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Quality Reports

FloridaHealthFinder.gov allows consumers to compare hospitals, ambulatory surgery centers, health plans, nursing home and prescription drugs on a variety of measure. FloridaHealthFinder also provides information on health insurance, medical  care resources for the uninsured, resources for seniors and much more.

Florida Hospital Fish Memorial President Joe Johnson said, "Florida Hospital Fish Memorial appreciates the services quality control organizations such as CMS (Centers for Medicare & Medicaid Services), Department of Health & Human Services, JCAHO (Joint Commission on Accreditation of Healthcare Organizations), and others give to hospitals. These tools enhance continuous improvement efforts and overall commitment to quality. We will continue to voluntarily report data on the quality of patient care in conjunction with the National Hospital Quality Initiative supported by CMS, an agency of the US Department of Health and Human Services that runs Medicare.

The team at Florida Hospital Fish Memorial is committed to providing the best care to every patient. We believe quality of care leads to quality of life. Although we are proud of the level of care and service we provide, we are always working to improve our excellent record of quality patient care. The CMS Hospital Quality Initiative gives us access to resources and hands-on training to support our quality improvement efforts."

We at FLORIDA HOSPITAL agree that medical decisions should be made by informed consumers and we encourage our neighbors to investigate important information about the quality of care we and other hospitals offer them. To contact us regarding Quality Reporting, email us.

Our mission guides our daily work in that with Christ as our example, we exist to assist in restoring and promoting the health and quality of life of those we serve. Florida Hospital  "Skill to Heal. Spirit to Care."


Current performance improvement initiatives at Florida Hospital Fish Memorial include participation in the National Hospital Quality Alliance. It may be helpful to refer to the following as you view the report:

  • Measure sample size varies with the size of the hospital. Florida Hospital Fish Memorial has 139 beds. Our scores may be impacted by the margin of error that can occur with small sample size for a small hospital versus a larger facility with greater patient volumes. Sample sizes for Heart Attack Care discharge measures may be smaller than expected because patients who are candidates for open heart surgery are stabilized at Florida Hospital Fish Memorial and then transferred to a facility that specializes in interventional cardiac care. Sample sizes also vary, because some patients in a disease category should not receive the standard treatment. For example, a heart attack patient should not receive a beta blocker if he has an allergy or other contraindication to that particular medication. Finally, although the patient may have received the appropriate treatment, it may not have been clearly documented in the medical record.

Quality reports are also available on the Joint Commission web site. Reports can be accessed at JCAHO.org and include a full year of data. Although the reports show that Florida Hospital Fish Memorial compares favorably to other accredited organizations both in the state of Florida and across the country, there is room for improvement. As we continue to focus on better patient outcomes, we have implemented Heart Attack, Heart Failure and Pneumonia order sets that address each component of the CMS and JCAHO quality measures. The order sets were developed by our medical staff to match national best practice standards. Research shows that evidenced-based order sets improve timeliness of care, process efficiency and most importantly, patient outcomes reducing hospital readmissions, medication error and mortality.

Again, thank you for your interest in Florida Hospital Fish Memorial. We are committed to restoring and promoting the health and quality of life of those we serve.

Public Information

E-Mail: complaint@jointcommission.org

Office of Quality Monitoring
(630) 792-5636

Office of Quality Monitoring
The Joint Commission
One Renaissance Boulevard
Oakbrook Terrace, IL 60181

For any questions on how to file your complaint, you may contact the Joint Commission at this toll free U.S. telephone number, (800) 994-6610, 8:30 to 5 pm, Central Time, weekdays.