Quality Report


Quality Report

Marin General Hospital

DBA: MarinHealth Medical Center
HCO ID: 10116
250 Bon Air Road
Greenbrae, CA, 94904
(415) 925-7000
www.mymarinhealth.org
Summary of Quality Information

Accreditation Programs

View Accreditation History
Gold Seal
Behavioral Health Care and Human Services
Accreditation Decision
Effective Date
10/26/2022
Last Full Survey Date
10/25/2022
Last On-Site Survey Date
10/25/2022
Gold Seal
Hospital
Accreditation Decision
Effective Date
10/29/2022
Last Full Survey Date
10/28/2022
Last On-Site Survey Date
10/28/2022

Advanced Certification Programs

View Certification History
Gold Seal
Inpatient Diabetes
Certification Decision
Effective Date
2/22/2023
Last Full Survey Date
2/21/2023
Last On-Site Survey Date
2/21/2023
Gold Seal
Primary Stroke Center
Certification Decision
Effective Date
2/18/2023
Last Full Survey Date
2/17/2023
Last On-Site Survey Date
2/17/2023

Sites

Braden Diabetes Center
1100 South Eliseo, suite 2
Greenbrae, CA, 94904

Available Services

  • Single Specialty Practitioner (Outpatient )

Hospital Outpatient Audiology & Speech Pathology
DBA: MarinHealth Outpatient Hearing (Audiology) & Speech Therapy
1350 S. Eliseo, suite #130
Greenbrae, CA, 94904

Available Services

  • Single Specialty Practitioner (Outpatient )

Hospital Outpatient Service - Physical Therapy
DBA: MarinHealth Outpatient Physical Therapy
1350 S. Eliseo Drive, Suite 250
Greenbrae, CA, 94904

Available Services

  • Single Specialty Practitioner (Outpatient )

Marin General Hospital
DBA: MarinHealth Medical Center
250 Bon Air Road
Greenbrae, CA, 94904

Available Services

  • Behavioral Health (Day Programs - Adult )
  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult )
  • Behavioral Health (Partial Hospitalization - Adult )
  • 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 )
  • 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 )
  • Plastic Surgery (Surgical Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Sterile Medication Compounding (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Thoracic Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Inpatient Diabetes
  • Primary Stroke Center

Marin General Hospital Outpatient Imaging Center
DBA: MarinHealth Outpatient Imaging Center
1240 South Eliseo, suite 103
Greenbrae, CA, 94904

Available Services

  • Single Specialty Practitioner (Outpatient )

MarinHealth Radiation Oncology
DBA: Marin Cancer Institute
1350 South Eliseo Drive, suite 100
Greenbrae, CA, 94904

Available Services

  • Single Specialty Practitioner (Outpatient )

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 2022 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Behavioral Health Care and Human Services 2022 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Reporting Period: January 2022 - December 2022
Hospital-Based Inpatient Psychiatric Services National Comparison: nd 2 Statewide Comparison: nd 2
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.