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Franciscan Health Rensselaer

Quality Care

Franciscan Health Rensselaer (JCH) strives to provide personal, professional care to all of its patients. In keeping with this goal, JCH participates in an ongoing quality initiative that collects data and reports the findings to the Indiana Hospital & Health Association who in turn distributes the information to multiple regulatory agencies, including the Indiana State Department of Health (ISDH). Data collection includes statistics on many measures of health care and includes the ten indicators requested in the nationwide initiative. These ten measures are included on the ISDH web site. Each measure requires an evaluation of 25 patients or more per quarter for results to be posted. There are many factors that must be met before data can be posted. Admission status and transfers are among these factors. In any given quarter, JCH may not have sufficient numbers of eligible measures to be posted due to the population of the county and the size of the patient base.

Franciscan Health Rensselaer has recently been designated as a Critical Access Hospital. Those hospitals are not required to report the measures. However, to better educate the public and to pursue improved patient care, the Hospital will continue to share the information.

Below you will find a list of agencies that license, certify or accredit JCH. Also listed are the quality initiative activities in which the Hospital participates.



Our Hospital meets or exceeds the licensure, certification or accreditation standards set by the following agencies:

  • Indiana State Department of Health (License/Licensure)

  • Medicare [Centers for Medicare & Medicaid Services (CMS)] (Conditions of Participation)

  • Federal Drug Administration (Pharmacy)

  • Nuclear Regulatory Commission (Nuclear Medicine)

  • Occupational Health and Safety Administration (OSHA)

  • Clinical Laboratory Improvement Act (CLIA) (Laboratory)

  • American Radiologists Association (ARA) (CT and Mammography)

  • Indiana State Fire Marshal

  • Life Safety Code/CMS (Patient safety)

  • Indiana State Board of Accounts (Finance)

Achieving a high level of performance is a daily priority that must be constantly monitored. Our Hospital's quality initiative activities include:

  • Quarterly evaluation of the 10 Quality Assurance Performance Improvement measures, by a multidisciplinary committee.

  • Monthly evaluation of indicators by each Hospital department.

  • Comparative Outcome Profile reviews, quarterly.

  • Quarterly review of indicator information by Hospital Management (HM).

  • Ongoing review of incident reports by administration and the Hospital's liability insurance carrier.

  • Ongoing review of Patient Questionnaires by HM.

  • Annual employee performance reviews by the respective department directors.

  • Nursing Care Plan reviews on all long term and skilled patients, quarterly by committee.

  • Life Safety Review by department directors, quarterly.

If you would like to learn more about Franciscan Health Rensselaer 's commitment to quality care, contact the Community Relations Department at (219) 866-5141, extension 2130, or toll free, (888) 511-5141, extension 2130.


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