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St. Louise Regional Hospital

Quality & Safety

St. Louise Regional Hospital strives to provide the safest and highest quality care to our patients, their families, and our community in a manner consistent with our values. Our care plans and processes are built on evidence-based practices, and we hold ourselves to the highest standards.

We seek to provide care that is safe, patient centered, effective, timely, efficient, and equitable. We measure our performance through a number of clinical process and outcome indicators and benchmark our performance against top performing medical centers within California and across the nation.

Dedicated to achieving excellent quality outcomes and building a culture of patient safety, St. Louise Regional Hospital has partnered with the Center for Medicare and Medicaid Services (CMS) and Premier in the Partnership for Patients Initiative to improve the quality, safety and affordability of health care for all Americans.

Medicare and Medicaid Services

St. Louise Regional Hospital has been acknowledged by CMS through the Medicare’s Value Based Purchasing Program received for its performance in evidence-based care (Core Measures). These measures include best practice in the care of Acute Myocardial Infarction (heart attacks), Heart Failure, Community Acquired Pneumonia, Surgical Care, Immunizations, Perinatal Care, Sepsis Care, Stroke Care and Prevention of Thromboembolisms (blood clots).

We are committed to keeping our patients safe and protecting them from harm. We have adopted the Joint Commission’s National Patient Safety Goals and have implemented practices throughout the medical center and clinics to support patient safety. St. Louise is a Medicare provider, and is fully accredited by the Joint Commission. The hospital has also achieved Joint Commission’s Advanced Certification as a Primary Stroke Center.

Transparency

We report our clinical care and patient experience performance data publicly through several venues: the Centers for Medicare and Medicaid (CMS), the Joint Commission and the California Hospital Compare.

The Joint Commission Public Notice Regarding Safety & Quality of Care

The Joint Commission periodically conducts an accreditation survey of St. Louise Regional Hospital. The purpose of the survey is to evaluate the organization’s compliance with nationally established Joint Commission standards. The survey results are used to determine whether — and the conditions under which — accreditation should be awarded to Saint Louise Regional Hospital.

The Joint Commission’s standards deal with organization and safety quality-of-care issues and the safety of the environment in which care is provided.

As a patient, family member, community representative or associate of St. Louise Regional Hospital, you have the right to notify The Joint Commission regarding any concern about the quality of care provided, safety of care provided, or safety of the environment in which care is provided. Anyone believing that he or she has pertinent and valid information about such matters should notify The Joint Commission.

Division of Accreditation Operations

Office of Quality Monitoring
Joint Commission on Accreditation of Healthcare Organizations
One Renaissance Boulevard
Oakbrook Terrace, IL 60181
Phone (800) 994-6610
Fax: (630) 792-5636
Email: [email protected]

This notice is posted in accordance with the Joint Commission’s requirements and may not be removed.

Quality Transparency Dashboard

Outcome MeasuresCLABSIColon SSINTSVSepsis Mortality30-day Readmission
Santa Clara Valley Medical Center
O'Connor Hospital
St. Louise Regional Hospital		 0.801.3821.0011.5815.20
California Level0.670.8622.9013.5015.48
National Level0.690.8725.9025.0015.60
Measure Period01/01/2019-12/31/201901/01/2019-12/31/201907/01/2019-6/30/201901/01/2019-12/31/201907/01/2019-6/30/2019
Program Status
YESThis hospital has a Maternity Safety Program in place. A maternity safety program provides a coordinated approach and emergency response to risks associated with pregnancy and childbirth.
YESThis hospital has a Sepsis Protocol in place. A sepsis protocol provides guidance for a coordinated approach to identification and treatment of an infection and inflammatory response which is present throughout the body.
YESThis hospital has a Respiratory Monitoring program in place. Respiratory monitoring provides guidance for assessment of risk of respiratory depression and includes continuous monitoring of breathing and functioning of the lungs and circulatory system when indicated.
Outcome Measure Definitions 
CLABSI - Central line - Associated Blood Stream Infection: A serious infection that occurs when germs enter the bloodstream through a central line. A central line is a special intravenous catheter (IV) that allows access to a major vein close to the heart and can stay in place for weeks or months. The value shown above is a Standardized infection Ratio (SIR), which is the ratio of observed-to-expected infections during the measure period. SIRs below 1.00 indicate that the observed number of infections during the measure period was lower than would be expected under normal conditions, whereas values above 1.00 indicate that the observed number of infections was higher than expected.
Limitations: In the calculation of the Standardized infection Ratio (SIR), the CDC adjusts for differences between hospitals. However, patient risk factors are not taken into account. These patient-specific variables (e.g., poor skin integrity, immunosuppression) can increase the risk of developing a central line infection Hence, the SIR for hospitals that care for more medically complex or immunosuppressed patients may not be adequately adjusted to account for those patient-specific risk factors.
Colon SSI - Colon Surgical Site Infection: An infection (usually bacteria (that occurs after a person has colorectal surgery that occurs at the body site where the surgery took place. While some involve only the skin, others are more serious and can involve tissues under the skin, organs, or implanted material. The value shown above is a Standardized Infection Ratio (SIR), which is the ratio of observed-to-expected infections during the measure period. SIRs below 1.00 indicate that the observed number of infections during the measure period was lower that would be expected under normal conditions, whereas values above 1.00 indicate that the observed number of infections was higher than expected.
Limitations: Some, but not all patient-specific risk factors are included in the adjustment of the SIR for these types of infections. However, not all relevant risk factors are included (e.g., trauma, emergency procedures may not be adequately adjusted to account for those patient-specific risk factors.
NTSV - Nulliparous, Term, Singleton, Vertex Cesarean Birth Rate: The percentage of cesarean (surgical) births among first-time mothers who are at least 37 weeks pregnant with one baby in a head down position (not breech or transverse). Lower values indicate that fewer cesareans were performed in the hospital among primarily low risk, first-time mothers.
Limitations: NTSV rates do not take into account certain obstetric conditions, such as placenta previa, that may make Cesarean delivery the safer route for both mother and infant.
Sepsis Mortality: Percent of patients, with a severe infection, who die in the hospital. Most sepsis cases (over 90%) start outside the hospital. Lower percentage of death indicates better survival.
Limitations: Use of discharge/administrative data is limiting since such data has lower specificity for diagnoses than clinical data. In addition, without risk adjustment for differences in patient-specific factors, comparing rates among hospitals is difficult.
30-day Readmission - Hospital-wide All-Cause 30-day Unplanned Readmission Rate: The percentage of patients who were unexpectedly readmitted within 30 days of discharge from the hospital for any reason. Lower values indicates that fewer case were unexpectedly readmitted after discharge.
Limitations: Some, but not all patient-specific risk factors are included in the adjustment of the readmission rate. However, not all relevant risk factors are included (e.g., trauma, emergency procedures).