Christus St Michael Health System


About the Facility

CMS Certification Number (CCN)
45T801
Ownership Type
Non-profit
CMS Region
Dallas
Certification Date
Address
2600 St Michael Dr
Phone Number
(903) 614-1000

Facility Medical Condition Statistics

All other conditions
210
Brain disease or condition (non-traumatic)
27
Brain injury (traumatic)
16
Hip or femur fracture
103
Hip or knee replacement, amputation or other bone or joint condition
141
Nervous system disorder (excluding stroke)
22
Spinal cord disease or condition (non-traumatic)
27
Spinal cord injury (traumatic)
Data not available for this reporting period.
Stroke
86

Facility Quality of Patient Care Measures

Catheter-associated urinary tract infections (CAUTI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
Not Available
SIR 95% confidence interval - upper limit
Not Available
Comparative performance category
Not Available
Catheter days
Not Available
Predicted number of infections (B)
Not Available
Number of infections reported (A)
Not Available
SIR (A/B)
Not Available
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
583
Denominator
583
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
11.6
Denominator
522
Average observed change score
13.2
Change in patients ability to move around
Average risk-adjusted change score
26.0
Denominator
522
Average observed change score
29.1
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
281
Denominator
522
Facility rate
53.8
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
230
Denominator
522
Facility rate
44.1
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
1
Denominator
583
Facility rate
0.2
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
Not Available
SIR 95% confidence interval - upper limit
Not Available
Comparative performance category
Not Available
Patient days
Not Available
Predicted number of infections (B)
Not Available
Number of infections reported (A)
Not Available
SIR (A/B)
Not Available
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
Not Available
Number of health care workers
Not Available
Rate of flu vaccination
Not Available
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
Not Available
Number of eligible stays
Not Available
Unadjusted potentially preventable readmission rate
Not Available
Risk-standardized potentially preventable readmission rate (RSRR)
Not Available
Lower limit of the 95% confidence interval on the RSRR
Not Available
Upper limit of the 95% confidence interval on the RSRR
Not Available
Comparative performance category
Not Available
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
Not Available
Number of eligible stays
Not Available
Unadjusted potentially preventable readmission rate
Not Available
Risk-standardized potentially preventable readmission rate (RSRR)
Not Available
Lower limit of the 95% confidence interval on the RSRR
Not Available
Upper limit of the 95% confidence interval on the RSRR
Not Available
Comparative performance category
Not Available
Rate of successful return to home or community from an IRF
Observed number of discharges to community (DTC)
Not Available
Number of eligible stays
Not Available
Observed discharge to community rate
Not Available
Risk-standardized discharge to community rate
Not Available
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
Not Available
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
Not Available
Comparative performance category
Not Available
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
Not Available
Number of eligible episodes
Not Available
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
581
Denominator
583
Facility rate
99.7
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
0
Denominator
581
Facility observed rate
0.0
Facility risk-adjusted rate
0.0
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
223
Number of health care workers
328
Rate of COVID-19 vaccination
68.0