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Quality Report

Summary of Quality Information
Mercy St. Vincent Medical Center
Org ID: 7110
2213 Cherry Street
Toledo, OH  43608
(419)251-3925
www.mercyweb.org

Accreditation
Programs 		Accreditation
Decision 		Effective
Date 		Last Full Survey Date Last On-Site Survey Date
Home Care
Accredited 7/2/2011 7/1/2011   7/1/2011  
Hospital
Accredited 7/2/2011 7/1/2011   5/31/2012  


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


Advanced Certification
Programs 		Certification
Decision 		Effective
Date 		Last Full
Review Date 		Last On-Site
Review Date
Primary Stroke Center
Certification 10/3/2011  5/25/2012  5/25/2012 





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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
2012 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:
Oct  2011 -
Sep  2012
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 above the target range/value.
This organization’s performance is above the target range/value.
Pneumonia Care See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above 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
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
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
   
  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
St VIncent Mercy Medical Center
1049 S. McCord Road
Holland, OH  43528
    Services:
    • Outpatient Clinics (Outpatient)
    St Vincent Mercy Medical Center
    1360 Arrowhead Road
    Maumee, OH  43537
    Other Clinics/Practices located at this site:
    • Mercy Arrowhead Surgery Center
    Services:
    • Ambulatory Surgery Center (Outpatient)
    • Anesthesia (Outpatient)
    • Perform Invasive Procedure (Outpatient)
    St Vincent Mercy Medical Center  *
    2213 Cherry Street
    Toledo, OH  43608
    Joint Commission Advanced Certification Programs:
    • Primary Stroke Center
      Services:
      • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult)
      • Burn Unit (Inpatient)
      • Cardiac Catheterization Lab (Surgical Services)
      • Cardiac Surgery (Surgical Services)
      • Cardiothoracic Surgery (Surgical Services)
      • Cardiovascular Unit (Inpatient)
      • Coronary Care Unit (Inpatient)
      • CT Scanner (Imaging/Diagnostic Services)
      • Dialysis Unit (Inpatient)
      • 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)
      • Hematology/Oncology Unit (Inpatient)
      • Home Health Aides
      • Home Health, Non-Hospice Services
      • Interventional Radiology (Imaging/Diagnostic Services)
      • Labor & Delivery (Inpatient)
      • Magnetic Resonance Imaging (Imaging/Diagnostic Services)
      • Medical /Surgical Unit (Inpatient)
      • Medical ICU (Intensive Care Unit)
      • Neuro/Spine ICU (Intensive Care Unit)
      • Neuro/Spine Unit (Inpatient)
      • Neurosurgery (Surgical Services)
      • Normal Newborn Nursery (Inpatient)
      • Nuclear Medicine (Imaging/Diagnostic Services)
      • Orthopedic Surgery (Surgical Services)
      • Orthopedic/Spine Unit (Inpatient)
      • Pediatric Unit (Inpatient)
      • Peer Support (Non 24 Hour Care)
      • Personal Care/Support Non-Hospice
      • Plastic Surgery (Surgical Services)
      • Post Anesthesia Care Unit (PACU) (Inpatient)
      • Radiation Oncology (Imaging/Diagnostic Services)
      • Skilled Nursing Services
      • Surgical ICU (Intensive Care Unit)
      • Surgical Unit (Inpatient)
      • Teleradiology (Imaging/Diagnostic Services)
      • Thoracic Surgery (Surgical Services)
      • Ultrasound (Imaging/Diagnostic Services)
      • Urology (Surgical Services)
      • Vascular Surgery (Surgical Services)
      St Vincent Mercy Medical Center
      13415 Eckel Junction Road
      Perrysburg, OH  43551
        Services:
        • Outpatient Clinics (Outpatient)
        St Vincent Mercy Medical Center
        3930 Sunforest Court Suite 200
        Toledo, OH  43623
          Services:
          • Outpatient Clinics (Outpatient)
          St Vincent Mercy Medical Center
          2200 Jefferson Avenue
          Toledo, OH  43604
            Services:
            • Single Specialty Practitioner (Outpatient)
            St Vincent Mercy Medical Center
            2400 Cherry Street
            Toledo, OH  43608
              Services:
              • Cardiac Catheterization Lab (Surgical Services)
              • Cardiac Surgery (Surgical Services)
              • Cardiothoracic Surgery (Surgical Services)
              • Cardiovascular Unit (Inpatient)
              • Coronary Care Unit (Inpatient)
              • EEG/EKG/EMG Lab (Imaging/Diagnostic Services)
              • Medical /Surgical Unit (Inpatient)
              St Vincent Mercy Medical Center
              2702 Navarre Suite 206
              Oregon, OH  43616
                Services:
                • Single Specialty Practitioner (Outpatient)
                St Vincent Mercy Medical Center
                3404 W. Sylvania Avenue
                Toledo, OH  43623
                  Services:
                  • Administration of Blood Product (Outpatient)
                  • Administration of High Risk Medications (Outpatient)
                  • Outpatient Clinics (Outpatient)
                  St. VIncent Mercy Medical Center
                  2213 Franklin Avenue
                  Toledo, OH  43620
                    Services:
                    • Outpatient Clinics (Outpatient)
                    St.Vincent Mercy Medical Center
                    3930 Sunforest Court
                    Toledo, OH  43623
                      Services:
                      • Outpatient Clinics (Outpatient)

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