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Quality & Safety

The assurance of safe, quality care is fundamental to the vision of St. John's Health. Meeting and exceeding the expectations of our patients and achieving best outcomes are central goals to which all employees at St. John's aspire.

To this end, St. John’s continually monitors various indices of the care received by our patients.Women's Choice Award St. John's Performance Improvement Plan, updated annually, strategically guides the collaborative staff effort to deliver high quality care. Senior leadership committees and the Board of Trustees oversee the organizational efforts.

Patient Safety and Quality Initiatives

  • Computerized Physician Order Entry – St. John’s has implemented Computerized Physician Order Entry (CPOE) for the majority of the medical staff. CPOE provides for patient safety through MD direct ordering of tests/medications and treatments through the computer. Shown to reduce errors related to handwriting or transcription errors.
  • ICU Physician Staffing – The St. John’s ICU is covered 24/7 by employed hospitalist physicians.
  • Safety Culture – Employee Perception of Culture of Safety Assessment completed. Action Plans to increase reporting and address communications issues is in progress. Improvements have been noted.
  • Health Care Safety Initiative – St. John’s has participated in an on-going program from Healthcare Performance Improvement that includes education and implementation of process improvement to reduce the opportunity for error and to improve communication.
  • Medication Reconciliation Process Improvements – Organization wide

Current Quality Core Measure Statistics

We currently measure hospital statistics each month through Core Measures, Patient Satisfaction, and Infection Rates.

Core Measures are specific data that are gathered from medical records. They measure precise areas for which care is rendered and received. Reviewing the St. John's Core Measures on a monthly basis and meeting best practice criteria assure that patients receive the safest, quality care. These measures include Community Acquired Pneumonia (CAP), Acute Myocardial Infarction (AMI), and the Surgical Care Improvement Project (SCIP).

Patient Satisfaction is information collected on surveys that patients receive after visiting St. John’s. This information is compiled by a third-party vendor and analyzed.

The provision of safe care through the infection prevention program is strategic to everyday practice at St. John's. The prevention of infection is a primary goal for all employees. Following guidelines from the Centers for Disease Control (CDC), hand hygiene is closely monitored. Ongoing education with the most up-to-date research for preventing infection and providing the safest patient care is a part of everyday life at SJH. The Infection Control Specialist at St. John's is central to a vital infection prevention program in which all staff is required to participate.

Hospital Compare

The Centers for Medicare & Medicaid Services (CMS) provides detailed statistics on all hospitals and health systems across the country. Find St. John's and our performance metrics on, the official U.S. Government website for Medicare.

St. John's on

National Accreditation

St. John's is nationally accreditated by DNV GL Healthcare. This accreditation is granted to those organizations that demonstrate adherence to strict standards in areas such as Leadership, Performance Improvement, Safety, Environment, Infection Control, Medication Management, Emergency Management, and Rights of the Individual.

DNV can be reached for compliments or complaints at:

  • DNV Website
  • DNV Email
  • Phone: 866-496-9647
  • Fax: 281-870-4818
  • Mail: DNV Healthcare USA Inc.
    Attn: Hospital Complaints
    4435 Aicholtz Road, Suite 900
    Cincinnati, OH 45245

St. John’s is also fully certified by ISO9001, the most widely accepted quality management system in use worldwide.

For more on our safety standards:

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