Quality Report


Quality Report

Salinas Valley Memorial Health Care System
HCO ID: 10058
450 East Romie Lane
Salinas, CA, 93901
(831) 757-4333
www.salinasvalleyhealth.com
Summary of Quality Information

Accreditation Programs

View Accreditation History
Gold Seal
Hospital
Accreditation Decision
Effective Date
4/24/2021
Last Full Survey Date
2/16/2024
Last On-Site Survey Date
3/26/2024

Advanced Certification Programs

View Certification History
Gold Seal
Primary Stroke Center
Certification Decision
Effective Date
2/28/2023
Last Full Survey Date
2/27/2023
Last On-Site Survey Date
2/27/2023

Core Certification Programs

Gold Seal
Chest Pain
Certification Decision
Effective Date
2/22/2023
Last Full Survey Date
2/21/2023
Last On-Site Survey Date
2/21/2023
Gold Seal
Joint Replacement - Hip
Certification Decision
Effective Date
3/11/2023
Last Full Survey Date
3/10/2023
Last On-Site Survey Date
3/10/2023
Gold Seal
Joint Replacement - Knee
Certification Decision
Effective Date
3/11/2023
Last Full Survey Date
3/10/2023
Last On-Site Survey Date
3/10/2023

Sites

(EEG) Neurodiagnostics Sleep Center
120 WIlgart Way
Salinas, CA, 93901

Available Services

  • Outpatient Clinics (Outpatient )

Salinas Valley Health Advanced Imaging
5 Lower Ragsdale Drive, Suite 103
Monterey, CA, 93940

Available Services

  • Outpatient Clinics (Outpatient )

Salinas Valley Health Cardiac Wellness
120 Wilgart Way, Suite B
Salinas, CA, 93901

Available Services

  • Outpatient Clinics (Outpatient )

Salinas Valley Health Cardiovascular Diagnostics
230 San Jose St. Suite B
Salinas, CA, 93901

Available Services

  • Outpatient Clinics (Outpatient )

Salinas Valley Health Outpatient Infusion
DBA: Outpatient Infusion
515 E. Romie Lane
Salinas, CA, 93901

Available Services

  • Administration of Blood Product (Outpatient )
  • Administration of High Risk Medications (Outpatient )
  • Hazardous Medication Compounding (Outpatient )
  • Outpatient Clinics (Outpatient )

Salinas Valley Health Sleep Center
120 Wilgart Way, Suite A
Salinas, CA, 93901

Available Services

  • Outpatient Clinics (Outpatient )

Salinas Valley Health Wound Healing Clinic
440 E. Romie Lane
Salinas, CA, 93901

Available Services

  • Outpatient Clinics (Outpatient )

Salinas Valley Memorial Healthcare System
450 East Romie Lane
Salinas, CA, 93901

Available Services

  • Brachytherapy (Imaging/Diagnostic Services )
  • Cardiac Catheterization Lab (Surgical Services )
  • Cardiac Surgery (Surgical Services )
  • Cardiothoracic Surgery (Surgical 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 )
  • Hazardous Medication Compounding (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 )
  • 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 )
  • Sleep Laboratory (Sleep Laboratory )
  • Sterile Medication Compounding (Inpatient )
  • Teleradiology (Imaging/Diagnostic Services )
  • Thoracic Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Chest Pain
  • Joint Replacement - Hip
  • Joint Replacement - Knee
  • Primary Stroke Center

SVH Nancy Ausonio Breast Health Center
240 San Jose Street
Salinas, CA, 93901

Available Services

  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Taylor Farms Family Health and Wellness Center
850 5th Street
Gonzales, CA, 93926

Available Services

  • Outpatient Clinics (Outpatient )

Organization Commentary

Dr. Allen Radner, Interim CEO

REGARDING USE OF ACE INHIBITORS FOR PATIENTS WITH LVSD (HEART FAILURE): Some patients are unable to take ACE inhibitors because of effects, which may include a cough (72%), low blood pressure (13%), and kidney problems (12%). Angiotensin-converting enzyme receptor blockers (ARB) provide the same benefits as ACE inhibitors without some of these possible side effects. Many of our patients have kidney disease; therefore, our doctors often prescribe ARBs rather than ACE Inhibitors. Although we collect data on use of ARBs, it has not been captured for publication in this database. If ARB data were included, our performance results would be significantly better. It is important to note that we have implemented action plans to improve prescribing for both ACEI and ARB whichever is appropriate for the patients' condition. We continually work towards improving our performance in quality, patient safety, and satisfaction while serving the community healthcare needs. Should you have any questions about our report, please call our Sr. Vice President/Medical Director who can discuss any or all of this report.

Cooperative Agreements

Hospital - Accredited by American College of Surgeons-Commission on Cancer (ACoS-COC)

National Patient Safety Goals and National Quality Improvement Goals

Symbol Key

  • starThis organization achieved the best possible results
  • plusThis organization's performance is better than the target range/value
  • checkThis organization's performance is similar to the target range/value
  • minusThis organization's performance is worse than the target range /value
  • naThis measure is not applicable for this organization
  • ndNot displayed

Measures 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.
  12. The measure rate is within optimal range.

Symbol Key

  • starThis organization achieved the best possible results
  • plusThis organization's performance is better than the target range/value
  • checkThis organization's performance is similar to the target range/value
  • minusThis organization's performance is worse than the target range/value
  • naThis measure is not applicable for this organization
  • ndNot displayed

Measures 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.
  12. The measure rate is within optimal range.

* This information can also be viewed at Hospital Compare.

**      Indicates per 1000 hours of patient care.
***   The measure was not in effect for this quarter.
----   Null value or data not displayed.

Hospital 2021 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Reporting Period: January 2022 - December 2022
Perinatal Care National Comparison: nd 2 Statewide Comparison: nd 2

New Changes to Quarterly Measure

Download Quarterly Measure Results

* State results are not calculated for the National Patient Safety Goals.