Quality Report


Quality Report

St. Vincent Hospital and Health Care Services, Inc.

DBA: Ascension St. Vincent Hospital
HCO ID: 7178
2001 West 86th Street
Indianapolis, IN, 46260
(317) 338-2345
www.stvincent.org
Summary of Quality Information

Accreditation Programs

View Accreditation History
Gold Seal
Behavioral Health Care and Human Services
Accreditation Decision
Effective Date
11/14/2023
Last Full Survey Date
11/13/2023
Last On-Site Survey Date
11/13/2023
Gold Seal
Hospital
Accreditation Decision
Effective Date
11/18/2023
Last Full Survey Date
11/17/2023
Last On-Site Survey Date
12/29/2023
Gold Seal
Laboratory
Accreditation Decision
Effective Date
2/18/2023
Last Full Survey Date
2/17/2023
Last On-Site Survey Date
2/17/2023

Advanced Certification Programs

View Certification History
Gold Seal
Advanced Comprehensive Stroke Center
Certification Decision
Effective Date
11/30/2022
Last Full Survey Date
11/29/2022
Last On-Site Survey Date
11/29/2022
Gold Seal
Ventricular Assist Device
Certification Decision
Effective Date
11/8/2023
Last Full Survey Date
11/7/2023
Last On-Site Survey Date
11/7/2023

Core Certification Programs

Gold Seal
Brain Tumor
Certification Decision
Effective Date
5/25/2022
Last Full Survey Date
4/6/2022
Last On-Site Survey Date
4/6/2022

Sites

Ascension St. Vincent Burn and Wound Clinic
DBA: St. Vincent Hospital and Health Care Services, Inc.
8333 Naab road, ste. 200
Indianapolis, IN, 46260

Available Services

  • Outpatient Clinics (Outpatient )

St Vincent Abdominal Transplant Services
DBA: St Vincent Hospital and Heath Care Services, Inc
8402 Harcourt Road, Suite 500
Indianapolis, IN, 46260

Available Services

  • Outpatient Clinics (Outpatient )

St Vincent Breast Center MRI
DBA: St. Vincent Hospital and Health Care Services, Inc
8550 Naab Road, Suite 110
Indianapolis, IN, 46260

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

St Vincent Cardiac Transplant Services
DBA: St. Vincent Hospital and Health Care Services, Inc
8333 Naab Road, Suite 300
Indianapolis, IN, 46260

Available Services

  • Outpatient Clinics (Outpatient )

St Vincent Indianapolis Breast Center
DBA: St. Vincent Hospital and Health Care Services, Inc
8550 Naab Road, Suite 300
Indianapolis, IN, 46260

Available Services

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

St Vincent Medication Management
DBA: St. Vincent Hospital and Health Care Services, Inc
8220 Naab Road, Suite 102
Indianapolis, IN, 46260

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

St Vincent Nuclear and Echo Lab
DBA: St. Vincent Hospital and Health Care Services, Inc
10590 N Meridian Street, Suite 300
Indianapolis, IN, 46290

Available Services

  • Outpatient Clinics (Outpatient )

St. Vincent Cardiovascular Lab, Suite 400
DBA: St. Vincent Hospital and Health Care Services, Inc
8333 Naab Rd, Suite 400
Indianapolis, IN, 46260

Available Services

  • Outpatient Clinics (Outpatient )

St. Vincent Hospital and Health Care Center
DBA: St. Vincent Rehab Westfield
631 E State Road 32
Westfield, IN, 46074

Available Services

  • Outpatient Clinics (Outpatient )

St. Vincent Hospital and Health Care Center
DBA: St. Vincent Rehab Zionsville West
6885 W Stone Gate suite 100
Zionsville, IN, 46077

Available Services

  • Outpatient Clinics (Outpatient )

St. Vincent Hospital and Health Care Center Inc
DBA: St. Vincent Rehab Noblesville West
5594 E. 146th Street, Suite 110
Noblesville, IN, 46062

Available Services

  • Outpatient Clinics (Outpatient )

St. Vincent Hospital and Health Care Center, Inc
DBA: St. Vincent Rehab Zionsville East
10895 N Michigan Rd ste 160
Zionsville, IN, 46077

Available Services

  • Outpatient Clinics (Outpatient )

St. Vincent Hospital and Health Care Center, Inc.
DBA: Ascension St. Vincent- Indianapolis South
8451 S Emerson Ave
Indianapolis, IN, 46237

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Anesthesia (Outpatient )
  • General Laboratory Tests
  • Perform Invasive Procedure (Outpatient )
  • Toxicology

St. Vincent Hospital and Health Care Center, Inc.
DBA: Ascension St. Vincent- Castleton
8602 Allisonville Road
Indianapolis, IN, 46250

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Anesthesia (Outpatient )
  • General Laboratory Tests
  • Perform Invasive Procedure (Outpatient )
  • Toxicology

St. Vincent Hospital and Health Care Center, Inc.
DBA: Ascension St Vincent-Avon
9613 E US Highway 36
Avon, IN, 46123

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Anesthesia (Outpatient )
  • General Laboratory Tests
  • Perform Invasive Procedure (Outpatient )
  • Toxicology

St. Vincent Hospital and Health Care Center, Inc.
DBA: Ascension St. Vincent- Plainfield
2412 E Main Street
Plainfield, IN, 46168

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Anesthesia (Outpatient )
  • General Laboratory Tests
  • Perform Invasive Procedure (Outpatient )
  • Toxicology

St. Vincent Hospital and Health Care Services, Inc
2001 W. 86th Street
Indianapolis, IN, 46260

Available Services

  • Brachytherapy (Imaging/Diagnostic Services )
  • Burn Unit (Inpatient )
  • 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 )
  • Dialysis Unit (Inpatient )
  • Ear/Nose/Throat Surgery (Surgical Services )
  • EEG/EKG/EMG Lab (Imaging/Diagnostic Services )
  • Gastroenterology (Surgical Services )
  • General Laboratory Tests
  • 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 )
  • 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 )
  • 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 )
  • 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 )
  • Transplant Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Advanced Comprehensive Stroke Center
  • Brain Tumor
  • Ventricular Assist Device

St. Vincent Pediatric Therapy Center Suite 300
DBA: St. Vincent Hospital and Health Care Services, Inc
8220 Naab Road
Indianapolis, IN, 46260

Available Services

  • Outpatient Clinics (Outpatient )

St. Vincent Primary Care Center
DBA: Ascension St. Vincent Primary Care Center
8414 Naab Rd
Indianapolis, IN, 46260

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Other Clinics/Practices Located at This Site:

  • Family Medicine Clinic Suite 120
  • Multidisciplinary Clinic, Suite 215
  • Primary Care Center Internal Medicine Clinic Suite 100
  • Primary Care Center OB-GYN Clinic Suite 210
  • Primary Care Center Pediatric Clinic Suite 200
  • St Vincent Primary Care Pharmacy Suite 140
  • St.Vincent Diagnostic Imaging Suite 130

St. Vincent Women's Rehabilitation Center
DBA: St. Vincent Hospital and Health Care Services, Inc
8550 Naab Road, Suite 100
Indianapolis, IN, 46260

Available Services

  • Outpatient Clinics (Outpatient )

St.Vincent Broadripple Physical Therapy
DBA: St. Vincent Hospital and Health Care Services, Inc
1001 Broad Ripple Avenue
Indianapolis, IN, 46220

Available Services

  • Outpatient Clinics (Outpatient )

St.Vincent Cardiovascular Lab, First Floor
DBA: St. Vincent Hospital and Health Care Services, Inc
8333 Naab Road
Indianapolis, IN, 46260

Available Services

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

St.Vincent Oncology Services
DBA: Ascension St. Vincent Hospital Cancer Center
8301 Harcourt Road
Indianapolis, IN, 46260

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

St.Vincent Outpatient Imaging Center
DBA: St. Vincent Hospital and Health Care Services, Inc
10801 N. Michigan Rd
Zionsville, IN, 46077

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

St.Vincent Outpatient Treatment Center
DBA: Ascension St. Vincent Outpatient Treatment Center
11455 North Meridian, Suite 250
Carmel, IN, 46032

Available Services

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

St.Vincent Pediatric Physical & Occupational Therapy
DBA: St. Vincent Hospital and Health Care Services, Inc
12425 Old Meridian St. A-1
Carmel, IN, 46032

Available Services

  • Outpatient Clinics (Outpatient )

St.Vincent Physical Therapy
DBA: St. Vincent Hospital and Health Care Services, Inc
14828 Greyhound Ct, Suite 150
Carmel, IN, 46032

Available Services

  • Outpatient Clinics (Outpatient )

St.Vincent Physical Therapy
DBA: St. Vincent Hospital and Health Care Services, Inc
1185 W. Carmel Drive, Building C
Carmel, IN, 46032

Available Services

  • Outpatient Clinics (Outpatient )

St.Vincent Stress Center
DBA: Ascension St.Vincent Stress Center
8401 Harcourt Road
Indianapolis, IN, 46260

Available Services

  • Addiction Services
  • Addiction Services
  • Addiction Services (Non-detox - Adult )
  • Behavioral Health (Day Programs - Adult )
  • Behavioral Health (Day Programs - Child/Youth )
  • Behavioral Health (Non 24 Hour Care - Adult )
  • Behavioral Health (Non 24 Hour Care - Child/Youth )
  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult )
  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Child/Youth )
  • Behavioral Health (Partial Hospitalization - Adult )
  • Behavioral Health (Partial Hospitalization - Child/Youth )
  • Chemical Dependency (Day Programs - Adult )
  • Chemical Dependency (Day Programs - Child/Youth )
  • Chemical Dependency (Non 24 Hour Care - Adult )
  • Chemical Dependency (Non 24 Hour Care - Child/Youth )
  • Chemical Dependency (24-hour Acute Care/Crisis Stabilization - Adult )
  • Chemical Dependency (24-hour Acute Care/Crisis Stabilization - Child/Youth )
  • Chemical Dependency (Partial Hospitalization - Adult )
  • Chemical Dependency (Partial Hospitalization - Child/Youth )
  • Chemical Dependency (Non-detox - Adult )
  • Eating Disorders
  • Eating Disorders
  • Eating Disorders (24-hour Acute Care/Crisis Stabilization - Adult )
  • Eating Disorders (24-hour Acute Care/Crisis Stabilization - Child/Youth )
  • General Laboratory Tests
  • Peer Support (Non 24 Hour Care )

St.Vincent Women's Hospital
DBA: Ascension St. Vincent Women's Hospital
8111 Township Line Road
Indianapolis, IN, 46260

Available Services

  • CT Scanner (Imaging/Diagnostic Services )
  • EEG/EKG/EMG Lab (Imaging/Diagnostic Services )
  • General Laboratory Tests
  • GI or Endoscopy Lab (Imaging/Diagnostic Services )
  • Gynecological Surgery (Surgical Services )
  • Gynecology (Inpatient )
  • Inpatient Unit (Inpatient )
  • Labor & Delivery (Inpatient )
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services )
  • Medical /Surgical Unit (Inpatient )
  • Non-Sterile Medication Compounding (Inpatient )
  • Normal Newborn Nursery (Inpatient )
  • Plastic Surgery (Surgical Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Sterile Medication Compounding (Inpatient )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )

Organization Commentary

Mr. Dan Parod, President of Central Region

The recommendations for improvement have been corrected and we welcome the JCAHO follow up evaluation.

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.

Disease-Specific Care Certification 2009 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Hospital 2023 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Behavioral Health Care and Human Services 2023 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Laboratory 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.