Quality Report


Quality Report

SCL Health - Front Range, Inc.

DBA: Lutheran Medical Center
HCO ID: 9418
8300 West 38th Avenue
Wheat Ridge, CO, 80033
(303) 425-4500
www.lutheranmedicalcenter.org
Summary of Quality Information

Accreditation Programs

Gold Seal
Behavioral Health Care and Human Services
Accreditation Decision
Effective Date
10/25/2023
Last Full Survey Date
8/15/2023
Last On-Site Survey Date
8/15/2023
Gold Seal
Home Care
Accreditation Decision
Effective Date
8/18/2023
Last Full Survey Date
8/17/2023
Last On-Site Survey Date
8/17/2023
Gold Seal
Hospital
Accreditation Decision
Effective Date
8/19/2023
Last Full Survey Date
8/18/2023
Last On-Site Survey Date
9/28/2023

Core Certification Programs

Gold Seal
Certification Decision
Effective Date
7/27/2022
Last Full Survey Date
7/26/2022
Last On-Site Survey Date
7/26/2022

Sites

SCL Health - Front Range, Inc.
DBA: Cancer Centers of Colorado: Medical Oncology-Infusion Center
400 Indiana St. Suite 300 & 310
Golden, CO, 80401

Available Services

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

SCL Health - Front Range, Inc.
DBA: Lutheran Breast Care Center
3655 Lutheran Parkway Suite 108
Wheat Ridge, CO, 80033

Available Services

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

SCL Health, Front Range Inc.
DBA: West Pines Behavioral Health
3400 Lutheran Parkway
Wheat Ridge, CO, 80033

Available Services

  • Addiction Services
  • Addiction Services (Non-detox - Adult )
  • Behavioral Health (Day Programs - Adult )
  • Behavioral Health (Non 24 Hour Care - Adult )
  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult )
  • Behavioral Health (Partial Hospitalization - Adult )
  • Chemical Dependency (Day Programs - Adult )
  • Chemical Dependency (24-hour Acute Care/Crisis Stabilization - Adult )
  • Chemical Dependency (Residential Care - Adult )
  • Chemical Dependency (Partial Hospitalization - Adult )
  • Chemical Dependency (Detox - Adult )
  • Chemical Dependency (Non-detox - Adult )

SCL Health, Front Range Inc.
DBA: Intermountain Health Hospice - Denver
3210 Lutheran Parkway
Wheat Ridge, CO, 80033

Available Services

  • Hospice Care

SCL Health, Front Range Inc.
DBA: Lutheran Medical Center
8300 West 38th Avenue
Wheat Ridge, CO, 80033

Available Services

  • Allergen Extract (Inpatient )
  • Brachytherapy (Imaging/Diagnostic 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 )
  • 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 )
  • 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 )
  • Sleep Laboratory (Sleep Laboratory )
  • Sterile Medication Compounding (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Surgical Unit (Inpatient )
  • Thoracic Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Sepsis

Organization Commentary

Mr. Scott Peek, CEO, Market President - Front Range

Organization Commentary on the Quality Report Lutheran Medical Center Wheat Ridge, CO HCO# 9418 Background Lutheran Medical Center supports the public release of performance results. We welcome the opportunity to share our results with consumers, patients, accrediting agencies and interested parties in an era in which performance is increasingly important. Lutheran Medical Center is part of an eight hospital system, SCL Health, and is committed to promoting transparency of performance information. We view the Joint Commission’s Quality Report as an exciting part of the transparency journey. This information helps us to understand our performance relative to others, identify opportunities for improvement and collaborate with our partners on best practices and evidence-based interventions Historically, Lutheran Medical Center has taken a leadership role in the public release of performance information through early efforts with the Centers for Medicare and Medicaid, the Colorado Hospital Association and the American Hospital Association. We use the information to set annual performance targets and to continually improve the quality and safety provided to our patients. Current performance In the latest reporting period (January 2013-December 2013), the performance at Lutheran Medical Center is above the national target/value in Heart Attack Care and Pneumonia Care. We are proud of the collaborative improvement work in our Emergency Department and our inpatient units to achieve these results. We have implemented strategies, such as the Lean improvement method and principles of High Reliability Organizations, to help us deliver consistent and reliable care. During the same period, the collaboration between the procedural areas and our inpatient units on the Surgical Care Improvement Project (SCIP) has resulted in performance that is above the target range in important surgical procedures for our community, including hip and joint replacement, knee replacement, open heart surgery and hysterectomy. We are proud of our results and the improvements in the care we provide to members of our community. Conclusion The medical staff members and our associates at Lutheran Medical Center are dedicated to improving the care provided to our patients and community. We welcome the opportunity to comment on our performance and to learn from others.

Cooperative Agreements

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.

Disease-Specific Care Certification 2009 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Hospital 2023 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Behavioral Health Care and Human Services 2023 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Home Care 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.