CALIFORNIA PACIFIC MEDICAL CTR - ST. LUKE'S CAMPUS (SAN FRANCISCO, CA) Detailed Hospital Profile

Use of Medical Imaging

Outpatients with low back pain who had an MRI without trying recommended treatments first, such as physical therapy.

This Hospital:	36.200%
State:	33.932%

Outpatients who had a follow-up mammogram or ultrasound within 45 days after a screening mammogram.

This Hospital:	4.300%
State:	8.180%

Outpatient CT scans of the abdomen that were combination (double) scans.

Here:	0.034%
California:	0.170%

Outpatients who got cardiac imaging stress tests before low-risk outpatient surgery

This Hospital:	5.200%
State:	5.492%

Hospital Consumer Assessment of Healthcare Providers

Number of Completed Surveys:: 300 or more
Survey Response Rate: 22%

How often did nurses communicate well with patients?

Sometimes or never

This Hospital:	8%
California:	7%

Usually

This Hospital:	23%
California:	21%

Always

Here:	69%
State:	72%

How often did doctors communicate well with patients?

Sometimes or never

This Hospital:	8%
State:	6%

Usually

This Hospital:	16%
California:	17%

Always

Here:	76%
California:	77%

How often did patients receive help quickly from hospital staff?

Sometimes or never

Here:	18%
California:	13%

Usually

This Hospital:	26%
State:	28%

Always

This Hospital:	56%
California:	59%

How often was patients' pain well controlled?

Sometimes or never

This Hospital:	9%
California:	8%

Usually

This Hospital:	23%
California:	25%

Always

This Hospital:	68%
California:	67%

How often did staff explain about medicines before giving them to patients?

Sometimes or never

Here:	25%
State:	23%

Usually

Here:	20%
State:	19%

Always

This Hospital:	55%
State:	58%

How often were the patients' rooms and bathrooms kept clean?

Sometimes or never

Here:	13%
State:	10%

Usually

Here:	22%
State:	21%

Always

Here:	65%
California:	69%

How often was the area around patients' rooms kept quiet at night?

Sometimes or never

Here:	18%
State:	18%

Usually

Here:	30%
California:	33%

Always

Here:	52%
California:	49%

Were patients given information about what to do during their recovery at home?

Yes

Here:	78%
California:	81%

Here:	22%
State:	19%

How do patients rate the hospital overall on a scale from 0 (lowest) to 10 (highest)?

6 or lower

This Hospital:	12%
State:	10%

7 or 8

Here:	28%
State:	24%

9 or 10

This Hospital:	60%
State:	66%

Would patients recommend the hospital to friends and family?

This Hospital:	7%
California:	7%

Yes, probably

Here:	30%
State:	24%

Yes, definitely

This Hospital:	63%
California:	69%

Process of Care

Heart Attack

Average number of minutes before outpatients with chest pain or possible heart attack got an ECG

Here:	5
State:	9

Average number of minutes before outpatients with chest pain or possible heart attack were transferred to another hospital

Here:	106
State:	78

Outpatients with chest pain or possible heart attack who got aspirin within 24 hours of arrival

This Hospital:	100.0%
State:	97.2%

Heart Failure

Percent of patients who were given an evaluation of Left Ventricular Systolic Dysfunction (LVSD)

This Hospital:	100.0%
California:	98.9%

Percent of Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD)

Here:	100.0%
State:	96.2%

Percent of Patients Given Discharge Instructions

This Hospital:	96.0%
California:	93.5%

Percent of Patients Given Smoking Cessation Advice/Counseling

This Hospital:	100.0%
State:	99.4%

Pneumonia

Percent of Patients Given Initial Antibiotic(s) within 6 Hours After Arrival

Here:	98.0%
California:	96.1%

Percent of Patients Whose Initial ER Blood Culture Was Performed Prior To Administration Of First Dose Of Antibiotics

Here:	99.0%
State:	96.7%

Percent of Patients Given Smoking Cessation Advice/Counseling

Here:	100.0%
State:	98.1%

Percent of Patients Given the Most Appropriate Initial Antibiotic(s)

This Hospital:	97.0%
California:	95.9%

Percent of Patients Assessed and Given Influenza Vaccination

This Hospital:	94.0%
State:	94.3%

Percent of Patients Assessed and Given Pneumococcal Vaccination

This Hospital:	97.0%
California:	95.8%

Children's Asthma

Percent of Children Who Received Reliever Medication While Hospitalized for Asthma

Here:	100.0%
State:	100.0%

Percent of Children Who Received Systemic Corticosteroid Medication While Hospitalized for Asthma

This Hospital:	100.0%
California:	99.5%

Percent of Children and their Caregivers Who Received a Home Management Plan of Care Document While Hospitalized for Asthma

This Hospital:	79.0%
California:	85.8%

Surgery

Percent of Surgery Patients given an antibiotic at the right time (within one hour before surgery) to help prevent infection

This Hospital:	100.0%
State:	98.1%

Percent of Surgery Patients whose preventive antibiotics were stopped at the right time (within 24 hours after surgery)

This Hospital:	100.0%
State:	96.3%

Percent of Surgery Patients who were given the right kind of antibiotic to help prevent infection

This Hospital:	100.0%
California:	98.2%

Percent of Surgery Patients who got treatment at right time (within 24 hours before or after surgery) to help prevent blood clot

Here:	100.0%
California:	96.0%

Percent of Surgery Patients whose doctors ordered treatments to prevent blood clots after certain types of surgeries

This Hospital:	100.0%
State:	96.9%

Percent of Surgery Patients needing hair removed from the surgical area before surgery who had hair removed using a safer method

This Hospital:	100.0%
State:	99.8%

Percent of Surgery Patients whose urinary catheters were removed on the first or second day after surgery

This Hospital:	100.0%
California:	93.9%

Surgery patients who were taking heart drugs called beta blockers before coming to the hospital, who were kept on them

This Hospital:	100.0%
California:	96.1%

Outpatients having surgery who got an antibiotic at the right time - within one hour before surgery (higher numbers are better)

This Hospital:	98.0%
California:	95.1%

Outpatients having surgery who got the right kind of antibiotic (higher numbers are better)

This Hospital:	100.0%
State:	95.5%

Patients having surgery who were actively warmed in the operating room or whose body temperature was near normal

Here:	100.0%
California:	99.6%

Outcome of Care

30-Day Mortality Rates from Heart Attack

Here:	16.2%
California:	14.9%

30-Day Mortality Rates from Heart Failure

This Hospital:	9.5%
State:	10.9%

30-Day Mortality Rates from Pneumonia

Here:	12.1%
State:	11.7%

30-Day Readmission Rates from Heart Failure

Here:	23.5%
State:	24.4%

30-Day Readmission Rates from Pneumonia

Here:	19.4%
California:	18.3%

Quality Measures

Percent of long-stay high-risk residents with pressure ulcers

Here:	14.0%
State:	7.5%

Percent of long-stay residents who lose too much weight

Here:	8.9%
State:	6.3%

Percent of long-stay residents who have had a catheter inserted and left in their bladder

This Hospital:	14.9%
California:	4.0%

Percent of long-stay residents with a urinary tract infection

This Hospital:	24.4%
State:	6.7%

Percent of long-stay residents who have depressive symptoms

This Hospital:	3.2%
California:	2.4%

Percent of long-stay residents who were physically restrained

This Hospital:	8.9%
State:	3.6%

Percent of long-stay residents assessed and given, appropriately, the seasonal influenza vaccine

This Hospital:	100.0%
California:	93.0%

Percent of long-stay residents assessed and given, appropriately, the pneumococcal vaccine

This Hospital:	100.0%
State:	94.0%

Percent of short-stay residents who self-report moderate to severe pain

Here:	23.5%
State:	21.2%

Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine

Here:	93.6%
California:	81.9%

Percent of short-stay residents assessed and given, appropriately, the pneumococcal vaccine

Here:	89.2%
California:	79.7%

Percent of short-stay residents who newly received an antipsychotic medication

Here:	8.2%
California:	2.2%

Percent of long-stay residents who received an antipsychotic medication

This Hospital:	6.7%
California:	19.0%

Inpatient Prospective Payment System (IPPS) - Medicare Provider Charge Data

Cardiac Arrhythmia and Conduction Disorders with Complications

Average Covered Charges

This Hospital:	$41,073
State:	$39,980

Average Total Payments

This Hospital:	$9,379
State:	$7,146

Number of discharges: 17

Here:	4.28%
State:	1.30%

Cardiac Arrhythmia and Conduction Disorders with Major Complications

Average Covered Charges

Here:	$60,633
California:	$59,369

Average Total Payments

Here:	$13,799
California:	$10,810

Number of discharges: 13

This Hospital:	3.27%
California:	0.79%

Cellulitis without Major Complications

Average Covered Charges

This Hospital:	$33,532
State:	$36,707

Average Total Payments

This Hospital:	$9,153
California:	$7,245

Number of discharges: 18

This Hospital:	4.53%
California:	2.08%

Chronic Obstructive Pulmonary Disease with Major Complications

Average Covered Charges

This Hospital:	$62,310
California:	$58,013

Average Total Payments

Here:	$13,332
State:	$10,305

Number of discharges: 15

Here:	3.78%
State:	2.00%

Diabetes with Complications

Average Covered Charges

Here:	$44,985
California:	$38,964

Average Total Payments

Here:	$9,044
California:	$7,470

Number of discharges: 14

This Hospital:	3.53%
California:	0.69%

Esophagitis, Gastroent and Miscellaneous Digestive Disorders with Major Complications

Average Covered Charges

Here:	$52,468
California:	$55,838

Average Total Payments

Here:	$12,921
California:	$10,485

Number of discharges: 11

This Hospital:	2.77%
California:	0.67%

Esophagitis, Gastroent and Miscellaneous Digestive Disorders without Major Complications

Average Covered Charges

This Hospital:	$60,450
State:	$36,899

Average Total Payments

Here:	$8,964
California:	$6,233

Number of discharges: 13

Here:	3.27%
California:	3.09%

G.I. Hemorrhage with Complications

Average Covered Charges

This Hospital:	$44,905
State:	$46,039

Average Total Payments

Here:	$11,484
California:	$8,685

Number of discharges: 19

This Hospital:	4.79%
State:	1.95%

Heart Failure and Shock with Complications

Average Covered Charges

This Hospital:	$53,913
California:	$47,292

Average Total Payments

This Hospital:	$12,310
State:	$8,831

Number of discharges: 24

Here:	6.05%
State:	2.91%

Heart Failure and Shock with Major Complications

Average Covered Charges

Here:	$59,152
California:	$70,963

Average Total Payments

This Hospital:	$16,503
California:	$13,159

Number of discharges: 14

Here:	3.53%
State:	3.03%

Heart Failure and Shock without Complications

Average Covered Charges

Here:	$37,501
California:	$32,995

Average Total Payments

This Hospital:	$7,669
California:	$5,851

Number of discharges: 11

Here:	2.77%
State:	1.02%

Intracranial Hemorrhage or Cerebral Infarction with Complications

Average Covered Charges

Here:	$80,214
California:	$55,669

Average Total Payments

This Hospital:	$13,588
State:	$9,837

Number of discharges: 11

Here:	2.77%
State:	1.65%

Kidney and Urinary Tract Infections without Major Complications

Average Covered Charges

This Hospital:	$91,695
State:	$36,114

Average Total Payments

This Hospital:	$15,611
California:	$6,728

Number of discharges: 11

Here:	2.77%
State:	2.98%

Major Joint Replacement or Reattachment of Lower Extremity without Major Complications

Average Covered Charges

This Hospital:	$106,047
State:	$88,239

Average Total Payments

This Hospital:	$24,424
State:	$17,187

Number of discharges: 31

This Hospital:	7.81%
State:	6.26%

Misc Disorders of Nutrition, Metabolism, Fluids or Electrolytes without Major Complications

Average Covered Charges

Here:	$46,099
California:	$32,446

Average Total Payments

Here:	$7,748
State:	$5,975

Number of discharges: 15

This Hospital:	3.78%
State:	2.21%

Renal Failure with Complications

Average Covered Charges

This Hospital:	$55,208
California:	$48,439

Average Total Payments

This Hospital:	$11,467
California:	$8,967

Number of discharges: 22

Here:	5.54%
State:	1.90%

Septicemia or Severe Sepsis without Mechanical Ventilation 96+ Hours with Major Complications

Average Covered Charges

Here:	$84,896
State:	$90,173

Average Total Payments

This Hospital:	$20,643
California:	$16,748

Number of discharges: 77

Here:	19.40%
California:	7.21%

Septicemia or Severe Sepsis without Mechanical Ventilation 96+ Hours without Major Complications

Average Covered Charges

Here:	$79,072
California:	$50,385

Average Total Payments

Here:	$14,465
California:	$9,612

Number of discharges: 18

Here:	4.53%
California:	2.35%

Simple Pneumonia and Pleurisy with Complications

Average Covered Charges

Here:	$44,444
California:	$48,755

Average Total Payments

Here:	$10,913
State:	$8,695

Number of discharges: 27

This Hospital:	6.80%
State:	2.75%

Simple Pneumonia and Pleurisy with Major Complications

Average Covered Charges

Here:	$83,823
California:	$70,362

Average Total Payments

Here:	$17,995
California:	$12,496

Number of discharges: 16

Here:	4.03%
California:	1.89%

Complaint Deficiency

Corridor and hallway doors that block smoke
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly located and lighted Exit signs
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Record of quarterly fire drills for each shift under varying conditions
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Properly working alarms on sprinkler valves
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Portable fire extinguishers
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Reasonably accommodate the needs and preferences of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Keep all essential equipment working safely
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide bedrooms that hold no more than 4 residents per room
- Harm: Potential for minimal harm
- Scope: Some
Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that private space is available in the nursing home for resident groups or residents' families to meet
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide housekeeping and maintenance services
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide necessary care and services to maintain the highest well being of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion
- Harm: Minimal harm or potential for actual harm
- Scope: Few
1) Make sure that each resident's drug regimen is free from unnecessary drugs; 2) Each resident's entire drug/medication is managed and monitored to achieve highest well being
- Harm: Minimal harm or potential for actual harm
- Scope: Few
1) Provide 3 meals at regular times; 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Safely provide drugs and other similar products available, which are needed every day and in emergencies, by a licensed pharmacist
- Harm: Minimal harm or potential for actual harm
- Scope: Few
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide bedrooms that hold no more than 4 residents per room
- Harm: Potential for minimal harm
- Scope: Some
Put a bathroom in or next to each resident's room
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Record of quarterly fire drills for each shift under varying conditions
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Proper medical gas storage and administration areas
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Properly installed electrical wiring and equipment
- Harm: Potential for minimal harm
- Scope: Many
Keep each resident free from physical restraints, unless needed for medical treatment
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Keep each resident free from drugs that restrain them, unless needed for medical treatment
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure each resident receives an accurate assessment by a qualified health professional
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses
- Harm: Minimal harm or potential for actual harm
- Scope: Few
1) Make sure that each resident's drug regimen is free from unnecessary drugs; 2) Each resident's entire drug/medication is managed and monitored to achieve highest well being
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Keep all essential equipment working safely
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Provide bedrooms that hold no more than 4 residents per room
- Harm: Potential for minimal harm
- Scope: Some
An approved installation, maintenance and testing program for fire alarm systems
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Some

Hospital Acquired Conditions

Falls and injuries

Here:	0.821%
California:	0.625%

Blood infection from a catheter in a large vein

This Hospital:	0.821%
California:	0.530%

Infection from a Urinary Catheter

Here:	0.410%
California:	0.608%

Severe pressure sores (bed sores)

Here:	0.410%
State:	0.321%

CALIFORNIA PACIFIC MEDICAL CTR - ST. LUKE'S CAMPUS - SAN FRANCISCO, CA

Use of Medical Imaging

Hospital Consumer Assessment of Healthcare Providers

Process of Care

Heart Attack

Heart Failure

Pneumonia

Children's Asthma

Surgery

Outcome of Care

Quality Measures

Inpatient Prospective Payment System (IPPS) - Medicare Provider Charge Data

Complaint Deficiency

Hospital Acquired Conditions

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