Quality Report


Quality Report

Bexar County Hospital District

DBA: University Health
HCO ID: 9216
4502 Medical Drive
San Antonio, TX, 78229-4493
(210) 358-2000
www.universityhealth.uhtx.com
Summary of Quality Information

Accreditation Programs

View Accreditation History
Gold Seal
Hospital
Accreditation Decision
Effective Date
1/6/2024
Last Full Survey Date
1/7/2022
Last On-Site Survey Date
4/12/2024

Advanced Certification Programs

View Certification History
Gold Seal
Advanced Comprehensive Stroke Center
Certification Decision
Effective Date
8/31/2022
Last Full Survey Date
8/30/2022
Last On-Site Survey Date
8/30/2022
Gold Seal
Advanced Palliative Care
Certification Decision
Effective Date
11/18/2023
Last Full Survey Date
11/17/2023
Last On-Site Survey Date
11/17/2023

Sites

Dialysis South
3750 Commercial Avenue
San Antonio, TX, 78221

Available Services

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

Dialysis Southeast
1407 Fair Avenue
San Antonio, TX, 78223-1439

Available Services

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

Dr. Robert L.M. Hilliard Health Center
919 Locke Street
San Antonio, TX, 78208

Available Services

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

Family Health Center - North
302 West Rector
San Antonio, TX, 78212

Available Services

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

Family Health Center - Southeast
1055 Ada Street
San Antonio, TX, 78223

Available Services

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

Family Health Center - Southwest
2121 Southwest 36th Street
San Antonio, TX, 78237-3360

Available Services

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

General Surgery Clinic
2425 Babcock Rd Ste 110
San Antonio, TX, 78229

Available Services

  • Single Specialty Practitioner (Outpatient )

Harlandale ISD School-Based Health Center
DBA: Collier School-Based Clinic
834 W. Southcross
San Antonio, TX, 78211

Available Services

  • Outpatient Clinics (Outpatient )

Health Center East - SAISD
DBA: Davis School-Based Clinic
4702 E. Houston
San Antonio, TX, 78220

Available Services

  • Outpatient Clinics (Outpatient )

Health Center West - SAISD
DBA: Tafolla School-Based Clinic
1303 West Cesar E. Chavez Blvd
San Antonio, TX, 78207

Available Services

  • Single Specialty Practitioner (Outpatient )

Huebner Commons
11703 Huebner Rd, Ste 104
San Antonio, TX, 78230

Available Services

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

Kennedy Clinic
1831 S. General McMullen
San Antonio, TX, 78226

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Outpatient Clinics (Outpatient )

Kenwood Clinic
302 Dora
San Antonio, TX, 78212

Available Services

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

Mays Cancer Center
7979 Wurzbach Rd.
San Antonio, TX, 78229

Available Services

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

Other Clinics/Practices Located at This Site:

  • Pancreas Tumor Center
  • Texas Liver Tumor Center

Medical Arts & Research Center (MARC)
8300 Floyd Curl Drive
San Antonio, TX, 78229

Available Services

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

Other Clinics/Practices Located at This Site:

  • Heart Station at the MARC
  • Medical Center - Ambulatory Surgery Center

Medical Center Pavilion
4647 Medical Drive
San Antonio, TX, 78229

Available Services

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

Naco Perrin Clinic
4020 Naco Perrin
San Antonio, TX, 78217

Available Services

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

Oakwell Specialty Clinic
3338 Oakwell Court, Ste. 160
San Antonio, TX, 78218

Available Services

  • Outpatient Clinics (Outpatient )

Refugee Health Services
1033 Ada Street Southeast Annex
San Antonio, TX, 78223

Available Services

  • Outpatient Clinics (Outpatient )

Robert B. Green Campus
903 West Martin
San Antonio, TX, 78207

Available Services

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

Shirley Schreiber School-Based Clinic
1256 Pinn Rd Bldg 9
San Antonio, TX, 78227

Available Services

  • Single Specialty Practitioner (Outpatient )

South Flores Clinic
7902 S. Flores
San Antonio, TX, 78211

Available Services

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

Southwest School-Based Clinic
11914 Dragon Lane
San Antonio, TX, 78252

Available Services

  • Outpatient Clinics (Outpatient )

Texas Diabetes Institute
701 South Zarzamora
San Antonio, TX, 78207

Available Services

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

UMA - Dominion Crossing
21727 IH-10 W. Ste #103 and #107
San Antonio, TX, 78257

Available Services

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

University Health Babcock
2425 Babcock, Ste 111
San Antonio, TX, 78229

Available Services

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

University Health Breast Center
8403 Wurzbach Rd., San Antonio
San Antonio, TX, 78229

Available Services

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

University Health Converse
8455 Crestway
Converse, TX, 78109

Available Services

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

University Health Dialysis - Medical Center
6146 Wurzbach Road
San Antonio, TX, 78238

Available Services

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

University Health Edgewood
911 Enrique Barrera
San Antonio, TX, 78237

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Outpatient Clinics (Outpatient )

University Health Inwood
15102 Huebner Rd.
San Antonio, TX, 78231

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Outpatient Clinics (Outpatient )

University Health Luckey Ranch
11930 US Hwy 90; Ste 110
San Antonio, TX, 78245

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Urgent Care (Outpatient )

University Health Sleep Lab - LaQuinta Inn & Suites
4431 Horizon Hill Blvd
San Antonio, TX, 78229

Available Services

  • Single Specialty Practitioner (Outpatient )

University Health Sleep Lab - Marriott Hotel
600 S. Santa Rosa
San Antonio, TX, 78204

Available Services

  • Single Specialty Practitioner (Outpatient )

University Health Westgate
5282 Medical Drive Ste 240
San Antonio, TX, 78229

Available Services

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

University Hospital
4502 Medical Drive
San Antonio, TX, 78229-4493

Available Services

  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult )
  • 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 )
  • Family Support (Non 24 Hour Care )
  • 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 )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Rehabilitation Unit (Inpatient )
  • Rehabilitation Unit (24-hour Acute Care/Crisis Stabilization )
  • 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
  • Advanced Palliative Care

Other Clinics/Practices Located at This Site:

  • Pediatric Dialysis (Not under Hospital CCN)

Zarzamora Clinic
4503 S. Zarzamora
San Antonio, TX, 78211

Available Services

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

Organization Commentary

Mr. George Hernandez, President/Chief Executive Officer

University Health System continuously strives to improve the quality of care provided to the residents of Bexar County and beyond. The Joint Commission on Accreditation of Healthcare Organizations Accreditation Survey is one way to evaluate our organization, and we clearly recognize the value in having JCAHO assess the delivery of patient care and provide recommendations for improvement. The System has addressed these recommended areas for improvement and has implemented change. We continually monitor our progress, building on our successes as we strive for excellence. We are proud of our accomplishments and are committed to our mission of providing the highest quality of care to our patients, teaching the next generation of health professionals, advancing medical knowledge and improving the delivery of care by supporting research, and promoting the good health of the community.

Cooperative Agreements

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

Laboratory - Accredited by American Society for Histocompatibility and Immunogenetics (ASHI)

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 2024 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.