outpatient)
  • Dermatology (Inpatient)
  • Developmental Disabilities - Hospital (Outpatient)
  • EEG/EKG/EMG Lab (Inpatient, Outpatient)
  • Emergency Room (Outpatient)
  • Endocrinology (Inpatient)
  • Family Practice (Inpatient)
  • Gastroenterology (Inpatient, Outpatient)
  • General Medical Services (Inpatient)
  • General Surgery (Inpatient, Outpatient)
  • GI or Endoscopy Lab (Inpatient, Outpatient)
  • Gynecology (Inpatient, Outpatient)
  • Hematology/Blood Treatment (Inpatient)
  • Imaging/Radiology (Inpatient, Outpatient)
  • Infectious Diseases (Inpatient)
  • Intensive Care Unit (Inpatient)
  • Internal Medicine (Inpatient)
  • Labor & Delivery (Inpatient)
  • Lithotripsy/Kidney Stone Treatment (Outpatient)
  • Magnetic Resonance Imaging (Inpatient, Outpatient)
  • Neonatal Intensive Care (Inpatient)
  • Nephrology (Inpatient, Outpatient)
  • Neurology (Inpatient)
  • Neurosurgery (Inpatient)
  • 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 (Outpatient)
  • Pediatric Care (Inpatient, Outpatient)
  • Plastic Surgery (Inpatient, Outpatient)
  • Podiatry (Outpatient)
  • Post Anesthesia Care Unit (PACU) (Inpatient, Outpatient)
  • Respiratory Care (Ventilator) (Inpatient)
  • Skilled Nursing Facility (Inpatient)
  • Telemetry (Inpatient)
  • Ultrasound (Inpatient, Outpatient)
  • Urology (Inpatient, Outpatient)
  • Vascular Surgery (Outpatient)
  • Wound Care (Inpatient)
California Pacific Medical Center - Pacific Campus  *
2333 Buchanan Street
San Francisco, CA  94115
Joint Commission Advanced Certification Programs:
  • Primary Stroke Center
  • Ventricular Assist Device
Services:
  • Audiology (Inpatient)
  • Behavioral Health (Non 24 Hour Care - Adult)
    (24-hour Acute Care/Crisis Stabilization - Adult)
  • Cancer Center/Oncology (Inpatient, Outpatient)
  • Cardiac Catheterization Lab (Inpatient, Outpatient)
  • Cardiac Surgery (Inpatient)
  • Cardiac Unit/Cardiology (Inpatient, Outpatient)
  • CT Scanner (Inpatient, Outpatient)
  • Dentistry (Inpatient)
  • Dermatology (Inpatient)
  • Dialysis (Inpatient, Outpatient)
  • EEG/EKG/EMG Lab (Inpatient, Outpatient)
  • Electroconvulsive Therapy (Inpatient)
  • Emergency Room (Outpatient)
  • Endocrinology (Inpatient)
  • Family Practice (Inpatient)
  • Gastroenterology (Inpatient)
  • General Medical Services (Inpatient)
  • General Surgery (Inpatient, Outpatient)
  • GI or Endoscopy Lab (Inpatient, Outpatient)
  • Gynecology (Inpatient)
  • Hematology/Blood Treatment (Inpatient)
  • Imaging/Radiology (Inpatient, Outpatient)
  • Infectious Diseases (Inpatient)
  • Infusion Services (Inpatient, Outpatient)
  • Intensive Care Unit (Inpatient)
  • Internal Medicine (Inpatient)
  • Magnetic Resonance Imaging (Inpatient, Outpatient)
  • Mental Health (Inpatient, Outpatient, 24-hour Acute Care/Crisis Stabilization)
  • Nephrology (Inpatient)
  • Neurology (Inpatient)
  • Neurosurgery (Inpatient)
  • Nuclear Medicine (Inpatient, Outpatient)
  • Operating Room (Inpatient, Outpatient)
  • Ophthalmology/Eye Surgery (Inpatient, Outpatient)
  • Oral Maxillofacial Surgery (Inpatient, Outpatient)
  • Orthopedic Surgery (Inpatient, Outpatient)
  • Otolaryngology/Ear, Nose, and Throat (Inpatient, Outpatient)
  • Outpatient Surgery (Outpatient)
  • Pain Management (Inpatient)
  • Pediatric Care (Inpatient, Outpatient)
  • Plastic Surgery (Inpatient, Outpatient)
  • Podiatry (Inpatient, Outpatient)
  • Post Anesthesia Care Unit (PACU) (Inpatient, Outpatient)
  • Pulmonary Function Lab (Inpatient, Outpatient)
  • Radiation Oncology (Inpatient, Outpatient)
  • Recovery/Infirmary (Outpatient)
  • Rehabilitation (Inpatient, Outpatient)
  • Respiratory Care (Ventilator) (Inpatient)
  • Rheumatology (Inpatient)
  • Telemetry (Inpatient)
  • Thoracic Surgery (Inpatient, Outpatient)
  • Ultrasound (Inpatient, Outpatient)
  • Urology (Inpatient, Outpatient)
  • Vascular Surgery (Inpatient, Outpatient)
  • Wound Care (Inpatient)

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