The Joint Commission
Quality Check
Quality Report

Summary of Accreditation Quality Information
Mercy Health - Tiffin Hospital LLC
DBA: Mercy Health - Tiffin Hospital
Org ID: 7104
45 Saint Lawrence Drive
Tiffin, OH  44883-0727
(419)455-7000
www.mercyweb.org


Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full Survey Date Last On-Site Survey Date
Home Care
Accredited 9/23/2011 9/22/2011   9/22/2011  
Hospital
Accredited 9/24/2011 9/23/2011   9/23/2011  


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





Special Quality Awards


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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
Home Care
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.
*
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:
Jul  2012 -
Jun  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 similar to the target range/value.
This organization’s performance is similar to 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
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to 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
   
 
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 - Tiffin Hospital LLC  *
DBA:  Mercy Health - Tiffin Hospital
45 Saint Lawrence Drive
Tiffin, OH  44883-0727
    Services:
    • Brachytherapy (Imaging/Diagnostic Services)
    • Cardiac Catheterization Lab (Surgical Services)
    • CT Scanner (Imaging/Diagnostic Services)
    • Ear/Nose/Throat Surgery (Surgical Services)
    • EEG/EKG/EMG Lab (Imaging/Diagnostic Services)
    • Gastroenterology (Surgical Services)
    • GI or Endoscopy Lab (Imaging/Diagnostic Services)
    • Gynecological Surgery (Surgical Services)
    • Gynecology (Inpatient)
    • Labor & Delivery (Inpatient)
    • Magnetic Resonance Imaging (Imaging/Diagnostic Services)
    • Medical /Surgical Unit (Inpatient)
    • Medical ICU (Intensive Care Unit)
    • Normal Newborn Nursery (Inpatient)
    • Nuclear Medicine (Imaging/Diagnostic Services)
    • Ophthalmology (Surgical Services)
    • Orthopedic Surgery (Surgical Services)
    • Pediatric Dentistry (Outpatient - Child/Youth)
    • Plastic Surgery (Surgical Services)
    • Positron Emission Tomography (PET) (Imaging/Diagnostic Services)
    • Post Anesthesia Care Unit (PACU) (Inpatient)
    • Sleep Laboratory (Sleep Laboratory)
    • Surgical ICU (Intensive Care Unit)
    • Teleradiology (Imaging/Diagnostic Services)
    • Ultrasound (Imaging/Diagnostic Services)
    • Urology (Surgical Services)
    Mercy Home Care
    435 West Market St
    Tiffin, OH  44883
      Services:
      • Home Health Aides
      • Home Health, Non-Hospice Services
      • Medical Social Services
      • Occupational Therapy
      • Personal Care/Support Non-Hospice
      • Physical Therapy
      • Skilled Nursing Services
      • Speech Language Pathology

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