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St. Francis Medical Center

3630 E. Imperial Highway
Lynwood, California 90262-2636

Survey Submission Date: August 31, 2020

Facility info, location, and more

Preventing and Responding to Patient Harm

Measure name	Leapfrog’s Standard	Hospital’s Progress
Effective Leadership to Prevent Errors	Hospitals should take meaningful steps to raise awareness about patient safety, hold leadership accountable for reducing unsafe practices, provide resources to implement a patient safety program, and develop systems and structures to support action to improve patient safety. more	ACHIEVED THE STANDARD
	Show more on this hospital’s performance Show less This hospital scored 120.00 out of 120.00 possible points.
Staff Work Together to Prevent Errors	Hospitals should assess their culture of safety and hold leadership accountable for implementing policies, procedures, and staff education to improve the culture of safety. more	ACHIEVED THE STANDARD
	Show more on this hospital’s performance Show less This hospital scored 120.00 out of 120.00 possible points.
Support for Nursing Workforce	Hospitals should assess their nursing staff levels and core competencies, included nurses in leadership, and develop and implement plans to address any areas of improvement. more	ACHIEVED THE STANDARD
	Show more on this hospital’s performance Show less This hospital scored 100.00 out of 100.00 possible points.
Handwashing	Hospitals should regularly monitor hand hygiene practices for everyone interacting with patients, and give feedback to ensure compliance. Hospitals should foster a culture of good hand hygiene, offer training and education, and provide equipment, such as paper towels, soap dispensers, and hand sanitizer. more	NOT AVAILABLE Due to the COVID-19 pandemic, data for this measure is not available
Appropriate Use of Antibiotics	Hospitals should have a program to combat antibiotic over-prescribing that includes all seven (7) core elements developed by the Centers for Disease Control and Prevention (CDC). more	LIMITED ACHIEVEMENT
Responding to Never Events	Hospitals should have a never events policy that includes all nine (9) actions that should occur following a “never event,” which includes apologizing to the patient and not charging for costs associated with the never event. more	ACHIEVED THE STANDARD

Medication Safety

Measure name

Leapfrog’s Standard

Hospital’s Progress

Safe Medication Administration

Hospitals should have nurses and other clinicians use BCMA in all medical/surgical units, intensive care units, and labor and delivery units to scan the patient and medication prior to administration at least 95% of the time. The BCMA system includes decision support to prevent errors and the hospital has processes to prevent workarounds.

ACHIEVED THE STANDARD

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Safe Medication Ordering

Hospitals should enter at least 85% of inpatient medication orders through the CPOE system.

CONSIDERABLE ACHIEVEMENT

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Medication Reconciliation

Hospitals should use a nationally endorsed protocol to track how well they are collecting and maintaining inpatient medication lists.

ACHIEVED THE STANDARD

Medication Documentation for Elective Outpatient Procedure Patients

Hospitals should document 90% or more of home medications, visit medications, and allergies/adverse reaction(s) in the patients’ clinical record.

LIMITED ACHIEVEMENT

Healthcare Associated Infections

Measure name	Leapfrog’s Standard	Hospital’s Progress
Infection in the Blood	Hospitals should have fewer than expected central-line associated blood stream infections. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC’s National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given various factors. A number lower than one means fewer infections than expected; a number more than one means more infections than expected. more	ACHIEVED THE STANDARD
	Show more on this hospital’s performance Show less This hospital’s standardized infection ratio (SIR) is: 0.000
Infection in the Urinary Tract	Hospitals should have fewer than expected catheter-associated urinary tract infections. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC’s National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given various factors. A number lower than one means fewer infections than expected; a number more than one means more infections than expected. more	CONSIDERABLE ACHIEVEMENT
	Show more on this hospital’s performance Show less This hospital’s standardized infection ratio (SIR) is: 0.460
C. difficile Infection	Hospitals should have fewer than expected colon infections from C. diff bacteria. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC’s National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given various factors. A number lower than one means fewer infections than expected; a number more than one means more infections than expected. more	CONSIDERABLE ACHIEVEMENT
	Show more on this hospital’s performance Show less This hospital’s standardized infection ratio (SIR) is: 0.690
MRSA Infection	Hospitals should have fewer than expected antibiotic resistant bacterial infections. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC’s National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given various factors. A number lower than one means fewer infections than expected; a number more than one means more infections than expected. more	LIMITED ACHIEVEMENT
	Show more on this hospital’s performance Show less This hospital’s standardized infection ratio (SIR) is: 1.628
Surgical Site Infection After Colon Surgery	Hospitals should have fewer than expected surgical site infections after major colon surgery. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC’s National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given various factors. A number lower than one means fewer infections than expected; a number more than one means more infections than expected. more	ACHIEVED THE STANDARD
	Show more on this hospital’s performance Show less This hospital’s standardized infection ratio (SIR) is: 0.347

Maternity Care

Measure name

Leapfrog’s Standard

Hospital’s Progress

Cesarean Sections

This is defined as first-time mothers giving birth to a single baby, at full-term, in the head-down position deliver their babies through a C-section. Hospitals should have a rate of C-sections of 23.9% or less.

CONSIDERABLE ACHIEVEMENT

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Early Elective Deliveries

This is defined as mothers being scheduled for cesarean sections or medication inductions prior to 39 weeks gestation without a medical reason. Hospitals should have a rate of early elective deliveries of 5% or less.

ACHIEVED THE STANDARD

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Episiotomies

This is defined as mothers having an incision made in the perineum (the birth canal) during childbirth. Hospitals should have a rate of episiotomies of 5% or less.

ACHIEVED THE STANDARD

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Maternity Care Processes

Hospitals should screen at least 90% of babies for jaundice and at least 90% of women undergoing a cesarean section receive treatment to prevent blood clots.

ACHIEVED THE STANDARD

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High-Risk Deliveries

Hospitals should deliver at least 50 very-low birth weight babies per year and ensure that at least 90% of mothers receive antenatal steroids prior to delivery OR the hospital must maintain a lower-than-average morbidity/mortality rate for very-low birth weight babies and ensure that at least 90% of mothers receive antenatal steroids prior to delivery.

SOME ACHIEVEMENT

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More Information

Number of Live Births

The hospital had 4,159 live births (i.e., liveborn infants) at this hospital location for the reporting time period.

Pediatric Care

Measure name

Leapfrog’s Standard

Hospital’s Progress

Experience of Children and Their Parents

Hospitals should perform better than most hospitals in five (5) areas:

Communication with Parent – Communication about your child’s medicines
Communication with Parent – Keeping you informed about your child’s care
Communication with Child – How well nurses communicate with your child
Communication with Child – How well doctors communicate with your child
Attention to Safety and Comfort – Preventing mistakes and helping you report concerns.

LIMITED ACHIEVEMENT

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There are 18 domains in the CAHPS Child Hospital Survey. Performance on the following five domains make up a hospital’s score on Leapfrog’s “Experience of Children and their Parents” measure. “Top Box Score” represents the percentage of respondents who gave the most favorable response.

CAHPS Child Hospital Survey Domain	Top Box Score
Communication with Parent – Communication about your child’s medicines
Communication with Parent – Keeping you informed about your child’s care
Communication with Child – How well nurses communicate with your child
Communication with Child – How well doctors communicate with your child
Attention to Safety and Comfort – Preventing mistakes and helping you report concerns

Although the other 13 domains are not included in a hospital’s score for this measure, outlined below is how this hospital performed on the remainder of the domains on the CAHPS Child Hospital Survey.

CAHPS Child Hospital Survey Domain	Top Box Score
Communication with Parent – Communication between you and your child’s nurses
Communication with Parent – Communication between you and your child’s doctors
Communication with Parent – Privacy when talking with doctors, nurses, and other providers
Communication with Parent – Preparing you and your child to leave the hospital
Communication with Parent – Keeping you informed about your child’s care in the Emergency Room
Communication with Child – Involving teens in their care
Attention to Safety and Comfort – Responsiveness to the call button
Attention to Safety and Comfort – Helping your child feel comfortable
Attention to Safety and Comfort – Paying attention to your child’s pain
Hospital Environment – Cleanliness of hospital room
Hospital Environment – Quietness of hospital room
Global Rating – Overall rating
Global Rating – Recommend hospital

Radiation Dose for Abdomen/Pelvis Scans

Hospitals should use a CT radiation dose for routine CT scans of the abdomen and pelvis that falls within national benchmarks.

LIMITED ACHIEVEMENT

Radiation Dose for Head Scans

Hospitals should have an average radiation dose for routine CT scans of the head that falls within national benchmarks.

LIMITED ACHIEVEMENT

Critical Care

Measure name	Leapfrog’s Standard	Hospital’s Progress
Specially Trained Doctors Care for Critical Care Patients	Hospitals should have intensivists present on-site at least eight hours a day, seven days per week or has intensivists present via 24/7 telemedicine with some on-site intensivist presence. When not in the ICU, the intensivist immediately responds to calls and has another physician or trained clinician who can immediately reach the patient. more	CONSIDERABLE ACHIEVEMENT
	Show more on this hospital’s performance Show less This hospital achieved the standard using on-site intensivist coverage.

Complex Adult Surgery

Measure name	Leapfrog’s Standard	Hospital’s Progress
Carotid Artery Surgery	Hospitals should perform at least 20 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 10 procedures annually. more	SOME ACHIEVEMENT
	Show more on this hospital’s performance Show less This hospital performed 9 carotid artery surgeries compared to Leapfrog’s standard of 20 procedures annually. As part of their process for privileging surgeons, this hospital does ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 10 procedures annually for carotid artery surgery. Additionally, this hospital does have protocols in place to ensure that carotid artery surgeries are only performed on patients that meet defined criteria.
Mitral Valve Repair and Replacement	Hospitals should perform at least 40 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 20 procedures annually. more	LIMITED ACHIEVEMENT
	Show more on this hospital’s performance Show less This hospital performed 1 mitral valve repairs and replacements compared to Leapfrog’s standard of 40 procedures annually. As part of their process for privileging surgeons, this hospital does not ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 20 procedures annually for mitral valve repair and replacement. Additionally, this hospital does have protocols in place to ensure that mitral valve repairs and replacements are only performed on patients that meet defined criteria.
Open Aortic Procedures	Hospitals should perform at least 10 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 7 procedures annually. more	DOES NOT APPLY
Bariatric Surgery for Weight Loss	Hospitals should perform at least 50 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 20 procedures annually. more	SOME ACHIEVEMENT
	Show more on this hospital’s performance Show less This hospital performed 16 bariatric surgeries for weight loss compared to Leapfrog’s standard of 50 procedures annually. As part of their process for privileging surgeons, this hospital does ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 20 procedures annually for bariatric surgeries for weight loss. Additionally, this hospital does have protocols in place to ensure that bariatric surgery for weight loss is only performed on patients that meet defined criteria.
Esophageal Resection for Cancer	Hospitals should perform at least 20 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 7 procedures annually. more	SOME ACHIEVEMENT
	Show more on this hospital’s performance Show less This hospital performed 1 esophageal resections for cancer compared to Leapfrog’s standard of 20 procedures annually. As part of their process for privileging surgeons, this hospital does ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 7 procedures annually for esophageal resection for cancer. Additionally, this hospital does indicate having a multidisciplinary tumor board that prospectively reviews cancer cases to ensure that esophageal resections for cancer are only performed on patients that meet defined criteria.
Lung Resection for Cancer	Hospitals should perform at least 40 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 15 procedures annually. more	SOME ACHIEVEMENT
	Show more on this hospital’s performance Show less This hospital performed 4 lung resections for cancer compared to Leapfrog’s standard of 40 procedures annually. As part of their process for privileging surgeons, this hospital does ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 15 procedures annually for lung resection for cancer. Additionally, this hospital does indicate having a multidisciplinary tumor board that prospectively reviews cancer cases to ensure that lung resections for cancer are only performed on patients that meet defined criteria.
Pancreatic Resection for Cancer	The hospital performs at least 20 procedures annually, and as part of their process for privileging surgeons, ensures that each surgeon performs at least 10 procedures annually. more	DOES NOT APPLY
Rectal Cancer Surgery	Hospitals should perform at least 16 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 6 procedures annually. more	LIMITED ACHIEVEMENT
	Show more on this hospital’s performance Show less This hospital performed 4 rectal cancer surgeries compared to Leapfrog’s standard of 16 procedures annually. As part of their process for privileging surgeons, this hospital does not ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 6 procedures annually for rectal cancer surgery. Additionally, this hospital does indicate having national accreditation from the American College of Surgeons or a multidisciplinary tumor board that prospectively reviews cancer cases to ensure that rectal cancer surgery is only performed on patients that meet defined criteria.

Care for Elective Outpatient Surgery Patients

Measure name	Leapfrog’s Standard	Hospital’s Progress
Elective Outpatient Surgery Recovery Staffing - Adult	Hospitals should ensure that a specially certified clinician and at least one physician or nurse anesthetist are present and immediately available while an adult patient is present until discharge. more	ACHIEVED THE STANDARD
Elective Outpatient Surgery Recovery Staffing - Pediatric	Hospitals should ensure that a specially certified clinician and at least one physician or nurse anesthetist are present and immediately available while a pediatric patient is present until discharge. more	ACHIEVED THE STANDARD
Safe Surgery Checklist - Elective Outpatient Surgery	Hospitals should go through all the elements of a complete safe surgery checklist on all patients every time a procedure is performed. more	ACHIEVED THE STANDARD
Experience of Patients Undergoing Elective Outpatient Surgery	Hospitals should perform better than most on four (4) areas including: (a) rating facilities and staff (b) communication about the procedure, (c) patients’ overall rating of the facility, and (d) patients willingness to recommend the facility. more	LIMITED ACHIEVEMENT

More Information

Patient Consent for Elective Outpatient Surgeries

The hospital provides written surgical consent forms 1-3 days prior to their procedure.

Patient Consent to Anesthesia for Elective Outpatient Surgeries

The hospital provides written anesthesia consent forms the day of their procedure.

Patient Selection

The hospital has a screening protocol to determine whether a patient’s procedure can safely be performed on an outpatient basis, and the protocol includes the following components:

History of difficult intubation	Yes
Difficult airway/aspiration risk	Yes
Body Mass Index (BMI)	Yes
American Society of Anesthesiologists (ASA) Physical Status Classification	Yes
Recent Medical History (within 30 days of scheduled procedure)	Yes
Cognitive Assessment	Yes
Sleep Apnea Assessment	Yes
Availability of transportation following discharge	Yes
Availability of a caregiver following discharge	Yes

Board Certification - Physician

Most (>=75%) physicians at this hospital who are authorized to perform procedures are board certified or board eligible

Board Certification - Anesthesiologist

Most (>=75%) of those providing anesthesia at this hospital who are authorized to perform procedures are board certified or board eligible

Elective Outpatient Surgery - Adult

Experts agree that patients often have better outcomes when their procedure is performed by a surgeon and surgical teams with adequate, ongoing experience performing a particular procedure. However, Leapfrog has not yet established minimum hospital or surgeon volume standards.

Dermatology (Skin)

Procedure		Number of Procedures Performed Annually
Complex Skin Repairs		1,345

Gastroenterology (Stomach and Digestive)

Procedure		Number of Procedures Performed Annually
Upper GI Endoscopies		633
Lower GI Endoscopies		1,612

General Surgery

Procedure		Number of Procedures Performed Annually
Cholecystectomies and Common Duct Explorations		159
Excisions of Skin Lesions		171
Hemorrhoid Procedures		18
Inguinal and Femoral Hernia Repairs		116
Laparoscopies		15
Lumpectomies or Quadrantectomies of Breast Procedures		76
Mastectomies		19
Other Hernia Repairs		124
Skin Grafts		162

Neurosurgery

Procedure		Number of Procedures Performed Annually
Spinal Fusions		1

Obstetrics and Gynecology

Procedure		Number of Procedures Performed Annually
Cervix Procedures		46
Hysteroscopies		94
Uterus and Adnexa Laparoscopies		126

Ophthalmology (Eyes)

Procedure		Number of Procedures Performed Annually
Anterior Segment Eye Procedures		193
Posterior Segment Eye Procedures		68

Orthopedic (Bones and Joints)

Procedure		Number of Procedures Performed Annually
Finger, Hand, Wrist, Forearm, and Elbow Procedures		115
General Orthopedic Procedures		1
Knee Procedures		58
Shoulder Procedures		139
Toe, Foot, Ankle, and Leg Procedures		32

Otolaryngology (Ear, Nose, Mouth, and Throat)

Procedure		Number of Procedures Performed Annually
Ear Procedures		71
Mouth Procedures		10
Nasal/Sinus Procedures		86
Pharynx/Adenoid/Tonsil Procedures		22

Plastic and Reconstructive Surgery

Procedure		Number of Procedures Performed Annually
Breast Repairs or Reconstructions		41
Musculoskeletal Grafts or Implants		3

Urology (Urinary Tract, Male Reproductive)

Procedure		Number of Procedures Performed Annually
Circumcisions		15
Cystourethroscopies		71
Male Genital Procedures		9
Male Sterilization Procedures		8

Elective Outpatient Surgery - Pediatric

Ophthalmology (Eyes)

Procedure		Number of Procedures Performed Annually
Anterior Segment Eye Procedures		5

Orthopedic (Bones and Joints)

Procedure		Number of Procedures Performed Annually
Finger, Hand, Wrist, Forearm, and Elbow Procedures		36
General Orthopedic Procedures		2
Knee Procedures		1
Shoulder Procedures		7
Toe, Foot, Ankle, and Leg Procedures		9

Otolaryngology (Ear, Nose, Mouth, and Throat)

Procedure		Number of Procedures Performed Annually
Ear Procedures		45
Nasal/Sinus Procedures		9
Pharynx/Adenoid/Tonsil Procedures		18

Urology (Urinary Tract, Male Reproductive)

Procedure		Number of Procedures Performed Annually
Circumcisions		19
Male Genital Procedures		3

St. Francis Medical Center

3630 E. Imperial Highway
Lynwood, California 90262-2636

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More Information

Teaching Hospital Status:	Teaching
Transfer Agreements for Outpatient Department Operating Rooms	Does Not Apply
Number of Outpatient Department Operating Rooms	9
Number of Outpatient Department Procedure Rooms	3
Number of acute-care beds:	314
Number of ICU beds:	36
Number of Adult Admissions	18165
Number of Pediatric Admissions	888
Number of ICU Admissions	2297
Number of NICU Admissions	530
Nursing Magnet Status:	No

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