Quality Report


Quality Report

Ascension Saint Thomas Hospital

DBA: Ascension Saint Thomas Hospital
HCO ID: 7891
4220 Harding Pike
Nashville, TN, 37205
(615) 222-2111
https://healthcare.ascension.org/Locations/Tennessee
Summary of Quality Information

Accreditation Programs

View Accreditation History
Gold Seal
Hospital
Accreditation Decision
Effective Date
12/2/2023
Last Full Survey Date
11/12/2021
Last On-Site Survey Date
12/1/2023
Gold Seal
Laboratory
Accreditation Decision
Effective Date
9/15/2023
Last Full Survey Date
9/14/2023
Last On-Site Survey Date
9/14/2023

Advanced Certification Programs

View Certification History
Gold Seal
Advanced Comprehensive Stroke Center
Certification Decision
Effective Date
7/1/2023
Last Full Survey Date
6/30/2023
Last On-Site Survey Date
6/30/2023
Gold Seal
Primary Stroke Center
Certification Decision
Effective Date
6/29/2023
Last Full Survey Date
6/28/2023
Last On-Site Survey Date
6/28/2023
Gold Seal
Ventricular Assist Device
Certification Decision
Effective Date
9/3/2022
Last Full Survey Date
9/2/2022
Last On-Site Survey Date
9/2/2022

Core Certification Programs

Gold Seal
Chest Pain
Certification Decision
Effective Date
9/1/2022
Last Full Survey Date
8/31/2022
Last On-Site Survey Date
8/31/2022
Gold Seal
Hip Fracture
Certification Decision
Effective Date
7/21/2023
Last Full Survey Date
7/20/2023
Last On-Site Survey Date
7/20/2023
Gold Seal
Joint Replacement - Hip
Certification Decision
Effective Date
7/19/2023
Last Full Survey Date
7/18/2023
Last On-Site Survey Date
7/18/2023
Gold Seal
Joint Replacement - Knee
Certification Decision
Effective Date
7/20/2023
Last Full Survey Date
7/19/2023
Last On-Site Survey Date
7/19/2023

Sites

Ascension Saint Thomas Hospital
DBA: Ascension Saint Thomas Breast Feeding Outreach
300 20th Avenue North, Suite 703
Nashville, TN, 37203

Available Services

  • Outpatient Clinics (Outpatient )

Craig Center for Advanced Wound Healing
DBA: Ascension Saint Thomas Craig Center-Advanced Wound Healing
2000 Murphy Avenue
Nashville, TN, 37203

Available Services

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

Saint Thomas Anticoagulation Monitoring Clinic
DBA: Ascension Saint Thomas Anticoagulation Monitoring Clinic
4220 Harding Pike
Nashville, TN, 37205

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

Saint Thomas Center for Breast Health, Midtown
DBA: Ascension Saint Thomas Center for Breast Health, Midtown
2004 Hayes Street #150
Nashville, TN, 37203

Available Services

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

Saint Thomas Center for Breast Health, West
DBA: Ascension Saint Thomas Center for Breast Health, West
4220 Harding Pike
Nashville, TN, 37205

Available Services

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

Saint Thomas Heart Failure Clinic
DBA: Ascension Saint Thomas Heart Failure Clinic
4230 Harding Pike
Nashville, TN, 37205

Available Services

  • Outpatient Clinics (Outpatient )

Saint Thomas Heart OP Cardiac Imaging Center
DBA: Ascension Saint Thomas Heart Cardiac Imaging Center, Lebanon
100 Physician's Way, Suite #305
Lebanon, TN, 37090

Available Services

  • Outpatient Clinics (Outpatient )

Saint Thomas Heart OP Cardiac Imaging Center
DBA: Ascension Saint Thomas Heart Cardiac Imaging Center, Goodlet
900 Conference Drive, Ste. 8
Goodlettsville, TN, 37072

Available Services

  • Outpatient Clinics (Outpatient )

Saint Thomas Heart OP Cardiac Imaging Center
DBA: Ascension Saint Thomas Heart Cardiac Imaging Center, West
4230 Harding Pike, Suite #325 HI
Nashville, TN, 37205

Available Services

  • Outpatient Clinics (Outpatient )

Saint Thomas Heart OP Cardiac Imaging Center
DBA: Ascension Saint Thomas Heart Cardiac Imaging Center,Franklin
4323 North Carothers Pkwy, Suite 310
Franklin, TN, 37067

Available Services

  • Outpatient Clinics (Outpatient )

Saint Thomas Heart OP Cardiac Imaging Center
DBA: Ascension Saint Thomas Heart Cardiac Imaging Center, Midtown
301 21ST Avenue North, Suite 100
Nashville, TN, 37203

Available Services

  • Outpatient Clinics (Outpatient )

Saint Thomas Heart Transplant Clinic
DBA: Ascension Saint Thomas Heart Transplant Clinic
4230 Harding Pike, Suite #450 HI
Nashville, TN, 37205

Available Services

  • Outpatient Clinics (Outpatient )

Saint Thomas Kidney Transplant Clinic
DBA: Ascension Saint Thomas Kidney Transplant Clinic
4220 Harding Pike, Suite 401
Nashville, TN, 37205

Available Services

  • Outpatient Clinics (Outpatient )

Saint Thomas Midtown Infusion Center
DBA: Ascension Saint Thomas Infusion Center
2000 Church Street
Nashville, TN, 37203

Available Services

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

Saint Thomas Midtown OP Diabetes Center
DBA: Ascension Saint Thomas Outpatient Diabetes Center
2000 Murphy Avenue
Nashville, TN, 37203

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

Saint Thomas West Hospital
DBA: Ascension Saint Thomas Hospital
2000 Church Street
Nashville, TN, 37203

Available Services

  • Brachytherapy (Imaging/Diagnostic Services )
  • Cardiac Catheterization Lab (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 )
  • 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 )
  • 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 )
  • Teleradiology (Imaging/Diagnostic Services )
  • Thoracic Surgery (Surgical Services )
  • Toxicology
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Chest Pain
  • Joint Replacement - Hip
  • Joint Replacement - Knee
  • Primary Stroke Center

Other Clinics/Practices Located at This Site:

  • Breast Feeding Outreach
  • Craig Center for Advanced Wound Healing at Midtown Hospital
  • Saint Thomas Center for Breast Health, Midtown
  • Saint Thomas Heart Midtown Hospital OP Cardiac Imaging Ctr
  • Saint Thomas Heart OP Cardiac Imaging Center, Franklin
  • Saint Thomas Heart OP Cardiac Imaging Center, Goodlettsville
  • Saint Thomas Midtown Infusion Center
  • Saint Thomas Midtown Outpatient Diabetes Center

Saint Thomas West Hospital
DBA: Ascension Saint Thomas Hospital
4220 Harding Pike
Nashville, TN, 37205

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 )
  • 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 (Inpatient )
  • Interventional Radiology (Outpatient )
  • Interventional Radiology (Imaging/Diagnostic Services )
  • 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 )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Nuclear Pharmacy (Inpatient )
  • 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 )
  • Teleradiology (Imaging/Diagnostic Services )
  • Thoracic Surgery (Surgical Services )
  • Toxicology
  • Transplant Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Advanced Comprehensive Stroke Center
  • Chest Pain
  • Hip Fracture
  • Joint Replacement - Hip
  • Joint Replacement - Knee
  • Ventricular Assist Device

Other Clinics/Practices Located at This Site:

  • Nashville Eye Center
  • Saint Thomas Anticoagulation Monitoring Clinic
  • Saint Thomas Center for Breast Health, West
  • Saint Thomas Heart Failure Clinic
  • Saint Thomas Heart OP Cardiac Imaging Center
  • Saint Thomas Heart OP Cardiac Imaging Center, Lebanon
  • Saint Thomas Heart Transplant Clinic
  • Saint Thomas Kidney Transplant Clinic

The Nashville Eye Center
DBA: Ascension Saint Thomas Ophthalmology Diagnostic and Treatmen
4220 Harding Pike Suite 310
Nashville, TN, 37205

Available Services

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

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
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.