Quality Report


Quality Report

Catholic Health Initiatives Colorado

DBA: Penrose Hospital
HCO ID: 1769
2222 North Nevada Avenue
Colorado Springs, CO, 80907
(719) 776-5000
https://www.centura.org/location/penrose-hospital
Summary of Quality Information

Accreditation Programs

Gold Seal
Hospital
Accreditation Decision
Effective Date
7/2/2022
Last Full Survey Date
7/1/2022
Last On-Site Survey Date
9/1/2022

Sites

Cardiac & Pulmonary Rehabilitation
3030 North Circle Drive, Suite 214, 215, & 217
Colorado Springs, CO, 80909

Available Services

  • Outpatient Clinics (Outpatient )

Catholic Health Initiatives of Colorado
DBA: St Francis Hospital
6001 East Woodmen Road
Colorado Springs, CO, 80923

Available 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 )
  • GI or Endoscopy Lab (Imaging/Diagnostic Services )
  • Gynecological Surgery (Surgical Services )
  • Gynecology (Inpatient )
  • Inpatient Unit (Inpatient )
  • Interventional Radiology (Imaging/Diagnostic Services )
  • Labor & Delivery (Inpatient )
  • 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 )
  • Plastic Surgery (Surgical Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Rehabilitation Unit (Inpatient )
  • Rehabilitation Unit (24-hour Acute Care/Crisis Stabilization )
  • Sleep Laboratory (Sleep Laboratory )
  • Sterile Medication Compounding (Inpatient )
  • Surgical Unit (Inpatient )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )

Penrose Hospital
2222 N. Nevada Ave.
Colorado Springs, CO, 80907

Available Services

  • Brachytherapy (Imaging/Diagnostic Services )
  • Cardiac Catheterization Lab (Surgical Services )
  • Cardiac Surgery (Surgical Services )
  • Cardiothoracic Surgery (Surgical Services )
  • Cardiovascular 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 )
  • Hazardous Medication Compounding (Inpatient )
  • Hematology/Oncology Unit (Inpatient )
  • Inpatient Unit (Inpatient )
  • Interventional Radiology (Imaging/Diagnostic Services )
  • Medical /Surgical Unit (Inpatient )
  • Medical ICU (Intensive Care Unit )
  • Neuro/Spine Unit (Inpatient )
  • Neurosurgery (Surgical Services )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Ophthalmology (Surgical Services )
  • Orthopedic Surgery (Surgical Services )
  • Orthopedic/Spine Unit (Inpatient )
  • Outpatient Clinics (Outpatient )
  • Plastic Surgery (Surgical Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Radiation Oncology (Imaging/Diagnostic Services )
  • Sterile Medication Compounding (Inpatient )
  • Surgical Unit (Inpatient )
  • Thoracic Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

St. Francis Cancer Center
6031 East Woodmen Road Suite 150
Colorado Springs, CO, 80923

Available Services

  • Anesthesia (Outpatient )
  • Perform Invasive Procedure (Outpatient )
  • Single Specialty Practitioner (Outpatient )

The Center for Women's Imaging at St. Peregrine
6031 East Woodmen Road Suite 240
Colorado Springs, CO, 80923

Available Services

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

Organization Commentary

Mrs. Kristi Olson, VP OPERATIONS & COO • CORP ADMIN PENROSE

Penrose-St. Francis Health Services (PSF) is pleased to participate in this effort to bring meaningful quality information to the public. Because this is a new initiative, data collection and submission, in the very specific definition and format required, is in the development phase. PSF is committed to: · Improving quality and ensuring patient safety as a top priority. · Facilitating consumer access to meaningful quality and safety information (one reason we’re pleased to be a part of the JCAHO Quality Report.) · Quality measurement and reporting to help raise awareness of the many quality improvement efforts at community hospitals—and push hospital to be better. · Many quality initiatives underway and numerous safety processes currently in place. Our Clinical Effectiveness Council, led by medical professionals, develops targeted interventions to improve performance on quality, service and patient safety. Specifically relating to the data contained in our Community Acquired Pneumonia, PSF has made several practice changes, including but not limited to: · Smoking cessation recommendations have been added to our discharge instructions for all diseases; · We have instituted a pilot project surrounding screening for and administering pneumococcal vaccination on two units, which went “house-wide” on July 1, 2004; · All cases where antibiotics are not started in the Emergency Department are reviewed and lessons learned disseminated to appropriate care providers. Penrose-St. Francis Health Services has recently been acknowledged with the following citations: The Solucient 100 Top Hospitals© National Benchmarks for Success Award The JD Power & Associates Trophy for Providing “An Outstanding Patient Experience” The 2004 HealthGrades Distinguished Hospital Award for Clinical Excellence

Cooperative Agreements

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
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.