Quality & Safety

Quality & Safety Awards

Fresno Surgical Hospital is committed to providing our patients with safe, high-quality surgical care. In fact, we have consistently been recognized as a top performer in both the state of California and nationally.

We set extremely high standards for our hospital and staff, and believe quality and safety should be continuously improved upon. That’s why we constantly collect and analyze data to ensure our processes and procedures are as efficient as possible and that the chance of errors is reduced even further.

Since 2005, FSH has earned accreditation from The Joint Commission, a nonprofit agency which surveys and accredits health care organizations every three years. The Joint Commission standards measure hospitals’ performance and ability to provide safe, high-quality care. These standards are regarded as the most rigorous in the industry. FSH is in compliance with the Joint Commission’s National Patient Safety Goals (NPSGs) which target areas such as reducing the risk of healthcare associated infections, preventing wrong site surgery and improving medication safety.

FSH also values feedback from our patients. This feedback is crucial to help us identify strengths and areas for improvement so that we can continue to deliver optimized surgical care to patients throughout the Central Valley.

Fresno Surgical Hospital has earned the following awards and recognition:

  • Achieved 5-Star Rating on a survey of Patients’ Experiences by the Federal Government’s Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) for 2021
  • Awarded Hospital of the Year by Physician Hospitals of America, 2016
  • Earned The Joint Commission’s Gold Seal of Approval – 2005, 2009, 2015
  • Named one of the 101 Hospitals with Great Orthopedic Programs for 2012 by Becker’s Hospital Review
  • Earned the maximum score in compliance with CDC hand-washing guidelines, according to Leapfrog Group benchmark data
  • Named one of 82 Physician Owned Hospitals to Know by Becker’s Hospital Review
  • Ranked number 26 on the 2012 Top 50 Hospitals with the Best Patient Ranking by Becker’s Hospital Review
  • Earned a 89% HCAHPS score in the category: “Would definitely recommend Fresno Surgical Hospital.” (Average scores – CA = 69%, U.S. = 71%)

Patient Satisfaction (HCAHPS)

Our reputation for patient satisfaction is one of the reasons patients and surgeons throughout the Central Valley choose FSH. From our compassionate staff to our hotel-like accommodations, FSH was designed to provide an optimal patient experience. What’s more, we empower every FSH employee to respond to patient concerns or special needs immediately and creatively.

In fact, on a survey of patients’ experiences, FSH was awarded a 5-Star Rating on the Federal Government’s Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) for 2021.

HCAHPS is a national standardized survey that reports on patients’ perspectives of hospital care. On these surveys patients rate hospitals on criteria such as: how well nurses and physicians communicated with them; cleanliness of patient rooms; how quickly they received help when needed; and overall opinion of the hospital, among others.

Below is a partial list of the ways FSH enhances the patient experience:

  • One of the highest nurse-to-patient ratios for surgical care of any hospital in Fresno. This ensures that our patients receive enhanced service. Our nurses respond immediately when the patient rings.
  • Nurses knock before entering a room to accommodate a patient’s dignity and privacy.
  • A registered nurse calls every patient at home before surgery to answer questions they may have about the procedure.
  • A peaceful pre-operative environment is designed to help alleviate anxiety. It includes: dimmed lighting, stereo headsets, reading material and a caring nursing staff focused entirely on preparing the patient for an optimal experience.
  • FSH’s Amenities Program was designed to provide comfort to patients’ family members and loved ones while they wait. A variety of amenities are available for check out including: local pagers (FSH staff will page when the patient is out of surgery), headphones, stationery, and blankets, to name a few. Additionally, refreshments are prepared by FSH’s chef and are available throughout the day.
  • Heated blankets provide enhanced comfort for patients in the recovery room.
  • Luxurious private suites with residential furniture and hotel-like elegance help to create a more relaxing environment. The interior design includes decorative window coverings, wall-to-wall carpeting, original artwork, and beautiful wood moulding.
  • Room-service meals made to order and prepared by a chef are delivered on a beautiful service tray with fresh-cut flowers.
  • Patients’ guests are encouraged to spend the night.
  • Inpatient rooms feature amenities normally found in high-end hotels.

This focus on patient satisfaction has helped FSH earn high ratings from the U.S. Department of Health & Human Services. The department’s HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) is a national survey that asks patients about their experiences during a recent hospital stay.

Fresno Surgical Hospital’s
Patient Survey Rating*

*Federal Government’s Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS)

Reporting period July 2020 – March 2021.

The Centers for Medicaid and Medicare developed an online tool to help consumers evaluate healthcare facilities. Visit Hospital Compare for more information on FSH and other hospitals.

Patient Safety & Regulatory Compliance

Patient safety is a top priority at FSH. As a Joint Commission-accredited hospital, we must meet the Commission’s rigorous safety standards.  We also constantly review and analyze our procedures so that we can continuously improve.  FSH’s safety initiatives include:

Medication Safety

FSH has instituted a Medication Error Reduction Plan to help ensure our patients’ safety. This multi-step plan includes several initiatives such as:

  • A registration procedure that ensures a patient’s medication history is current and accurate each time they enter the hospital. That history is collaboratively reviewed by the patient’s nurse, pharmacist and physician.
  • A specialized procedure developed by a team of nurses, pharmacists, physicians, technicians and information technology staff to separate, label and identify medications that have look-alike or sound-alike names.
  • A standardized process to correctly identify patients which includes the “5 Basic Rights to Medication Safety”:
    • The right patient
    • The right medication
    • The right dose
    • The right time
    • The right route
  • A regular review of our medication processes and procedures to identify weaknesses or deficiencies that could contribute to errors.

Rapid Response Team

FSH’s Rapid Response Teams are groups of clinicians, comprised of doctors, nurses and technicians, who bring critical care expertise to the bedside. Rapid Response Teams are called into action to intervene and care for patients who are showing early signs of deterioration or who become unstable. Rapid Response Teams can identify problems in a timely fashion so that the patient gets the proper medical interventions early in the process before the condition escalates into a critical or life-threatening situation.

Hospital Wide Infection Prevention Task Force

The FSH Hospital Wide Infection Prevention Task Force is a committee that includes front-line staff and leaders from various hospital departments.  This task force meets regularly to discuss risk factors for infections and how each department and individual staff member can be actively involved in infection prevention.

The task force works throughout the hospital to further promote awareness of issues such as the importance of proper environmental cleaning methods, sterilization of surgical instruments, hand hygiene, flu vaccination for all healthcare workers, and proper sterile techniques in our ORs and for medication administration and dressing changes.

The task force also continuously informs staff about the impact that a surgical site infection has on an individual patient in terms of pain, suffering, longer recovery time and financial costs. Then, staff is educated on how they can personally reduce the risk of these infections by strictly adhering to safety procedures.

The national average for hospitals’ infection rates is two percent. FSH’s rate is consistently better than the national average, falling at less than one percent.  Still, we are constantly working to improve even further.

MRSA & Surgical Site Infection Prevention

FSH continuously educates our staff about preventing Methicillin-Resistant Staphylococcus Aureus (MRSA), a type of antibiotic-resistant bacteria, and surgical site infections.  We also regularly review and refine of procedures to ensure our patients are as safe as possible.

The number of MRSA cases is growing nationally. To help combat the increase of this bacteria and to comply with California law (SB 1058) we are taking a proactive approach to help eliminate the spread of MRSA within the hospital through the following methods:

  • Implementation of SB 1058 – Implementing pre-screening rapid MRSA testing for our surgical in-patient population.
  • Continuous use of Universal Standards – Proper hand hygiene and barrier precautions (gloves and gowns when necessary).
  • Installation of easy-to-use hand sanitizers – Throughout Fresno Surgical Hospital there are strategically placed hand sanitizers for the use of our patients, visitors, personnel, and physicians.
  • Monitoring – An on-going program has been created to monitor staff and physician use of proper universal standards and hand hygiene compliance.
  • Surveillance – Conducted monthly with follow-up of all reported infections whether or not they are MRSA-related.

According to the federal Centers for Disease Control and Prevention, surgical site infections occur in two to five percent of all surgeries. However, FSH’s rate of surgical site infections is below the national average.

To reduce the risk of surgical site infection, FSH protocols include:

  • Appropriate pre-op antibiotics before and after surgery
  • Proper hair removal at the surgical site before surgery
  • Maintaining the patient’s body temperature during surgery
  • Fresno Surgical Hospital continues to analyze our data and processes to make improvements where needed

If you have a question or concern regarding patient safety or regulatory compliance, please call our Director of Quality. The information will be kept confidential as regulated by patient privacy laws.

Fresno Surgical Hospital

Katie Shilling, Director of Quality



For more information or to file a concern:

California Department of Public Health

285 W. Bullard Ave., Ste. 101

Fresno, CA 93704

Phone:  559-437-1500


California Department of Public Health

P.O. Box 997413

Sacramento, CA 95899-7413

Phone: 916-445-4171


The Joint Commission

Office of Quality Monitoring

One Renaissance Boulevard

Oakbrook Terrace, Illinois 60181

Email: patientsafetyreport@jointcommission.org

Phone (Toll Free):  800-994-6610

Fax: 630-792-5636


“It was a fantastic experience. The staff is incredible. They were very friendly to both me and my family.” – patient

“If you are going to have surgery, this is the place to have it.” – patient

“I was totally impressed. The room was great. There nurses were there when I needed them. The overall experience was terrific.” – patient

“The surgery gave me my life back.” – patient

“The people really care about taking care of you while you are there.” – patient

“The staff compassion was exceptional. They crossed their T’s and dotted their I’s.” – patient

“The food here is wonderful!” – patient

“The rooms are so nice, it makes you feel like you’re in a hotel.” – patient

“I would come back here in a heartbeat.” – patient

“I was really impressed with the pre-surgery information regarding what to expect in terms of my recovery – both from the doctor and the hospital.” – patient

“It is very easy to recommend Fresno Surgical Hospital to anyone, any day of the week.” – patient

“Best experience I could have ever been through for my procedure! From the moment I arrived I felt in charge, cared for, and cared about by the most amazing staff anyone could dream of. Everyone explained what was going on in detail, offered to answer any questions, and made sure to include my family at all times. I can’t say enough good things about this place!” – patient

“A lot of patients tell me they had a great experience at Fresno Surgical Hospital.” – surgeon

“I trust the nurses. I know they are going to take great care of my patients.” – surgeon

“One of the advantages of Fresno Surgical Hospital is the new technology and surgical equipment.” – surgeon

“The equipment FSH has in the OR is, in my opinion, second to none. It allows complex surgeries to be done here safely and effectively.” – surgeon

“Countless numbers of patients request to have their surgery at Fresno Surgical Hospital for many reasons, like the private rooms, the low nurse-to-patient ratio, and the hotel-like concierge environment. I think that helps with recovery.” – surgeon

“We’re always looking at how we can improve, how we can care better for our patients.” – nurse

“We really treat each patient individually.” – nurse

“We have great team work and a great staff. I’ve had patients tell me, ‘Wow! Everyone is so happy here.’” – nurse

“It’s nice to be part of a team where you know patients are being taken care of. You get to go home and feel good about what you do.”  – nurse

Hospital Compare

The Centers for Medicaid and Medicare developed an online tool, Hospital Compare, to help consumers evaluate healthcare facilities. Hospital Compare provides information regarding the quality of care provided at Medicare-certified hospitals nationwide.  This information can help you determine which hospital is the best choice for your healthcare needs.

Visit Hospital Compare for more information on FSH and other hospitals.

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