Quality Report


Quality Report

CHRISTUS Santa Rosa Health Care Corporation

DBA: CHRISTUS Santa Rosa Hospital – Medical Center
HCO ID: 9218
2827 Babcock Road
San Antonio, TX, 78229
(210) 704-3342
christussantarosa.org
Summary of Quality Information

Accreditation Programs

Gold Seal
Hospital
Accreditation Decision
Effective Date
4/14/2018
Last Full Survey Date
4/13/2018
Last On-Site Survey Date
5/23/2018
Gold Seal
Laboratory
Accreditation Decision
Effective Date
6/9/2017
Last Full Survey Date
6/8/2017
Last On-Site Survey Date
6/8/2017

Advanced Certification Programs

Gold Seal
Certification Decision
Effective Date
11/18/2016
Last Full Survey Date
11/17/2016
Last On-Site Survey Date
11/17/2016
Gold Seal
Certification Decision
Effective Date
12/22/2016
Last Full Survey Date
11/16/2016
Last On-Site Survey Date
11/16/2016

Sites

CHRISTUS Santa Rosa Alon Emergency Center
DBA: CHRISTUS Santa Rosa Alon Emergency Center
11503 N.W. Military Hwy, Building 500 Suite 122
San Antonio, TX, 78231

Available Services

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

Certification Programs

  • Acute Stroke Ready Hospital

CHRISTUS Santa Rosa Creekside Emergency Center,New Braunfels
DBA: CHRISTUS Santa Rosa Creekside Emergency Center,New Braunfels
244 Creekside Crossing
New Braunfels, TX, 78130

Available Services

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

CHRISTUS Santa Rosa Emergency Center-Bandera
8703 Bandera Blvd.
San Antonio, TX, 78250

Available Services

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

CHRISTUS Santa Rosa Healthcare System-Alamo Heights
DBA: CHRISTUS Santa Rosa Hospital-Alamo Heights
403 Treeline Park, Building 1
San Antonio, TX, 78209

Available Services

  • CT Scanner (Imaging/Diagnostic Services )
  • 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 )
  • Inpatient Unit (Inpatient )
  • Interventional Radiology (Imaging/Diagnostic Services )
  • Medical /Surgical Unit (Inpatient )
  • Neurosurgery (Surgical Services )
  • Ophthalmology (Surgical Services )
  • Orthopedic Surgery (Surgical Services )
  • Plastic Surgery (Surgical Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Ultrasound (Imaging/Diagnostic Services )

CHRISTUS Santa Rosa Hospital - Medical Center
DBA: CHRISTUS Santa Rosa Hospital - Medical Center
2827 Babcock Road
San Antonio, TX, 78229

Available Services

  • Cardiac Catheterization Lab (Surgical Services )
  • Cardiac Surgery (Surgical Services )
  • Cardiothoracic Surgery (Surgical Services )
  • CT Scanner (Imaging/Diagnostic Services )
  • 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 )
  • 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 )
  • 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 )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Surgical Unit (Inpatient )
  • Thoracic Surgery (Surgical Services )
  • Toxicology
  • Transplant Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Primary Stroke Center

CHRISTUS Santa Rosa Hospital - New Braunfels
DBA: CHRISTUS Santa Rosa Hospital - New Braunfels
600 North Union Avenue
New Braunfels, TX, 78130

Available Services

  • Cardiac Catheterization Lab (Surgical Services )
  • Cardiac Surgery (Surgical Services )
  • Cardiothoracic Surgery (Surgical Services )
  • CT Scanner (Imaging/Diagnostic Services )
  • Ear/Nose/Throat Surgery (Surgical Services )
  • EEG/EKG/EMG Lab (Imaging/Diagnostic Services )
  • Gastroenterology (Surgical Services )
  • General Laboratory Tests
  • Gynecological Surgery (Surgical Services )
  • Gynecology (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 )
  • Normal Newborn Nursery (Inpatient )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Orthopedic Surgery (Surgical Services )
  • Outpatient Clinics (Outpatient )
  • Plastic Surgery (Surgical Services )
  • Positron Emission Tomography (PET) (Imaging/Diagnostic Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Sleep Laboratory (Sleep Laboratory )
  • Surgical ICU (Intensive Care Unit )
  • Surgical Unit (Inpatient )
  • Thoracic Surgery (Surgical Services )
  • Toxicology
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Primary Stroke Center

CHRISTUS Santa Rosa Hospital New Braunfels OutPt. Chemothery
600 North Union Avenue
New Braunfels, TX, 78130

Available Services

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

CHRISTUS Santa Rosa Hospital- Westover Hills
DBA: CHRISTUS Santa Rosa Hospital- Westover Hills
11212 State Highway 151
San Antonio, TX, 78251

Available Services

  • Cardiac Catheterization Lab (Surgical Services )
  • Cardiac Surgery (Surgical Services )
  • Cardiothoracic Surgery (Surgical Services )
  • Cardiovascular Unit (Inpatient )
  • CT Scanner (Imaging/Diagnostic Services )
  • 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 )
  • Inpatient Unit (Inpatient )
  • Interventional Radiology (Inpatient )
  • Interventional Radiology (Imaging/Diagnostic Services )
  • Labor & Delivery (Inpatient )
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services )
  • Medical /Surgical Unit (Inpatient )
  • Medical ICU (Intensive Care Unit )
  • Neurosurgery (Surgical Services )
  • Normal Newborn Nursery (Inpatient )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Orthopedic Surgery (Surgical Services )
  • Outpatient Clinics (Outpatient )
  • Pediatric General Surgery (Inpatient - Child/Youth )
  • Plastic Surgery (Surgical Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • 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

  • Primary Stroke Center

Christus Santa Rosa Hospital-New Braunfels POCT
600 North Union Street
New Braunfels, TX, 78130

Available Services

  • General Laboratory Tests

Other Clinics/Practices Located at This Site:

  • Christus Santa Rosa Outpatient Imaging
  • Christus Santa Rosa Outpatient Wound Care and Hyperbaric Cen

CHRISTUS Santa Rosa Imaging Center- Alamo Heights
423 Treeline Park Ste 100
San Antonio, TX, 78209

Available Services

  • Outpatient Clinics (Outpatient )

CHRISTUS Santa Rosa Orthopaedics & Sports Medicine
DBA: CHRISTUS Orthopaedics & Sports Medicine - San Antonio
2829 Babcock Road Suite 435 Tower 2
San Antonio, TX, 78229

Available Services

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

CHRISTUS Santa Rosa Orthopaedics & Sports Medicine-Alamo Hei
156 West Sunset Suite 200
San Antonio, TX, 78209

Available Services

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

CHRISTUS Santa Rosa Westover Hills - Cardiac Opt Rehab Srv
11212 State Hwy 151, Medical Plaza 2, Suite 316
San Antonio, TX, 78251

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

CHRISTUS Santa Rosa Westover Hills-Outpatient Rehab
DBA: Westover Hills-Outpatient Rehab
11212 State Highway 151, MOB 2, Suite 305
San Antonio, TX, 78251

Available Services

  • Outpatient Clinics (Outpatient )

CHRISTUS Santa Rosa Wound Care & Hyperaric Center - CSR-MC
DBA: CHRISTUS Santa Rosa Wound Care & Hyperaric Center - CSR-MC
2833 Babcock Road, Tower 2; Ste 105
San Antonio, TX, 78229

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

CHRISTUS Santa Rosa Wound Care & Hyperbaric Center
315 N. San Saba, Ste. 107
San Antonio, TX, 78207

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

CHRISTUS Santa Rosa Wound Care & Hyperbaric Center--CSR-WH
11212 State Hwy 151, Med Plaza 2 Ste300
San Antonio, TX, 78251

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

CHRISTUS Santa Rosa Wound Care & Hyperbaric CSRH-NB
598 N. Union
New Braunfels, TX, 78130

Available Services

  • Anesthesia (Outpatient )
  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

CHRISTUS Santa Rosa-Alamo Heights Outpatient Surgery - POCT
DBA: CHRISTUS Santa Rosa Hospital-Alamo Heights Outpatient Surg
403 Treeline Park
San Antonio, TX, 78209

Available Services

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

Christus Santa Rosa-Cardiothoracic Center in New Braunfels
DBA: Cardiothoracic Center
730 N. Houston Avenue
New Braunfels, TX, 78130

Available Services

  • Single Specialty Practitioner (Outpatient )

CHRISTUS Santa Rosa-Rehabilitation Services
DBA: CHRISTUS Santa Rosa-Rehabilitation Services
750 Landa, Suite A
New Braunfels, TX, 78130

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

National Patient Safety Goals and National Quality Improvement Goals

Symbol Key

  • starThis organization achieved the best possible results
  • plusThis organization's performance is above the target range/value
  • checkThis organization's performance is similar to the target range/value
  • minusThis organization's performance is below 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.

Symbol Key

  • starThis organization achieved the best possible results
  • plusThis organization's performance is above the target range/value
  • checkThis organization's performance is similar to the target range/value
  • minusThis organization's performance is below 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.

The Joint Commission only reports measures endorsed by the National Quality Forum.
* 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.

Laboratory 2017 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Hospital 2018 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Reporting Period: April 2017 - March 2018
Emergency Department National Comparison: nd 2 Statewide Comparison: nd 2
Hospital-Based Inpatient Psychiatric Services National Comparison: nd 2 Statewide Comparison: nd 2
Immunization National Comparison: nd 2 Statewide Comparison: nd 2
Perinatal Care National Comparison: nd 2 Statewide Comparison: nd 2

New Changes to Quarterly Measure

Download Quarterly Measure Results

The Joint Commission only reports measures endorsed by the National Quality Forum.
* State results are not calculated for the National Patient Safety Goals.