Quality Report


Quality Report

CHRISTUS Santa Rosa Hospital - San Marcos

DBA: CHRISTUS Santa Rosa San Marcos
HCO ID: 9226
1301 Wonder World Drive
San Marcos, TX, 78666
(512) 353-8979
www.christushealth.org/santa-rosa/san-marcos
Summary of Quality Information

Accreditation Programs

View Accreditation History
Gold Seal
Hospital
Accreditation Decision
Effective Date
2/25/2022
Last Full Survey Date
2/24/2022
Last On-Site Survey Date
2/24/2022
Gold Seal
Laboratory
Accreditation Decision
Effective Date
2/3/2024
Last Full Survey Date
2/2/2024
Last On-Site Survey Date
2/2/2024

Advanced Certification Programs

View Certification History
Gold Seal
Primary Stroke Center
Certification Decision
Effective Date
9/20/2023
Last Full Survey Date
9/19/2023
Last On-Site Survey Date
1/22/2024

Core Certification Programs

Gold Seal
Joint Replacement - Hip
Certification Decision
Effective Date
8/30/2022
Last Full Survey Date
8/29/2022
Last On-Site Survey Date
8/29/2022
Gold Seal
Joint Replacement - Knee
Certification Decision
Effective Date
8/30/2022
Last Full Survey Date
8/29/2022
Last On-Site Survey Date
8/29/2022

Sites

CHRISTUS Santa Rosa Heart & Vascular San Marcos
DBA: Same
1340 WONDER WORLD DR VISTA #4 STE 201
San Marcos, TX, 78666

Available Services

  • Outpatient Clinics (Outpatient )

CHRISTUS Santa Rosa Hospital - San Marcos
1301 Wonder World Drive
San Marcos, TX, 78666

Available Services

  • Cardiac Catheterization Lab (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 )
  • 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 )
  • Non-Sterile Medication Compounding (Inpatient )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Orthopedic Surgery (Surgical Services )
  • Outpatient Clinics (Outpatient )
  • Plastic Surgery (Surgical Services )
  • Positron Emission Tomography (PET) (Imaging/Diagnostic Services )
  • Sleep Laboratory (Sleep Laboratory )
  • Sterile Medication Compounding (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Teleradiology (Imaging/Diagnostic Services )
  • Thoracic Surgery (Surgical Services )
  • Toxicology
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

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

CHRISTUS Santa Rosa Hospital Sleep Lab
1340 Wonder World Dr. Bldg 2 Suite 2100
San Marcos, TX, 78666

Available Services

  • Outpatient Clinics (Outpatient )

CHRISTUS Santa Rosa Hospital Wound Care Institute
1305 Wonder World Drive Suite 101
San Marcos, TX, 78666

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

CHRISTUS Santa Rosa Multi-Specialty Clinic - San Marcos
DBA: Same
1305 Wonder World Dr. STE 100
San Marcos, TX, 78666

Available Services

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

CHRISTUS Santa Rosa Wimberly Lab and Xray Express
201 Farm to Market RD 3237 #110
Wimberley, TX, 78676

Available Services

  • Outpatient Clinics (Outpatient )

PT Solutions Physical Therapy
DBA: PT Solutions Physical Therapy
2084 Central Plaza, STE 104
New Braunfels, TX, 78130

Available Services

  • Outpatient Clinics (Outpatient )

PT Solutions Physical Therapy
DBA: Same
1602 Aquarena Springs Dr STE 101
San Marcos, TX, 78666

Available Services

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

PT Solutions Physical Therapy - San Marcos
1340 Wonder World Drive, Suite 2100
San Marcos, TX, 78666

Available Services

  • 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 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 2022 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Laboratory 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.