Quality Report


Quality Report

CHI Health Creighton University Medical Center Bergan Mercy

DBA: CHI Health Creighton University Medical Center Bergan Mercy
HCO ID: 3978
7500 Mercy Road
Omaha, NE, 68124
(402) 398-6020
www.chihealth.com
Summary of Quality Information

Accreditation Programs

View Accreditation History
Gold Seal
Home Care
Accreditation Decision
Effective Date
9/1/2022
Last Full Survey Date
8/31/2022
Last On-Site Survey Date
8/31/2022
Gold Seal
Hospital
Accreditation Decision
Effective Date
9/2/2022
Last Full Survey Date
9/1/2022
Last On-Site Survey Date
10/11/2022

Sites

CHI Health Creighton University Medical Center Bergan Mercy
DBA: CHI Health CUMC Bergan Mercy Rehabilitation Care South Omaha
4220 L Street Suite 102
Omaha, NE, 68107

Available Services

  • Outpatient Clinics (Outpatient )

CHI Health Creighton University Medical Center Bergan Mercy
DBA: CHI Health CUMC Bergan Mercy Rehabilitation Care LaVista
8248 South 96th Street Suite 102
La Vista, NE, 68128

Available Services

  • Outpatient Clinics (Outpatient )

CHI Health Creighton University Medical Center Bergan Mercy
DBA: CHI Health CUMC Bergan Mercy Presurgical Screening Clinic
7710 Mercy Road Suite 140
Omaha, NE, 68124

Available Services

  • Single Specialty Practitioner (Outpatient )

CHI Health Creighton University Medical Center Bergan Mercy
DBA: CHI Health CUMC Bergan Rehabilitation Care - Bergan Mercy
7710 Mercy Rd, Ste 100
Omaha, NE, 68124-2346

Available Services

  • Outpatient Clinics (Outpatient )

CHI Health Creighton University Medical Center Bergan Mercy
DBA: CHI Health CUMC Bergan Mercy Lasting Hope Recovery Center
415 S. 25th Ave
Omaha, NE, 68131

Available Services

  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult )

CHI Health Creighton University Medical Center Bergan Mercy
DBA: CHI Health CUMC Bergan Mercy Outpatient Rehabilitation
2412 Cuming Street Suite 102
Omaha, NE, 68131

Available Services

  • Outpatient Clinics (Outpatient )

CHI Health Creighton University Medical Center Bergan Mercy
DBA: CHI Health CUMC Bergan Renewed Hope Boutique
7710 Mercy Road, Suite 120
Omaha, NE, 68124

Available Services

  • Breast Prostheses and Accessories
  • Prosthetics (Home Medical Equipment)

CHI Health Creighton University Medical Center Bergan Mercy
DBA: CHI Health CUMC Bergan Advanced Wound Care Center
7710 Mercy Road, Medical Building One, Suite 130
Omaha, NE, 68124

Available Services

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

CHI Health Creighton University Medical Center Bergan Mercy
DBA: CHI Health Creighton University Medical Center Bergan Mercy
7500 Mercy Road
Omaha, NE, 68124

Available Services

  • Brachytherapy (Imaging/Diagnostic Services )
  • 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 )
  • 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 )
  • Neuro/Spine Unit (Inpatient )
  • Neurosurgery (Surgical Services )
  • Non-Sterile Medication Compounding (Inpatient )
  • 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 )
  • Positron Emission Tomography (PET) (Imaging/Diagnostic Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Radiation Oncology (Imaging/Diagnostic Services )
  • Sterile Medication Compounding (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Surgical Unit (Inpatient )
  • Thoracic Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

CHI Health Creighton University Medical Center- Bergan Mercy
DBA: CHI Health CUMC-Bergan Mercy Cardiopulmonary Rehab
7710 Mercy Road Suite 226
Omaha, NE, 68124

Available Services

  • Outpatient Clinics (Outpatient )

CHI Health Creighton University Medical Center- Bergan Mercy
DBA: CHI Health CUMC University Campus Emergency Department
2412 Cuming Street, Suite 100
Omaha, NE, 68131

Available Services

  • Administration of Blood Product (Outpatient )
  • Administration of High Risk Medications (Outpatient )
  • Anesthesia (Outpatient )
  • Perform Invasive Procedure (Outpatient )

CHI Health Creighton University Medical Center-Bergan Mercy
DBA: CHI Health CUMC Bergan Mercy Vascular Lab
9850 Nicholas Street, Suite 250
Omaha, NE, 68114

Available Services

  • Outpatient Clinics (Outpatient )

Organization Commentary

Ms. Julie Goebel, Interim President

Alegent Health has been very proactive in participating in the public release of quality data because we strongly believe that it will help us to continue to improve the quality of care we provide our patients. We are excited to be participating in the Quality Check program of the JCAHO, and are one of only two Nebraska health systems voluntarily participating in the national Medicare demonstration project to improve quality patient care. Early in 2003, Bergan Mercy Medical Center, through its participation with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) CORE Measures, identified opportunities for improving the quality of care provided to patients admitted to Bergan Mercy with the diagnosis of Heart Failure. The time frame depicted in this data does not reflect results of the improvement activities that have been initiated at Bergan Mercy to date. Bergan Mercy has a multidisciplinary Heart Failure Performance Improvement team in place, that is actively working not only to improve the Heart Failure CORE Measure scores, but also to improve the overall quality and coordination of care provided to heart failure patients across our continuum of care. Alegent Health looks forward to using this benchmarking process to continue to enhance care for its patients.

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
Home Care 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.