Quality Report


Quality Report

Catholic Health Initiatives Colorado

DBA: St. Mary-Corwin Hospital
HCO ID: 9406
1008 Minnequa Avenue
Pueblo, CO, 81004
(719) 557-4000
https://www.centura.org/location/st-mary-corwin-hospital
Summary of Quality Information

Accreditation Programs

View Accreditation History
Gold Seal
Hospital
Accreditation Decision
Effective Date
1/11/2023
Last Full Survey Date
6/21/2022
Last On-Site Survey Date
1/10/2023

Sites

Southern Colorado Family Medicine
902 Lakeview Drive
Pueblo, CO, 81004

Available Services

  • Outpatient Clinics (Outpatient )

St. Mary Corwin Medical Center
1008 Minnequa Avenue
Pueblo, CO, 81004

Available Services

  • CT Scanner (Imaging/Diagnostic Services )
  • EEG/EKG/EMG Lab (Imaging/Diagnostic Services )
  • Gastroenterology (Surgical Services )
  • GI or Endoscopy Lab (Imaging/Diagnostic Services )
  • Hazardous Medication Compounding (Inpatient )
  • Hematology/Oncology Unit (Inpatient )
  • Inpatient Unit (Inpatient )
  • Interventional Radiology (Inpatient )
  • Interventional Radiology (Outpatient )
  • Interventional Radiology (Imaging/Diagnostic Services )
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services )
  • Medical /Surgical Unit (Inpatient )
  • Medical ICU (Intensive Care Unit )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Orthopedic Surgery (Surgical Services )
  • Orthopedic/Spine Unit (Inpatient )
  • Outpatient Clinics (Outpatient )
  • Pediatric Otolaryngology (Inpatient - Child/Youth )
  • Pediatric Otolaryngology (Outpatient - Child/Youth )
  • 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 Unit (Inpatient )
  • Teleradiology (Imaging/Diagnostic Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )

St. Mary Corwin Wound Hyperbaric and Ostomy Center
DBA: Off Campus outpatient Wound Hyperbaric and Ostomy care
4112 Outlook Blvd, Ste 250
Pueblo, CO, 81008

Available Services

  • Single Specialty Practitioner (Outpatient )

Organization Commentary

Mr. Michael Cafasso, CEO

Improving quality and ensuring patient safety has always been a top priority at St. Mary-Corwin. Reports such as JCAHO’s are just one of many sources of information about hospital care with no single report being all-inclusive. We want consumers to have access to meaningful quality and safety information, and that is why we are pleased to be a part of the JCAHO Quality Report. St. Mary-Corwin also encourages you to talk with your physician, nurses, friends and family when making your decision for healthcare delivery. In order to be relevant and to make the best decision about your healthcare, quality information must be current. Healthcare can change quickly so up-to-date information is paramount. Quality measurement and reporting helps raise awareness of the numerous quality improvement efforts in progress at community hospitals. St. Mary-Corwin has many quality initiatives underway and numerous safety processes in place. Our hospital-based clinical effectiveness teams, led by medical professionals, develop targeted interventions to improve performance on quality and patient safety. St. Mary-Corwin continues its performance improvement with our multidisciplinary cardiac clinical effectiveness team representing the continuum of care from presentation to emergency department through cardiac rehab. Because quality is a top priority at St. Mary-Corwin, we have a physician dedicated to performance improvement and a nurse practitioner currently focusing on improvement in the care of heart failure patients. We are confident that our performance related to heart attack care, based on 2004 data relative to performance improvement processes and various quality initiatives, is similar to most accredited organizations in the State of Colorado.

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

New Changes to Quarterly Measure

Download Quarterly Measure Results

* State results are not calculated for the National Patient Safety Goals.