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Where We Stand at St. Mary

Where We Stand at St. Mary

Deirdre Donaghy, MD, 
Chief Medical Officer

"Patient Safety is the highest priority at St. Mary Medical Center."  

Welcome to the Quality portion of our website. Our goal is to educate our community about the quality of evidence-based medicine we practice at St. Mary and to inform you of the measures we take to ensure you receive the best care delivered within the highest standards of safety and best practices.

As a result of these efforts, St. Mary is accredited by the Joint Commission and we are in full compliance with all applicable quality and patient safety standards. Moreover, our way is not to simply meet the standards of care, St. Mary is committed to exceeding those benchmarks by providing true service excellence.  We believe that quality and patient safety is broader – encompassing the patient’s total experience with St. Mary.  This involves the patient’s experience either as an inpatient or outpatient, from arrival, through diagnosis and treatment, to post-visit education and counseling.

If, after reviewing the quality and safety information, you want to know more about St. Mary’s plans and programs, please email me or our patient safety officer. We want to hear about your experiences at St. Mary.

The St. Mary way is to ensure that the patient experiences nothing less than the best quality and safest clinical treatment and services possible.

Does St. Mary Medical Center provide safe, quality care?


Overall Appropriate Care


Provided by the Pennsylvania Health Care Quality Alliance, the Appropriate Care Measure is a composite score of multiple indicators assessing the quality of care a hospital provides. The Appropriate Care score takes into consideration quality measures across four topics (heart attack, heart failure, pneumonia and surgical care) and 27 unique treatments. 

In data collected from October 2009 to September 2010, St. Mary Medical Center (97 percent) outperforms average Appropriate Care scores for the Delaware Valley* (92 percent) and the Commonwealth of Pennsylvania (90 percent). 

 *PHCQA defines "Delaware Valley" hospitals as those located within Bucks, Chester, Delaware, Montgomery and Philadelphia counties.



What are patients saying about St. Mary Medical Center?

St. Mary Medical Center works hard to give our patients positive experiences while in our hospital.  And - we're proud to say - it shows. 

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), a nationwide survey process, asks patients to rate their overall hospital experiences on a scale from 1 to 10.  In the most recent HCAHPS report analyzing data collected in 2010, 78 percent of St. Mary pfatients rated their overall experience with our hospital a "9" or "10," with 10 being the highest possible score. 


Patient Ratings: "9" or "10" 

An analysis of the HCAHPS data by the Pennsylvania Health Care Quality Alliance shows that St. Mary outperforms both the averages for all Pennsylvania and Delaware Valley* hospitals with a higher percentage of "9" or "10" ratings.

Sixteen percent of patients rate St. Mary a "7" or "8."   Only 6 percent of patients scored the hospital a "6 or lower." 

*PHCQA defines "Delaware Valley" hospitals as those located within Bucks, Chester, Delaware, Montgomery and Philadelphia counties.


Do patients recommend St. Mary Medical Center to family and friends?


Hospital Recommendation Score

Yes. Eighty-one percent of patients indicate they would recommend the hospital to their friends and family, according to the Pennsylvania Health Care Quality Alliance.  St. Mary outperforms averages from hospitals both within the Delaware Valley* (71 percent) and across the state (67 percent).

In addition, St. Mary Medical Center's score is within one percentage point of the national benchmark - 82 percent - the level at which the top 10 percent of hospitals in the country perform.

*PHCQA defines "Delaware Valley" hospitals as those located within Bucks, Chester, Delaware, Montgomery and Philadelphia counties. This analysis is based on data collected in 2010.


Do St. Mary Medical Center patients have positive outcomes?

The Centers for Medicare and Medicaid track two measures to assess patient outcomes - the 30-day readmission rate and 30-day mortality rate (death rate) for patients receiving treatment for heart attack, heart failure or pneumonia.  These measures use data reflecting patient admissions between 2007 and 2010.  Within each category, CMS assigns one of three descriptors, "No Different than the US National Rate," reflecting the majority of cases, "Better than the US National Rate," or "Worse than the US National Rate."

St. Mary Medical Center's 30-day readmission rate for heart attack, heart failure and pneumonia patients is "no different than the average rate" among hospitals in the nation. 


For "heart attack," "heart failure" and "pneumonia" patients, the mortality rate was "no different than" the national average.

A number of complex circumstances contribute to mortality indicators, including a patient's expressed directives regarding end-of-life care. For more information about critical decisions during end-of-life care, click here.

Does St. Mary give back to the community?

In a word - yes.

In 2011 our community benefit exceeded $16.5 million dollars - our largest investment to date.  To help ensure that these dollars are making the greatest impact and addressing the most pressing and prevalent needs, St. Mary conducted a Community Health Needs Assessment in 2010.  The assessment, "The Key to a Healthy Community" is available on our website at The assessment identifies healthcare gaps and prioritizes the barriers to optimal health in Bucks County, especially among the poor. With this understanding, we can align our resources to integrate health promotion activities, disease prevention programs, and social services to more responsively meet the needs of our community.

  • The St. Mary Mother Bachmann Maternity Center delivered 400 babies in 2011.
  • The St. Mary Children's Health Center provided approximately 3,000 children with primary and preventive healthcare services in 2011.
  • St. Mary Community Ministries, composed of the St. Mary Family Resource Center, Mother Bachmann Maternity Center, and the St. Mary Children's Health Center, provided healthcare and social services to more than 6,000 adults and children in 2011.
  • With St. Mary Medical Center's financial support of over $200,000, the Adult Health Clinic operated by the Bucks County Health Improvement Partnership (BCHIP) provided primary care to over 1,400 uninsured men and women from July 2010 to June 2011.
  • St. Mary Medical Center provided more than $2.8 million in financial assistance to individuals who cannot afford to pay for all or part of their medical care, and more than $6.0 million in uncompensated care for Medicaid recipients in 2011. In addition, we provided $7.6 million in Community Benefit Services.
  • In 2010, St. Mary expanded its service to the frail and elderly to help them continue to live independently through LIFE St. Mary.