Quality Report


Quality Report

St. Joseph Health Regional Hospital

DBA: ST JOSEPH HEALTH REGIONAL HOSPITAL
HCO ID: 8962
2801 Franciscan Drive
Bryan, TX, 77802-2544
(979) 776-3777
www.stjoseph.stlukeshealth.org
Summary of Quality Information

Accreditation Programs

View Accreditation History
Gold Seal
Hospital
Accreditation Decision
Effective Date
7/8/2023
Last Full Survey Date
3/22/2024
Last On-Site Survey Date
3/22/2024

Advanced Certification Programs

View Certification History
Gold Seal
Primary Heart Attack Center
Certification Decision
Effective Date
10/13/2022
Last Full Survey Date
10/12/2022
Last On-Site Survey Date
10/12/2022
Gold Seal
Primary Stroke Center
Certification Decision
Effective Date
3/18/2023
Last Full Survey Date
3/17/2023
Last On-Site Survey Date
3/17/2023

Core Certification Programs

Gold Seal
Chest Pain
Certification Decision
Effective Date
10/14/2022
Last Full Survey Date
10/13/2022
Last On-Site Survey Date
10/13/2022

Sites

CHI SJ College Station Breast Diagnostic Center
1602 Rock Prairie Rd., Suite 3250
College Station, TX, 77845

Available Services

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

CHI St Joseph Health Therapy Services
2013 South Market Street
Brenham, TX, 77833

Available Services

  • Outpatient Clinics (Outpatient )

CHI St. Joseph Health Cancer Center
2215 E. Villa Maria
Bryan, TX, 77802

Available Services

  • Outpatient Clinics (Outpatient )

CHI St. Joseph Health Diagnostic Imaging Center - Bryan
2722 Osler Blvd
Bryan, TX, 77802

Available Services

  • Single Specialty Practitioner (Outpatient )

CHI St. Joseph Health Imaging
DBA: Diagnostic Imaging Center St. Joseph Health
4411 Texas 6 Frontage Rd
College Station, TX, 77845

Available Services

  • Single Specialty Practitioner (Outpatient )

CHI St. Joseph Health Lab Draw
2801 29th street suite 107
Bryan, TX, 77802

Available Services

  • Laboratory Draw Station (Outpatient )

CHI St. Joseph Health Outpatient Services
1600 Joseph Dr.
Bryan, TX, 77802

Available Services

  • Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

  • CHI St. Joseph Health Sleep Lab

CHI St. Joseph Health Sports Medicine
2803 Earl Rudder Frwy., Ste. 102
College Station, TX, 77845

Available Services

  • Outpatient Clinics (Outpatient )

CHI St. Joseph Health Therapy Services College Station
4421 Hwy. 6 S., Ste. 200
College Station, TX, 77845

Available Services

  • Outpatient Clinics (Outpatient )

St. Joseph Health College Station Hospital
1604 Rock Prairie Road
College Station, TX, 77845

Available Services

  • Cardiac Catheterization Lab (Surgical Services )
  • 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 )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Orthopedic 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 )
  • Teleradiology (Imaging/Diagnostic Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )

Certification Programs

  • Chest Pain
  • Primary Stroke Center

St. Joseph Health Regional Hospital
DBA: CHI St. Joseph Health Regional Hospital
2801 Franciscan Dr.
Bryan, TX, 77802-2544

Available Services

  • 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 )
  • 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 )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • 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 )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Primary Heart Attack Center
  • Primary Stroke Center

Therapy Services
3526 Longmire Drive
College Station, TX, 77845

Available Services

  • Single Specialty Practitioner (Outpatient )

Wound Care and Hyperbaric Center
1605 Rock Prairie Road, Suite 102
College Station, TX, 77845

Available Services

  • Outpatient Clinics (Outpatient )

Organization Commentary

Ms. Kim Shaw, Market President/ CEO

St Joseph Regional Health System and its subsidiaries actively pursues improving the quality of health care by involving physicians, nurses, clinical support staff, and other team members in continuous performance improvements. We believe the public should be able to make health care decisions based on a variety of quality related information. The data from JCAHO is one of several sources of information available to the public and should be considered along with other information available about the quality of their care. Comparison in quality between hospitals is dificult due to varying patient populations and increased risk factors that may not be accounted for in the reports. Very sick patients may have more complicating health factors than can be represented in the results shown by JCAHO. The choice of a health care facility should be based on all available information in conjunction with guidance from your physician or other health care provider.

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.