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
Additional Links
>	The Joint Commission
>	International Center for Patient Safety
>	Joint Commission International

Quality Report

Summary of Accreditation Quality Information

Mercy St. Charles Hospital
Org ID: 7108
2600 Navarre Avenue
Oregon, OH 43616
(419)696-7200
WWW.MERCYWEB.ORG

Accreditation Decision: Accredited	Decision Effective Date: May 10, 2008
This organization is in full compliance with all applicable standards.

Accredited Programs	Last Full Survey Date	Last On-Site Survey Date
Hospital	5/9/2008	5/9/2008

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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

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

Blood Vessel Surgery

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)

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

Center for Health Promotion
1001 Isaac Streets Drive
Oregon, OH 43616

General Outpatient Services (Outpatient)

Community Health North
1500 Superior Street
Toledo, OH 43604

General Outpatient Services (Outpatient)

Elmore Health Center
3105 South State Route 51
Elmore, OH 43416

General Outpatient Services (Outpatient)

Mercy St. Charles Hospital *
2600 Navarre Avenue
Oregon, OH 43616

Audiology (Inpatient, Outpatient)
Behavioral Health (Day Programs - Adult)
(24-hour Acute Care/Crisis Stabilization - Adult)
Cancer Center/Oncology (Inpatient, Outpatient)
Dialysis (Inpatient, Outpatient)
EEG/EKG/EMG Lab (Inpatient, Outpatient)
Electroconvulsive Therapy (Inpatient, Outpatient)
Emergency Room (Outpatient)
Family Practice (Inpatient, Outpatient)
Gastroenterology (Inpatient, Outpatient)
General Medical Services (Inpatient, Outpatient)
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, Outpatient)
Labor & Delivery (Inpatient)
Lithotripsy/Kidney Stone Treatment (Inpatient, Outpatient)
Magnetic Resonance Imaging (Inpatient, Outpatient)
Mental Health (Inpatient, Outpatient, 24-hour Acute Care/Crisis Stabilization)
Neonatal Intensive Care (Inpatient)
Nephrology (Inpatient, Outpatient)
Neurology (Inpatient, Outpatient)

Nuclear Medicine (Inpatient, Outpatient)
Nursery (Inpatient)
Obstetrics (Inpatient)
Occupational Health (Outpatient)
Operating Room (Inpatient, Outpatient)
Oral Maxillofacial Surgery (Inpatient, Outpatient)
Orthopedic Surgery (Inpatient, Outpatient)
Outpatient Surgery (Outpatient)
Pain Management (Inpatient, Outpatient)
Pediatric Care (Inpatient)
Plastic Surgery (Inpatient)
Podiatry (Outpatient)
Post Anesthesia Care Unit (PACU) (Inpatient, Outpatient)
Pulmonary Function Lab (Inpatient, Outpatient)
Radiation Oncology (Inpatient, Outpatient)
Rehabilitation (Inpatient, Outpatient)
Sleep Center (Outpatient)
Subacute Care (Inpatient)
Telemetry (Inpatient)
Thoracic Surgery (Inpatient, Outpatient)
Ultrasound (Inpatient, Outpatient)
Urgent Care/Emergency Medicine (Outpatient)
Vascular Surgery (Inpatient, Outpatient)
Wound Care (Inpatient, Outpatient)

Mercy Women's Care at St. Charles
2702 Navarre Ave.
Oregon, OH 43616

General Outpatient Services (Outpatient)

Navarre Park Family Health Center
1020 Varland
Oregon, OH 43616

General Outpatient Services (Outpatient)

Oregon Clinic Lab
3841 Navarre Ave
Oregon, OH 43616

General Outpatient Services (Outpatient)

Point Place PT
4645 N. Summit St
Toledo, OH 43611

General Outpatient Services (Outpatient)

Point Shoreland Lab
2755 Shoreland Ave
Toledo, OH 43611

General Outpatient Services (Outpatient)

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