St. Rose Hospital believes that every patient should receive quality patient care every time they stay with us. Patients and families know quality care when they experience it. A nurse’s kind gesture in caring for you and your loved ones; a doctor’s bedside manner, the hospital’s healing environment, and getting the patient home safely to continue the healing process—all of these things affect how people feel about the quality of their healthcare.

When hospitals talk about quality, it is generally in reference to very specific clinical data collected and analyzed to ensure that the hospital is compliant to evidence-based standards. There are a number of external agencies and groups have different ways of reporting clinical outcomes that can affect the way they rate a hospital on a certain quality measure.

However, the number one reason for Quality is to improve upon and reduce known risks to ensure safe &happy patients and families.

At St. Rose Hospital, we strive to provide:

  • SAFE: Free of unavoidable and preventable harm
  • EFFECTIVE: Providing services based on scientific knowledge and best practice.
  • TIMELY & EFFICIENT: Avoiding waste and reducing harmful delays for both those who receive and provide care.
  • PATIENT CENTERED: Providing care that is respectful of and responsive to individual patient preferences, needs and values, ensuring those patients’ values guide all clinical decisions.
  • EQUITABLE: Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socio-economic status.

In 2017, our key focus areas in Quality for St. Rose Hospital are as follows:

  • Patient Satisfaction
  • Readmissions Reduction
  • Mortality Reduction
  • Complication of Care Prevention
  • Efficient Use of Medical Imaging
  • Timeliness of Care and Services Improvements

St. Rose Hospital achieves our goals by:

  • Measurement and Trending of Data
  • Risk Management Strategies
  • Performance Optimizing Strategies
  • Use the Plan, Do, Study & Act Methodology

Quality Initiatives

Quality Data & Reporting

St. Rose Hospital is committed to providing the safest environment and the highest standards of quality care for our patients. All quality data is available on the hospital compare website.

At St. Rose Hospital, we are constantly collecting and monitoring data to measure our progress and implementing improvements where needed. We are also dedicated to continuously sharing quality data with the public. Quality is everyone’s business and the public has the right to know what to expect with the quality of their hospital visits. St. Rose Hospital wants to ensure you are well informed about our quality, so we partner with external reporting agencies to externally report & benchmark our success and areas for improvement.

St. Rose Hospital works with and reports data to the following highly recognized organizations to keep you safe and to constantly improve upon our care:

Service Excellence

We at St. Rose Hospital would like to ensure we exceed patient expectations and help to improve their overall hospital experience. Your safety and care at St. Rose Hospital is very important to us. We strongly encourage you to actively participate in your care by asking questions and sharing any concerns you might have.

WE WILL Take Care of You …
Our dedicated staff offers a patient-centered approach that goes beyond just medical treatment. Our goal is to ensure all patients leave St. Rose Hospital satisfied and willing to recommend our services to their family and friends.

If you feel the services we provided have in any way compromised patient safety or did not met the accepted quality of care standards, please contact the unit manager of the department or our Patient Experience Coordinator at (510) 264-4153 to resolve any issues.

If you do not feel these concerns have been adequately addressed after contacting our management team, please feel free to contact The Joint Commission by phone at 800.994.6610 or via e-mail at complaint@jointcommission.org.

You can also write to The Joint Commission at:
Office of Quality Monitoring
The Joint Commission
One Renaissance Boulevard
Oakbrook Terrace, IL 60181

If you feel your mammography concerns have not been adequately addressed by the hospital, you may direct your mammography complaints to:

American College of Radiology
Attn: Accreditation Program Patient Complaints
1891 Preston White Drive
Reston, VA 20191-4397
Fax: (703) 648-9176
Mamm-accred@acr.org (must be in writing)

Radiological Health Branch, Department of Health Services
601 North 7th Street
P.O. Box 997414, MS-7610
Sacramento, CA 94234-7320
Fax: (916) 327-5106 (written or verbal)

Patient Satisfaction Survey
After you are discharged from the hospital, you may be selected to participate in a telephone survey. The surveyor will ask questions about your hospital stay. Please take the time to answer the patient satisfaction survey. Your feedback will allow us to share compliments with our staff and also improve our services.

Infection Prevention and Control

St. Rose Hospital is committed to keeping patients safe from infection. We have a full-time board-certified infection prevention nurse and an infectious disease physician who are dedicated to reducing and preventing healthcare-associated infections (HAIs). Our team is constantly striving to prevent infections by implementing the most current and innovative evidence-based strategies and standards.

Our Data
All hospitals struggle with reducing the incidence of infections but St Rose Hospital continues to have had many successes in reducing infections:

  • ZERO catheter-associated urinary tract infections (CAUTIs) for a full year
  • ZERO post-operative sepsis infections for a full year
  • We have achieved the LOWEST RATE of Clostridium Difficile in over 5 years


These are just a few of our recent successes which highlight our staff’s commitment and dedication to the safety and wellbeing of our patients. For a complete look at our hospital infection data, click here.

Hand Hygiene
Hand hygiene is the best way to prevent spreading germs!

  • Patients and visitors should use the hospital facilities to wash their hands and then disinfect using the alcohol gel from the dispensers. Do not use the bathrooms in patient room.
  • Staff members are required to clean their hands with liquid soap and water or alcohol sanitizer before and after they come into contact with patients and their environment, regardless of whether or not the patients have infections.
  • There are posters and signs around the hospital to remind staff, patients and visitors to keep their hands clean at all times.
  • We use continuous hand hygiene training and audits to regularly check to see that the staff are following the proper hand hygiene policy.
  • If you are worried about staff members forgetting to wash their hands, our hospital encourages patients to remind us – it’s the right thing to do.


Visitors (Protection of Our Loved Ones)
Staying in touch with family and friends is an important part of a patient’s treatment, recovery and overall wellbeing. St. Rose Hospital expects visitors to follow some simple infection control advice to assist in patient recovery and keeping everyone safe:

  • Stay at home if you are sick. Do not visit until you are free of symptoms for at least 48 hours
  • Do not sit on patient beds. Utilize chairs and ask for additional chairs if needed.
  • Children (especially babies) are vulnerable to germs. We encourage you to leave your children at home when visiting patients.
  • The most important time to clean your hands is immediately before you have contact with your friend or relative. Use the hand sanitizers located in and outside of the patient’s room.
  • Clean hands when you are leaving patient care areas.
  • Please follow any additional instructions given to you by unit staff.


Infection Control Officer​ ​- Debra Birce, RN, CIC: (510) 780-4350