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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
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
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:
Jan  2009 -
Dec  2009
Heart Attack 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 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 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.
  • Blood Vessel Surgery
 See Detail
Not displayed.
3
Not displayed.
3
  • 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.
  • 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.
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
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 Therapy (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 and Physical Medicine (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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