Quality Report


Quality Report

Bon Secours St. Mary's Hospital of Richmond Inc.

DBA: Bon Secours St. Mary's Hospital
HCO ID: 6387
5801 Bremo Road
Richmond, VA, 23226
(804) 287-7214
https://bonsecours.com/richmond
Summary of Quality Information

Accreditation Programs

Gold Seal
Hospital
Accreditation Decision
Effective Date
10/7/2017
Last Full Survey Date
10/6/2017
Last On-Site Survey Date
5/16/2019

Advanced Certification Programs

Gold Seal
Certification Decision
Effective Date
3/14/2018
Last Full Survey Date
3/13/2018
Last On-Site Survey Date
9/11/2018
Gold Seal
Certification Decision
Effective Date
5/1/2018
Last Full Survey Date
4/30/2018
Last On-Site Survey Date
4/30/2018
Gold Seal
Certification Decision
Effective Date
5/12/2018
Last Full Survey Date
5/11/2018
Last On-Site Survey Date
5/11/2018
Gold Seal
Certification Decision
Effective Date
2/22/2018
Last Full Survey Date
2/21/2018
Last On-Site Survey Date
2/21/2018

Core Certification Programs

Gold Seal
Certification Decision
Effective Date
5/11/2018
Last Full Survey Date
5/10/2018
Last On-Site Survey Date
5/10/2018
Gold Seal
Certification Decision
Effective Date
3/21/2018
Last Full Survey Date
3/20/2018
Last On-Site Survey Date
3/20/2018
Gold Seal
Certification Decision
Effective Date
3/21/2018
Last Full Survey Date
3/20/2018
Last On-Site Survey Date
3/20/2018

Sites

Bon Secours St. Mary's Hospital of Richmond Inc.
DBA: Bon Secours St. Mary's Hospital
5801 Bremo Road
Richmond, VA, 23226

Available Services

  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult )
  • Brachytherapy (Imaging/Diagnostic Services )
  • Cardiac Catheterization Lab (Surgical Services )
  • Cardiac Surgery (Surgical Services )
  • Cardiothoracic Surgery (Surgical Services )
  • Cardiovascular Unit (Inpatient )
  • Chemical Dependency (24-hour Acute Care/Crisis Stabilization - Adult )
  • Chemical Dependency (Detox - Adult )
  • 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 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 )
  • 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 )
  • Surgical ICU (Intensive Care Unit )
  • Surgical Unit (Inpatient )
  • Thoracic Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Acute Myocardial Infarction
  • Advanced Comprehensive Stroke Center
  • Advanced Palliative Care
  • Heart Failure
  • Joint Replacement - Hip
  • Joint Replacement - Knee
  • Ventricular Assist Device

Bon Secours St. Mary's Hospital of Richmond Inc.
DBA: Bon Secours Patterson Avenue Family Practice
9600 Patterson Ave
Henrico, VA, 23229

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Other Clinics/Practices Located at This Site:

  • Bon Secours Patterson Ave. Sports Medicine and Physical Ther

Bon Secours St. Mary's Hospital of Richmond Inc.
DBA: Cardiovascular Associates of Virginia
7001 Forest Ave Suite 200
Richmond, VA, 23230

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Single Specialty Practitioner (Outpatient )

Bon Secours St. Mary's Hospital of Richmond Inc.
DBA: Bon Secours Commonwealth Internal Medicine Associates
9220 Forest Hill Ave Suite 1-A
Richmond, VA, 23235

Available Services

  • Outpatient Clinics (Outpatient )

Bon Secours St. Mary's Hospital of Richmond Inc.
DBA: Bon Secours Wound Care Center
6900 Forest Avenue, Suite 115
Richmond, VA, 23230

Available Services

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

Bon Secours St. Mary's Hospital of Richmond Inc.
DBA: Bon Secours Physical Therapy and Sports Performance at Washi
2401 W. Leigh Street, Suite 110
Richmond, VA, 23220

Available Services

  • Outpatient Clinics (Outpatient )

Bon Secours St. Mary's Hospital of Richmond Inc.
DBA: St Marys Grove Avenue Imaging Center
2201 Grove Avenue
Richmond, VA, 23220

Available Services

  • Outpatient Clinics (Outpatient )

Bon Secours St. Mary's Hospital of Richmond Inc.
DBA: Cardiovascular Associates of Virginia
11601 Ironbridge Road
Chester, VA, 23831

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Single Specialty Practitioner (Outpatient )

Bon Secours St. Mary's Hospital of Richmond Inc.
DBA: Cardiovascular Associates of Virginia
13700 St. Francis Boulevard
Midlothian, VA, 23114

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Single Specialty Practitioner (Outpatient )

Bon Secours St. Mary's Hospital of Richmond Inc.
DBA: Bon Secours Monument Internal Medicine
5855 Bremo Road, Suite 102, MOB North
Richmond, VA, 23226

Available Services

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

Bon Secours St. Mary's Hospital of Richmond Inc.
DBA: West End Internal Medicine
7001 Forest Avenue, Suite 2500
Richmond, VA, 23230

Available Services

  • Outpatient Clinics (Outpatient )

Bon Secours St. Mary's Hospital of Richmond Inc.
DBA: Bon Secours Cardiac Wellness Center
7001 Forest Avenue, Suite 101
Richmond, VA, 23230

Available Services

  • Outpatient Clinics (Outpatient )

Bon Secours St. Mary's Hospital of Richmond Inc.
DBA: Bon Secours Richmond-Off-site Reprocessing Center (ORC)
2521 Brittons Hill Rd, Richmond, VA 23230
Richmond, VA, 23230

Available Services

  • Single Specialty Practitioner (Outpatient )

Bon Secours St. Mary's Hospital of Richmond Inc.
DBA: Bon Secours St. Mary's Short Pump Emergency Center
12320 West Broad Street
Henrico, VA, 23233

Available Services

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

Bon Secours St. Mary's Hospital of Richmond, Inc
DBA: Bon Secours St. Marys Perinatal Center
5855 Bremo Road, MOB North, Suite 306
Richmond, VA, 23226

Available Services

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

Bon Secours St. Mary's Hospital of Richmond, Inc.
DBA: Bon Secours St. Mary's Women's Imaging Center
5875 Bremo Road MOB South, Suite 105
Richmond, VA, 23226

Available Services

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

Bon Secours St. Mary's Hospital of Richmond, Inc.
DBA: Bon Secours St. Mary's Sleep Lab
5875 Bremo Road, MOB South, Suit 709
Richmond, VA, 23226

Available Services

  • Outpatient Clinics (Outpatient )

Bon Secours St. Mary's Hospital of Richmond, Inc.
DBA: Bon Secours Laboratory Services of Richmond
14051 St. Francis Blvd, Suite 2204
Midlothian, VA, 23114

Available Services

  • Laboratory Draw Station (Outpatient )

Bon Secours St. Mary's Hospital of Richmond, Inc.
DBA: Bon Secours Laboratory Services, Richmond
9220 Forest Hill Avenue, Suite 1-A
Richmond, VA, 23235

Available Services

  • Laboratory Draw Station (Outpatient )

Bon Secours St. Mary's Hospital of Richmond, Inc.
DBA: Bon Secours St. Mary's Hospital Lymphedema Clinic
5875 Bremo Road, Suite 611
Richmond, VA, 23226

Available Services

  • Outpatient Clinics (Outpatient )

Special Quality Awards

   Due to our commitment to accurate data reporting, The Joint Commission is suspending the practice of updating Special Quality Awards until
  further notice
  • 2015 Magnet Award
  • 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program
  • 2014 Magnet Award
  • 2014 ACS National Surgical Quality Improvement Program

National Patient Safety Goals and National Quality Improvement Goals

Symbol Key

  • starThis organization achieved the best possible results
  • plusThis organization's performance is above the target range/value
  • checkThis organization's performance is similar to the target range/value
  • minusThis organization's performance is below 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.

Symbol Key

  • starThis organization achieved the best possible results
  • plusThis organization's performance is above the target range/value
  • checkThis organization's performance is similar to the target range/value
  • minusThis organization's performance is below 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.

The Joint Commission only reports measures endorsed by the National Quality Forum.
* 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 2019 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Reporting Period: October 2018 - September 2019
Emergency Department 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

The Joint Commission only reports measures endorsed by the National Quality Forum.
* State results are not calculated for the National Patient Safety Goals.