The Joint Commission
Quality Check
Quality Report

Summary of Quality Information
St. Francis Regional Medical Center
Org ID: 8194
1455 St. Francis Ave.
Shakopee, MN  55379
(952)428-3000
www.stfrancis-shakopee.com/


Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full Survey Date Last On-Site Survey Date
Hospital
Accredited 12/17/2011 12/16/2011   12/16/2011  


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




Certified
Programs
Certification
Decision
Effective
Date
Last Full
Review Date
Last On-Site
Review Date
Heart Failure
Certification 2/7/2013  2/6/2013  2/6/2013 



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.
11. There were no eligible patients that met the denominator criteria.
National Patient Safety Goals and National Quality Improvement Goals
    Compared to other Joint Commission Accredited Organizations
    Nationwide Statewide
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:
Jan  2013 -
Dec  2013
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
Not displayed.
3
Not displayed.
3
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
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 above the target range/value.
This organization’s performance is above 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
St. Francis Capable Kids Pediatric Therapy Center
1661 Park Ridge Drive
Chaska, MN  55318
    Services:
    • Outpatient Clinics (Outpatient)
    St. Francis Capable Kids Pediatric Therapy Center
    6350 West 143rd Street
    Savage, MN  55378
      Services:
      • Outpatient Clinics (Outpatient)
      St. Francis Health Services in Chaska (Diagnostic Services)
      111 Hundertmark Road
      Chaska, MN  55318
        Services:
        • Outpatient Clinics (Outpatient)
        St. Francis Health Services in Jordan
        DBA:  Primary Care Clinic
        265 Creek Lane South
        Jordan, MN  55352
          Services:
          • Perform Invasive Procedure (Outpatient)
          • Single Specialty Practitioner (Outpatient)
          St. Francis Health Services in Savage (Diagnostic Services)
          6350 West 143rd Street
          Savage, MN  55378
            Services:
            • Outpatient Clinics (Outpatient)
            St. Francis Regional Medical Center  *
            1455 St. Francis Ave.
            Shakopee, MN  55379
            Joint Commission Certified Programs:
            • Heart Failure
              Services:
              • Coronary Care Unit (Inpatient)
              • 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)
              • Interventional Radiology (Imaging/Diagnostic Services)
              • 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)
              • Outpatient Clinics (Outpatient)
              • Pediatric Unit (Inpatient)
              • 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)
              • Surgical Unit (Inpatient)
              • Teleradiology (Imaging/Diagnostic Services)
              • Thoracic Surgery (Surgical Services)
              • Ultrasound (Imaging/Diagnostic Services)
              • Urology (Surgical Services)
              • Vascular Surgery (Surgical Services)
              St. Francis Rehab and Sports Medicine at ACCUA
              8690 Eagle Creek Parkway
              Savage, MN  55378
                Services:
                • Outpatient Clinics (Outpatient)
                St. Francis Rehabilitation & Sports Medicine
                6350 West 143rd Street
                Savage, MN  55378
                  Services:
                  • Outpatient Clinics (Outpatient)
                  St. Francis Rehabilitation and Sports Medicine
                  1661 Park Ridge Drive, Suite 100
                  Chaska, MN  55318
                    Services:
                    • Outpatient Clinics (Outpatient)
                    St. Francis Rehabilitation and Sports Medicine
                    1601 St. Francis Ave., Suite 200
                    Shakopee, MN  55379
                      Services:
                      • Outpatient Clinics (Outpatient)
                      St. Francis Sleep Diagnostics Center
                      500 South Marshall Road, Suite 220
                      Shakopee, MN  55379
                        Services:
                        • Outpatient Clinics (Outpatient)

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