The Joint Commission
Quality Check
Quality Report

Summary of Quality Information
Mercy Medical Center
Org ID: 8248
1111 6th Avenue
Des Moines, IA  50314
(515)247-3121
www.mercydesmoines.org


Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full Survey Date Last On-Site Survey Date
Behavioral Health Care
Accredited 3/19/2014 3/18/2014   3/18/2014  
Hospital
Accredited 3/22/2014 3/21/2014   3/21/2014  


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 9/18/2013  9/17/2013  9/17/2013 




Other Accredited Programs / Services
Hospital  -  Accredited by American College of Surgeons-Commission on Cancer (ACoS-COC)


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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
Behavioral Health Care
2014 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
2014 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:
Apr  2013 -
Mar  2014
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 similar to the target range/value.
This organization’s performance is similar to the target range/value.
Perinatal Care See Detail
Not displayed.
2
Not displayed.
2
Pneumonia Care See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
Stroke Care See Detail
Not displayed.
8
Not displayed.
8
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 similar to the target range/value.
This organization’s performance is similar to 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 similar to the target range/value.
This organization’s performance is similar to 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 similar to the target range/value.
This organization’s performance is similar to the target range/value.
  • Open Heart 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.
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
MCL Westown Parkway Patient Service Center
5901 Westown Parkway, Suite 236
West Des Moines, IA  50266
    Services:
    • Laboratory Draw Station (Outpatient)
    Mercy Cancer Center - West Lakes Imaging
    12495 University Avenue, Suite 210
    Clive, IA  50325
      Services:
      • Outpatient Clinics (Outpatient)
      Mercy Cancer Center Radiation Oncology
      12495 University Avenue, First Floor; Clive, Iowa 50325
      Clive, IA  50325
        Services:
        • Administration of High Risk Medications (Outpatient)
        • Outpatient Clinics (Outpatient)
        Mercy East Imaging
        5900 E. University, Suite 200
        Pleasant Hill, IA  50327
          Services:
          • Outpatient Clinics (Outpatient)
          Mercy First Step
          1750 - 48th Street Suite 2
          Des Moines, IA  50310
            Services:
            • Behavioral Health (Day Programs - Adult)
              (Partial - Adult)
            • Chemical Dependency (Day Programs - Adult/Child/Youth)
              (Partial - Adult/Child/Youth)
            • Peer Support (Non 24 Hour Care)
            Mercy Medical Center  *
            1111 6th Avenue
            Des Moines, IA  50314-2611
            Joint Commission Advanced Certification Programs:
            • Primary Stroke Center
              Services:
              • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult/Child/Youth)
              • 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)
              • Inpatient Unit (Inpatient)
              • 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)
              • Ophthalmology (Surgical Services)
              • Orthopedic Surgery (Surgical Services)
              • Orthopedic/Spine Unit (Inpatient)
              • Outpatient Clinics (Outpatient)
              • Pediatric Unit (Inpatient)
              • Plastic Surgery (Surgical Services)
              • Positron Emission Tomography (PET) (Imaging/Diagnostic Services)
              • Post Anesthesia Care Unit (PACU) (Inpatient)
              • Radiation Oncology (Imaging/Diagnostic Services)
              • Rehabilitation Unit (Inpatient, 24-hour Acute Care/Crisis Stabilization)
              • Surgical ICU (Intensive Care Unit)
              • Surgical Unit (Inpatient)
              • Thoracic Surgery (Surgical Services)
              • Transplant Surgery (Surgical Services)
              • Ultrasound (Imaging/Diagnostic Services)
              • Urology (Surgical Services)
              • Vascular Surgery (Surgical Services)
              Mercy Medical Center - West Lakes Hospital
              1755 59th Place
              West Des Moines, IA  50266
                Services:
                • Cardiac Catheterization Lab (Surgical Services)
                • CT Scanner (Imaging/Diagnostic Services)
                • Ear/Nose/Throat Surgery (Surgical Services)
                • EEG/EKG/EMG Lab (Imaging/Diagnostic Services)
                • Gastroenterology (Surgical Services)
                • Gynecological Surgery (Surgical Services)
                • Inpatient Unit (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)
                • Plastic Surgery (Surgical Services)
                • Post Anesthesia Care Unit (PACU) (Inpatient)
                • Surgical ICU (Intensive Care Unit)
                • Ultrasound (Imaging/Diagnostic Services)
                • Urology (Surgical Services)
                Mercy North Ambulatory Surgery Center
                800 E. First Street, Suite 1000
                Ankeny, IA  50021
                Other Clinics/Practices located at this site:
                • MCL North - Suite 1400
                • Mercy North Pharmacy - Suite 1800
                Services:
                • Ambulatory Surgery Center (Outpatient)
                • Anesthesia (Outpatient)
                • Perform Invasive Procedure (Outpatient)
                Mercy North Imaging
                800 E. First Street
                Ankeny, IA  50021
                  Services:
                  • Outpatient Clinics (Outpatient)
                  Mercy Outpatient Cardiac Testing
                  5880 University Avenue, Suite 211
                  West Des Moines, IA  50266
                    Services:
                    • Outpatient Clinics (Outpatient)
                    Mercy Sleep Center
                    1449 NW 128th St.
                    Clive, IA  50325
                      Services:
                      • Outpatient Clinics (Outpatient)
                      Mercy Sleep Center - Ames
                      1816 Philadelphia Street
                      Ames, IA  50010
                        Services:
                        • Outpatient Clinics (Outpatient)
                        Mercy Weight Loss and Nutrition Center
                        12493 University Avenue, Suite 110
                        Clive, IA  50325
                          Services:
                          • Outpatient Clinics (Outpatient)
                          Mercy West
                          1601 NW 114th Street
                          Clive, IA  50325
                          Other Clinics/Practices located at this site:
                          • MCL West Suite #134
                          • Mercy West Endoscopy Suite # 244
                          • Mercy West Mammography Suite #149
                          • Mercy West Pharmacy Suite # 234
                          Services:
                          • Anesthesia (Outpatient)
                          • Outpatient Clinics (Outpatient)
                          • Perform Invasive Procedure (Outpatient)
                          Mercy West Imaging
                          1601 NW 114th Street, Suite 128
                          Clive, IA  50325
                            Services:
                            • Outpatient Clinics (Outpatient)
                            Riverside Rehabilitation
                            501 Southwest Seventh Street, Suite Q
                            Des Moines, IA  50309
                              Services:
                              • Outpatient Clinics (Outpatient)

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