Quality Report


Quality Report

Sacred Heart Health Services

DBA: Avera Sacred Heart Hospital
HCO ID: 4540
501 Summit
Yankton, SD, 57078
(605) 668-8707
https://www.avera.org/locations/sacred-heart/
Summary of Quality Information

Accreditation Programs

View Accreditation History
Gold Seal
Hospital
Accreditation Decision
Effective Date
8/12/2023
Last Full Survey Date
8/11/2023
Last On-Site Survey Date
9/19/2023

Sites

Avera Cancer Institute Yankton
DBA: Avera Medical Group Radiation Oncology Yankton
1115 W. 9th Street
Yankton, SD, 57078

Available Services

  • Outpatient Clinics (Outpatient )

Avera Medical Group Ear, Nose & Throat Yankton
DBA: Avera Medical Group Ear, Nose & Throat Yankton
409 summit Street Suite 3200
Yankton, SD, 57078

Available Services

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

Avera Medical Group Pain Management, Yankton
DBA: Avera Medical Group Pain Management, Yankton
409 Summit Street, Suite 3400
Yankton, SD, 57078

Available Services

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

Other Clinics/Practices Located at This Site:

  • Avera Medical Group Palliative Medicine

Avera Medical Group Podiatry Yankton
DBA: Avera Medical Group Podiatry Yankton
409 Summit St Suite 2600
Yankton, SD, 57078

Available Services

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

Avera Sacred Heart Wound Care & Hyperbaric Treatment Center
DBA: Avera Sacred Heart Wound Care & Hyperbaric Treatment Center
409 Summit Street Suite 2500
Yankton, SD, 57078

Available Services

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

Sacred Heart Health Services
DBA: Avera Sacred Heart Hospital
501 Summit
Yankton, SD, 57078

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 )
  • Gynecological Surgery (Surgical Services )
  • Gynecology (Inpatient )
  • Hazardous Medication Compounding (Inpatient )
  • Inpatient Unit (Inpatient )
  • Interventional Radiology (Inpatient )
  • Interventional Radiology (Imaging/Diagnostic Services )
  • Labor & Delivery (Inpatient )
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services )
  • Medical /Surgical Unit (Inpatient )
  • Medical ICU (Intensive Care Unit )
  • Non-Sterile Medication Compounding (Inpatient )
  • Normal Newborn Nursery (Inpatient )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Ophthalmology (Surgical Services )
  • Orthopedic Surgery (Surgical Services )
  • 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 )
  • Swing Beds
  • Teleradiology (Imaging/Diagnostic Services )
  • Thoracic Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Sacred Heart Health Services
DBA: Avera Medical Group Family Medicine
2525 Fox Run Parkway Ste 200
Yankton, SD, 57078

Available Services

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

Other Clinics/Practices Located at This Site:

  • Avera Medical Group- Occupational Medicine

Sacred Heart Health Services
DBA: Avera Medical Group Behavioral Health Yankton
409 summit St. Ste 3300
Yankton, SD, 57078

Available Services

  • Behavioral Health (Non 24 Hour Care - Adult )
  • Community Integration (Non 24 Hour Care )
  • Family Support (Non 24 Hour Care )
  • Peer Support (Non 24 Hour Care )

Sacred Heart Health Services
DBA: Avera Surgical Hospital
2601 Fox Run Parkway
Yankton, SD, 57078

Available Services

  • Outpatient Clinics (Outpatient )

Organization Commentary

Mr. Douglas EKeren, CEO

Avera Sacred Heart Hospital (ASHH) continues to maintain high standards of care as reflected by the Accreditation decision. The data of the National Quality Improvement Goals represent empirical interventions that are to be carried out for the positive outcomes. The data produced for analysis is generated from the documentation in the patient record. The presence and/or absence of the documentation were found to be a significant factor in the reporting of this organization's data. The initial reports indicated that lack of verifying documentation resulted in the lower percentages for compliance. After the reports were received by the organization, a performance improvement project was undertaken to improve documentation of interventions. The introduction and implementation of an electronic medical record has assisted in recording the documentation of the interventions prescribed in the quality initiatives. The practitioner's commitment to quality initiatives and to improved documentation has resulted in significant improvement in 2004. This continuous performance improvement is part of ASHH's ongoing effort to achieve high quality care and maintain accreditation standards.

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 2023 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.