Quality Report


Quality Report

Hennepin Healthcare System, Inc
HCO ID: 8157
701 Park Avenue
Minneapolis, MN, 55415
(612) 873-2338
www.hcmc.org
Summary of Quality Information

Accreditation Programs

View Accreditation History
Gold Seal
Behavioral Health Care and Human Services
Accreditation Decision
Effective Date
7/15/2021
Last Full Survey Date
7/14/2021
Last On-Site Survey Date
7/14/2021
Gold Seal
Home Care
Accreditation Decision
Effective Date
8/17/2022
Last Full Survey Date
7/16/2021
Last On-Site Survey Date
8/16/2022
Gold Seal
Hospital
Accreditation Decision
Effective Date
7/17/2021
Last Full Survey Date
7/16/2021
Last On-Site Survey Date
9/14/2021

Sites

Brooklyn Park Clinic
7650 Zane Ave N.
Brooklyn Park, MN, 55443

Available Services

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

Clinic and Specialty Center
715 8th Street S
Minneapolis, MN, 55415

Available Services

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

East Lake Clinic
2215 East Lake Street, Suite 500
Minneapolis, MN, 55407

Available Services

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

Golden Valley Clinic
5653 Duluth Street
Minneapolis, MN, 55422

Available Services

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

Hennepin Healthcare System, Inc
701 Park Avenue
Minneapolis, MN, 55415

Available Services

  • Behavioral Health (Day Programs - Adult )
  • 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 (Partial Hospitalization - Adult )
  • Brachytherapy (Imaging/Diagnostic Services )
  • Burn Unit (Inpatient )
  • Cardiac Catheterization Lab (Surgical Services )
  • Cardiac Surgery (Surgical Services )
  • Cardiothoracic Surgery (Surgical Services )
  • Cardiovascular 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 )
  • GI or Endoscopy Lab (Imaging/Diagnostic Services )
  • Gynecological Surgery (Surgical Services )
  • Gynecology (Inpatient )
  • Hazardous Medication Compounding (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 )
  • Pediatric Unit (Inpatient )
  • Pharmacy/Dispensary,General Services
  • Plastic Surgery (Surgical Services )
  • Positron Emission Tomography (PET) (Imaging/Diagnostic Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Radiation Oncology (Imaging/Diagnostic Services )
  • Rehabilitation Unit (Inpatient )
  • Rehabilitation Unit (24-hour Acute Care/Crisis Stabilization )
  • Sleep Laboratory
  • Sleep Laboratory (Sleep Laboratory )
  • Specialty Pharmacy
  • Sterile Medication Compounding (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Teleradiology (Imaging/Diagnostic Services )
  • Thoracic Surgery (Surgical Services )
  • Transplant Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Hennepin Healthcare System, Inc.
DBA: MVNA
825 South 8th Street , SL10
Minneapolis, MN, 55404

Available Services

  • Home Health Aides
  • Home Health, Non-Hospice Services
  • Medical Social Services
  • Occupational Therapy
  • Physical Therapy
  • Skilled Nursing Services
  • Speech Language Pathology

North Loop Clinic
800 Washington Avenue North
Minneapolis, MN, 55401

Available Services

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

Richfield Clinic
790 West 66th Street
Richfield, MN, 55423

Available Services

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

St. Anthony Village Clinic
2714 County Road 88
St Anthony Village, MN, 55418

Available Services

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

Whittier Clinic
2810 Nicollet Ave.
Minneapolis, MN, 55408

Available Services

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

Organization Commentary

Mrs. Jennifer DeCubellis, Chief Executive Officer

Hennepin Healthcare System, Inc. 2014 - program certifications/accreditations. Verified Level I Adult Trauma Center by the American College of Surgeons Verified Level I Pediatric Trauma Center by the American College of Surgeons Verified Burn Center by the American Burn Association and the American College of Surgeons Comprehensive Cancer Center, accreditation Commission on Cancer fo the American College of Surgeons Comprehensive Cancer Center, Quality Oncology Practice Initiative Certification Program Comprehensive Cancer Center, Certified Survivorship Training and Rehabilitation (STAR) Program by Oncology Rehab Partners Accreditation by the Commission on the Accreditation of Rehabilitation Facilities - Knapp Rehabilitation Center, comprehensive rehabilitation program. OB Testing Unit - certified by the American Institute of Ultrasound Medicine; member Nuchal Translucency Quality Review program Accreditation, American Academy of Sleep Medicine, Minnesota Regional Sleep Disorders Center Certification, American Association of Cardiovascular and Pulmonary Rehabilitation Accredited Diabetes Educaton program by the American Association of Diabetes Educators Bariatric Surgery Center of Excellence by the American Society for Metabolic & Bariatric Surgery Designated Adult Renal Transplant Center, CMS certified HCMC EMG Laboratory accreditation with exemplary status by the American Association of Neuromuscular and Electrodiagnostic Medicine Certified Center of Excellence by the Huntington's Disease Society of America, since 1999 Certified Center of Excellence by the ALS Association, since 1995

Cooperative Agreements

Hospital - Accredited by American College of Surgeons-Commission on Cancer (ACoS-COC)

Complementary Agreements

Hospital - Accredited by UHMS Clinical Hyperbaric Facility - Level 1

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 2021 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Behavioral Health Care and Human Services 2021 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.