QualityReport

Accreditation Quality Report
>	Summary of Accreditation Quality Information
>	Accredited Programs
>	Accreditation National Patient Safety Goals
>	Sites and Services
>	Accreditation History
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>	The Joint Commission
>	International Center for Patient Safety
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Quality Report

Summary of Accreditation Quality Information

Mercy Hospital of Tiffin, Ohio, Inc.
Org ID: 7104
45 Saint Lawrence Drive
Tiffin, OH 44883-0727
(419)455-7000
www.mercyweb.org

Accreditation Decision: Accredited	Decision Effective Date: November 22, 2008
This organization is in full compliance with all applicable standards.

Accredited Programs	Last Full Survey Date	Last On-Site Survey Date
Home Care	11/21/2008	11/21/2008
Hospital	11/21/2008	11/21/2008
Pathology and Clinical Laboratory	4/30/2008	4/30/2008

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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

Home Care

2008 National Patient Safety Goals

See Detail

Hospital

2008 National Patient Safety Goals

See Detail

National Quality Improvement Goals:

Reporting Period:
Jul 2008 -
Jun 2009

Heart Attack Care

See Detail

Heart Failure Care

See Detail

Pneumonia Care

See Detail

Surgical Care Improvement Project (SCIP)

SCIP - Cardiac

See Detail

SCIP - Infection Prevention

For All Reported Procedures:

See Detail

Colon/Large Intestine Surgery

See Detail

Hip Joint Replacement

See Detail

Hysterectomy

See Detail

Knee Replacement

See Detail

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)

Pathology and Clinical Laboratory

2008 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

McAuley Health Services
486 West Perry Street
Tiffin, OH 44883

General Laboratory Tests
Single Specialty Practitioner (Outpatient)

Mercy Home Care
45 St. Lawrence Drive
Tiffin, OH 44883

Home Health Services
Home Personal Care and/or Support Services

Mercy Hospital of Tiffin, Ohio, Inc. *
45 Saint Lawrence Drive
Tiffin, OH 44883-0727

Allergy (Outpatient)
Asthma (Outpatient)
Asthma, Pediatrics (Outpatient)
Cancer Center/Oncology (Inpatient, Outpatient)
Cardiac Unit/Cardiology (Inpatient, Outpatient)
CT Scanner (Inpatient, Outpatient)
Diabetes Mellitus (Outpatient)
EEG/EKG/EMG Lab (Inpatient, Outpatient)
Emergency Room (Outpatient)
Emphysema (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)
Imaging/Radiology (Inpatient, Outpatient)
Infusion Services (Inpatient, Outpatient)
Intensive Care Unit (Inpatient)
Internal Medicine (Inpatient, Outpatient)
Labor & Delivery (Inpatient)
Lithotripsy/Kidney Stone Treatment (Inpatient, Outpatient)
Magnetic Resonance Imaging (Inpatient, Outpatient)
Neurology (Outpatient)
Nuclear Medicine (Inpatient, Outpatient)
Nursery (Inpatient)

Obstetrics (Inpatient, Outpatient)
Occupational Health (Outpatient)
Operating Room (Inpatient, Outpatient)
Ophthalmology/Eye Surgery (Outpatient)
Oral Maxillofacial Surgery (Inpatient, Outpatient)
Orthopedic Surgery (Inpatient, Outpatient)
Otolaryngology/Ear, Nose, and Throat (Inpatient, Outpatient)
Outpatient Surgery (Outpatient)
Pain Management (Outpatient)
Pediatric Allergy/Immunology (Outpatient - Child/Youth)
Pediatric Care (Inpatient, Outpatient)
Pediatric Dentistry (Outpatient - Child/Youth)
Peripheral Vascular Disease (Outpatient)
Plastic Surgery (Inpatient, Outpatient)
Podiatry (Inpatient, Outpatient)
Post Anesthesia Care Unit (PACU) (Inpatient, Outpatient)
Pulmonary Function Lab (Inpatient, Outpatient)
Radiation Oncology (Outpatient)
Respiratory Care (Ventilator) (Inpatient)
Sleep Center (Outpatient)
Subacute Care (Inpatient)
Telemetry (Inpatient)
Tobacco Treatment / Cessation (Outpatient)
Toxicology
Ultrasound (Inpatient, Outpatient)
Urology (Inpatient, Outpatient)
Wound Care (Outpatient)

Occupational Health Services and Mercy Community Lab
437 West Market Street
Tiffin, OH 44883

General Laboratory Tests
General Outpatient Services (Outpatient)

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