Quality Report


Quality Report

Tri-City Medical Center

DBA: Tri-City Medical Center
HCO ID: 9995
4002 Vista Way
Oceanside, CA, 92056
(760) 724-8411
www.tricitymed.org
Summary of Quality Information

Accreditation Programs

View Accreditation History
Gold Seal
Home Care
Accreditation Decision
Effective Date
5/13/2022
Last Full Survey Date
5/12/2022
Last On-Site Survey Date
8/2/2022
Gold Seal
Hospital
Accreditation Decision
Effective Date
5/14/2022
Last Full Survey Date
5/13/2022
Last On-Site Survey Date
8/2/2022

Advanced Certification Programs

View Certification History
Gold Seal
Thrombectomy-Capable Stroke Center
Certification Decision
Effective Date
11/9/2023
Last Full Survey Date
11/8/2023
Last On-Site Survey Date
11/8/2023

Sites

Outpatient Services-Custody Unit
3925 Waring Court C3
Oceanside, CA, 92056

Available Services

  • Outpatient Clinics (Outpatient )

Tri-City Home Care
DBA: Tri-City Hospital Home care
2095 W. Vista Way # 220
Vista, CA, 92083

Available Services

  • Home Health Aides
  • Home Health, Non-Hospice Services
  • Medical Social Services
  • Occupational Therapy
  • Physical Therapy
  • Skilled Nursing Services
  • Speech Language Pathology

Tri-City Medical Center
4002 Vista Way
Oceanside, CA, 92056

Available Services

  • Brachytherapy (Imaging/Diagnostic Services )
  • 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 )
  • 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 )
  • 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 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 )
  • Plastic Surgery (Surgical Services )
  • Positron Emission Tomography (PET) (Imaging/Diagnostic Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Rehabilitation Unit (Inpatient )
  • Rehabilitation Unit (24-hour Acute Care/Crisis Stabilization )
  • Sterile Medication Compounding (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Surgical Unit (Inpatient )
  • Teleradiology (Imaging/Diagnostic Services )
  • Thoracic Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Thrombectomy-Capable Stroke Center

Other Clinics/Practices Located at This Site:

  • Cardiac Rehab

Tri-City Medical Center Outpatient Behavioral Health
510 West Vista Way
Vista, CA, 92083

Available Services

  • Behavioral Health (Non 24 Hour Care - Adult )
  • Community Integration (Non 24 Hour Care )
  • Family Support (Non 24 Hour Care )
  • Peer Support (Non 24 Hour Care )

Tri-City Medical Center– Carlsbad
DBA: Wound Care Center
6260 El Camino Real
Carlsbad, CA, 92009

Available Services

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

Tri-City Outpatient Infusion Center
DBA: Tri-City Outpatient Infusion Center
3617 Vista way
Oceanside, CA, 92056

Available Services

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

Organization Commentary

Dr. Gene Ma, Chief Executive Officer

Tri-City Medical Center is dedicated to working with JCAHO in assessing, improving, and communicating the standard of healthcare provided by the Medical Center. In fact, we voluntarily participate in a host of other quality improvement programs including the American Hospital Association quality initiatives, as well as PEP-C, which is a survey of how our customers rate us, and Leapfrog's safety practice measures. It is important to note that scores such as these are "snapshots in time” and represent historical results. We have identified an opportunity to improve our documentation (paperwork). For example, we thoroughly educate and coach our cardiac patients prior to discharge, but hadn't always documented the detail of this within the patient's medical record as thoroughly as we might have. We established ongoing teams including doctors, nurses and other health care specialties to improve these practices and have made substantial progress. It remains the core mission of Tri-City Medical Center to continuously strive to meet the healthcare needs of the communities we serve.

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 2022 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Home Care 2022 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.