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St. Francis Medical Center

3630 E. Imperial Highway
Lynwood, California 90262-2636

Survey Submission Date: November 11, 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	PENDING LEAPFROG VERIFICATION This facility's responses are undergoing Leapfrog’s standard data verification process
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	PENDING LEAPFROG VERIFICATION This facility's responses are undergoing Leapfrog’s standard data verification process
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	PENDING LEAPFROG VERIFICATION This facility's responses are undergoing Leapfrog’s standard data verification process
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	PENDING LEAPFROG VERIFICATION This facility's responses are undergoing Leapfrog’s standard data verification process
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	PENDING LEAPFROG VERIFICATION This facility's responses are undergoing Leapfrog’s standard data verification process
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	PENDING LEAPFROG VERIFICATION This facility's responses are undergoing Leapfrog’s standard data verification process

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. more	PENDING LEAPFROG VERIFICATION This facility's responses are undergoing Leapfrog’s standard data verification process
Safe Medication Ordering	Hospitals should enter at least 85% of inpatient medication orders through the CPOE system. more	PENDING LEAPFROG VERIFICATION This facility's responses are undergoing Leapfrog’s standard data verification process
Medication Reconciliation	Hospitals should use a nationally endorsed protocol to track how well they are collecting and maintaining inpatient medication lists. more	PENDING LEAPFROG VERIFICATION This facility's responses are undergoing Leapfrog’s standard data verification process
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. more	PENDING LEAPFROG VERIFICATION This facility's responses are undergoing Leapfrog’s standard data verification process

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	PENDING LEAPFROG VERIFICATION This facility's responses are undergoing Leapfrog’s standard data verification process
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	PENDING LEAPFROG VERIFICATION This facility's responses are undergoing Leapfrog’s standard data verification process
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	PENDING LEAPFROG VERIFICATION This facility's responses are undergoing Leapfrog’s standard data verification process
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	PENDING LEAPFROG VERIFICATION This facility's responses are undergoing Leapfrog’s standard data verification process
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	PENDING LEAPFROG VERIFICATION This facility's responses are undergoing Leapfrog’s standard data verification process

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. more	PENDING LEAPFROG VERIFICATION This facility's responses are undergoing Leapfrog’s standard data verification process
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. more	PENDING LEAPFROG VERIFICATION This facility's responses are undergoing Leapfrog’s standard data verification process
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. more	PENDING LEAPFROG VERIFICATION This facility's responses are undergoing Leapfrog’s standard data verification process
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. more	PENDING LEAPFROG VERIFICATION This facility's responses are undergoing Leapfrog’s standard data verification process
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. more	PENDING LEAPFROG VERIFICATION This facility's responses are undergoing Leapfrog’s standard data verification process

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. more	PENDING LEAPFROG VERIFICATION This facility's responses are undergoing Leapfrog’s standard data verification process
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. more	PENDING LEAPFROG VERIFICATION This facility's responses are undergoing Leapfrog’s standard data verification process
Radiation Dose for Head Scans	Hospitals should have an average radiation dose for routine CT scans of the head that falls within national benchmarks. more	PENDING LEAPFROG VERIFICATION This facility's responses are undergoing Leapfrog’s standard data verification process

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	PENDING LEAPFROG VERIFICATION This facility's responses are undergoing Leapfrog’s standard data verification process

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	PENDING LEAPFROG VERIFICATION This facility's responses are undergoing Leapfrog’s standard data verification process
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	PENDING LEAPFROG VERIFICATION This facility's responses are undergoing Leapfrog’s standard data verification process
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	PENDING LEAPFROG VERIFICATION This facility's responses are undergoing Leapfrog’s standard data verification process
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	PENDING LEAPFROG VERIFICATION This facility's responses are undergoing Leapfrog’s standard data verification process
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	PENDING LEAPFROG VERIFICATION This facility's responses are undergoing Leapfrog’s standard data verification process
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	PENDING LEAPFROG VERIFICATION This facility's responses are undergoing Leapfrog’s standard data verification process
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	PENDING LEAPFROG VERIFICATION This facility's responses are undergoing Leapfrog’s standard data verification process
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	PENDING LEAPFROG VERIFICATION This facility's responses are undergoing Leapfrog’s standard data verification process

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	PENDING LEAPFROG VERIFICATION This facility's responses are undergoing Leapfrog’s standard data verification process
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	PENDING LEAPFROG VERIFICATION This facility's responses are undergoing Leapfrog’s standard data verification process
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	PENDING LEAPFROG VERIFICATION This facility's responses are undergoing Leapfrog’s standard data verification process
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	PENDING LEAPFROG VERIFICATION This facility's responses are undergoing Leapfrog’s standard data verification process

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
Number of Outpatient Department Procedure Rooms
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