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Quality Report
University of North Carolina HospitalsHCO ID: 6478101 Manning DriveChapel Hill, NC, 27514(984) 974-3041w w w.unchealthcare.org
Summary of Quality Information
Accreditation Programs
View Accreditation History
Behavioral HealthCare
AccreditationDecisionAccredited
EffectiveDate8/17/2016
Last Full SurveyDate8/16/2016
Last On-SiteSurvey Date8/16/2016
Home Care AccreditationDecisionAccredited
EffectiveDate8/18/2016
Last Full SurveyDate8/17/2016
Last On-SiteSurvey Date8/17/2016
Hospital AccreditationDecisionAccredited
EffectiveDate10/1/2016
Last Full SurveyDate8/19/2016
Last On-SiteSurvey Date9/30/2016
© 2016 The Joint Commission, All Rights Reserved.
Advanced Certification Programs
View Certification History
AdvancedComprehensiveStroke Center
CertificationDecisionCertification
EffectiveDate12/13/2014
Last Full SurveyDate1/24/2017
Last On-SiteSurvey Date1/24/2017
Ventricular AssistDevice
CertificationDecisionCertification
EffectiveDate11/9/2016
Last Full SurveyDate11/8/2016
Last On-SiteSurvey Date11/8/2016
Sites
Alcohol & Substance AbuseProgram, UNC Hospitals1101 Weaver Dairy Road, Suite 103Chapel Hill, NC, 27514
Available Services
Chemical Dependency (Non 24 HourCare - Adult )Chemical Dependency (Non 24 HourCare - Child/Youth )Peer Support (Non 24 Hour Care )
Alcohol and DrugDetoxification Unit atWakeBrook, UNC HealtSuite A, 107 Sunnybrook Rd.Raleigh, NC, 27610
Available Services
Behavioral Health (Residential Care -Adult )Case Management (Non 24 HourCare - Adult )Community Integration (Non 24 HourCare )Family Support (Non 24 Hour Care )
Ambulatory Care Clinics, UNCHospitals102 Mason Farm Rd.Chapel Hill, NC, 27599
Available Services
Outpatient Clinics (Outpatient )
Other Clinics/Practices Locatedat This Site:
ACC Orthopaedic Radiology, UNCHospitalsACC Physical Therapy, UNCHospitalsACC Radiology, UNC Hospitals
© 2016 The Joint Commission, All Rights Reserved.
Hand Rehabilitation Center, UNCHospitalsKidney and HypertensionSpeciality Clinic, UNC HospitalsMcLendon Lab, UNC HospitalsOutpatient Pharmacy, UNCHospitals
Ambulatory Surgical Center,UNC Hospitals102 Mason Farm RoadChapel Hill, NC, 27514
Available Services
Administration of Blood Product(Outpatient )Administration of High RiskMedications (Outpatient )Ambulatory Surgery Center(Outpatient )Anesthesia (Outpatient )Perform Invasive Procedure(Outpatient )
Benign Hematology Clinic ,UNC Hospitals6013 Farrington Road, Suite 201Chapel Hill, NC, 27517
Available Services
Outpatient Clinics (Outpatient )
Burlington Imaging and BreastCenter, UNC Hospitals1225 Huffman Mill RoadChapel Hill, NC, 27515
Available Services
Outpatient Clinics (Outpatient )
Burn Reconstruction andAesthetics Center, UNC HealthCareDBA: Burn Reconstruction andAesthetics Center151 Old University Station Rd.Chapel Hill, NC, 27514
Available Services
Anesthesia (Outpatient )Perform Invasive Procedure(Outpatient )Single Specialty Practitioner(Outpatient )
Cardiac Rehabilitation, UNCHospitalsMeadowmont Village, 100 Sprunt
Available Services
Outpatient Clinics (Outpatient )
© 2016 The Joint Commission, All Rights Reserved.
StreetChapel Hill, NC, 27517
Carolina Pointe II OrthopaedicRadiology, UNC Hospitals6011 Farrington Rd, Suite 201Chapel Hill, NC, 27517
Available Services
Single Specialty Practitioner(Outpatient )
Carolina Pointe II Radiology,UNC HospitalsCarolina Pointe II, 6013 FarringtonRoad, Ste. 102Chapel Hill, NC, 27517-8822
Available Services
Single Specialty Practitioner(Outpatient )
Center for Rehabilitation Care,UNC Hospitals1807 North Fordham Blvd.Chapel Hill, NC, 27516
Available Services
Outpatient Clinics (Outpatient )
Comprehensive CancerSupport Program, UNCHospitalsDBA: CCSP170 Manning Drive, CB#7305Chapel Hill, NC, 27599-7305
Available Services
Outpatient Clinics (Outpatient )
Comprehensive CancerSupport Program, UNCHospitalsDBA: CCSP6011 Farrington RoadChapel Hill, NC, 27517
Available Services
Outpatient Clinics (Outpatient )
Diabetes & Endocinology Clinicat Meadowmont, UNCHospitals300 Meadowmont Village Circle,Suite 202Chapel Hill, NC, 27517
Available Services
Single Specialty Practitioner(Outpatient )
© 2016 The Joint Commission, All Rights Reserved.
Endoscopy Center, UNCHospitals300 Meadowmont Village, Suite 335Chapel Hill, NC, 27517
Available Services
Administration of High RiskMedications (Outpatient )Ambulatory Surgery Center(Outpatient )Anesthesia (Outpatient )Perform Invasive Procedure(Outpatient )
Facility Based Crisis atWakebrook, UNC Health CareSuite B, 107 Sunnybrook Rd.Raleigh, NC, 27609
Available Services
Behavioral Health (Residential Care -Adult )Case Management (Non 24 HourCare - Adult )
Other Clinics/Practices Locatedat This Site:
UNC Hospital at WakebrookPharmacy
Geriatric Specialty Clinic, UNCHospitalsCarolina Point II, 6011 FarringtonRoad, Suite 101Chapel Hill, NC, 27514
Available Services
Single Specialty Practitioner(Outpatient )
GI Medicine Clinic, UNCHospitals5915 Farrington Road, Suite 105Chapel Hill, NC, 27517
Available Services
Single Specialty Practitioner(Outpatient )
GI Procedures at Hillsborough,UNC Health Care460 Waterstone DriveHillsborough, NC, 27278
Available Services
Administration of High RiskMedications (Outpatient )Anesthesia (Outpatient )Outpatient Clinics (Outpatient )Perform Invasive Procedure(Outpatient )
Hearing and Voice Center, UNCHospitalsCarolina Crossing, 2226 Nelson
Available Services
Outpatient Clinics (Outpatient )
© 2016 The Joint Commission, All Rights Reserved.
Hwy, Suite 100Chapel Hill, NC, 27514
Heart & Vascular Center, UNCHospitals300 Meadowmont Village Circle,Suite 301Chapel Hill, NC, 27517
Available Services
Administration of High RiskMedications (Outpatient )Outpatient Clinics (Outpatient )Perform Invasive Procedure(Outpatient )
Other Clinics/Practices Locatedat This Site:
Cardiovascular Studies, UNCHospitalsMeadowmont Peripheral VascularLab, UNC HospitalsVascular Interventional Radiology,UNC Hospitals
Home Health, UNC Hospitals1101 Weaver Dairy Road Suite 200Chapel Hill, NC, 27514
Available Services
Home Health AidesHome Health, Non-Hospice ServicesHospice CareMedical Social ServicesOccupational TherapyPhysical TherapySkilled Nursing ServicesSpeech Language Pathology
Homecare Specialists, UNCHospitals4400 Emperor Blvd.Durham, NC, 27703
Available Services
Canes and CrutchesClinical RespiratoryCommodesContinuous Passive Motion (CPM)DeviceContinuous Positive AirwayPressureDurable Medical EquipmentEnteral Equipment and/or SuppliesEnteral NutrientsExternal Infusion Pump SuppliesExternal Infusion PumpsGastric Suction PumpsHospital Beds - ElectricHospital Beds - ManualNebulizers EquipmentNegative Pressure WoundOxygen
Other Clinics/Practices Locatedat This Site:
Pharmacy
© 2016 The Joint Commission, All Rights Reserved.
Parenteral Equipment and/orSuppliesParenteral NutrientsPatient Lifts and AccessoriesPharmacy/Dispensary,GeneralServicesPower Operated Vehicles (orscooters)Power WheelchairsProsthetics (Home MedicalEquipment)Respiratory Assist DevicesRespiratory EquipmentSeat Lift MechanismsSuction PumpSuppliesSupport Surfaces for Beds (New)Tens UnitsTracheostomy SuppliesUltaviolet Light DevicesWalkers, Canes and CrutchesWheelchair Seating / CushionsWheelchairs - Manual Non-CustomWheelchairs-Standard ManualRelated Accessories and Repairs
Imaging and Spine Center, UNCHospitals1350 Raleigh RoadChapel Hill, NC, 27517
Available Services
Anesthesia (Outpatient )Outpatient Clinics (Outpatient )Perform Invasive Procedure(Outpatient )
Other Clinics/Practices Locatedat This Site:
Occupational Therapy/PhysicalTherapy, UNC HospitalsSpine Center and NeurosurgeryClinic, UNC Hospitals
McCreary Cancer Center, AService of UNC Hospitals212 Mulberry Street, SWLenoir, NC, 28645
Available Services
Administration of Blood Product(Outpatient )Administration of High RiskMedications (Outpatient )Outpatient Clinics (Outpatient )
N.C. Children's Specialty Clinic, Available Services
© 2016 The Joint Commission, All Rights Reserved.
UNC Hospitals4414 Lake Boone Trail, Ste 505Raleigh, NC, 27607
Outpatient Clinics (Outpatient )
Neurology Clinic, UNCHospitals194 Finley Golf Course RdChapel Hill, NC, 27517
Available Services
Single Specialty Practitioner(Outpatient )
Occupational Therapy/PhysicalTherapy Clinic, UNC HospitalsDBA: OccupationalTherapy/Physical Therapy ClinicCarolina Pointe II, 6013 FarringtonRoad, Ste.301, Bldg.200Chapel Hill, NC, 27517
Available Services
Outpatient Clinics (Outpatient )
Oncology Services, UNCHospitalsHillsborough Campus, 460Waterstone DriveHillsborough, NC, 27278
Available Services
Administration of High RiskMedications (Outpatient )Single Specialty Practitioner(Outpatient )
Pain Management Clinic, UNCHospitalsSouthern Village- 410 Market St,Suite 362.Chapel Hill, NC, 27516
Available Services
Outpatient Clinics (Outpatient )
Pittsboro Business Center -Hospice, UNC HospitalsDBA: UNC Hospice480 Hillsboro Street, Suite 800Pittsboro, NC, 27312
Rheumatology Specialty Clinic,UNC Hospitals6013 Farrington Road, Building 200,Suite 301
Available Services
Administration of High RiskMedications (Outpatient )
© 2016 The Joint Commission, All Rights Reserved.
Chapel Hill, NC, 27514 Outpatient Clinics (Outpatient )
Therapeutic Infusion Center,UNC Hospitals6013 Farrington Rd., Suite 201Chapel Hill, NC, 27517
Available Services
Single Specialty Practitioner(Outpatient )
UNC Hospitals at Wakebrook111 Sunnybrook Rd.Raleigh, NC, 27609
Available Services
Behavioral Health (24-hour AcuteCare/Crisis Stabilization - Adult )Community Integration (Non 24 HourCare )Family Support (Non 24 Hour Care )
Other Clinics/Practices Locatedat This Site:
UNC Health Care at Wake BrookPharmacy
UNC Hospitals Family MedicineRadiologyDBA: Family Medicine Radiology590 Manning Drive, Room 184Chapel Hill, NC, 27599
Available Services
Single Specialty Practitioner(Outpatient )
Other Clinics/Practices Locatedat This Site:
UNC Hospitals Family MedicineCenter Laboratory
UNC Hospitals HillsboroughCampus430 Waterstone DriveHillsborough, NC, 27278
Available Services
CT Scanner (Imaging/DiagnosticServices )EEG/EKG/EMG Lab(Imaging/Diagnostic Services )Gastroenterology (Surgical Services)Gynecological Surgery (SurgicalServices )Inpatient Unit (Inpatient )Magnetic Resonance Imaging(Imaging/Diagnostic Services )Medical /Surgical Unit (Inpatient )Medical ICU (Intensive Care Unit )Neurosurgery (Surgical Services )Nuclear Medicine(Imaging/Diagnostic Services )Ophthalmology (Surgical Services )Orthopedic Surgery (Surgical
© 2016 The Joint Commission, All Rights Reserved.
Services )Outpatient Clinics (Outpatient )Surgical ICU (Intensive Care Unit )Ultrasound (Imaging/DiagnosticServices )Urology (Surgical Services )
UNC Hospitals Laboratory,Carolina Pointe IICarolina Point II, 6013 FarringtonRoad, Suite 101Chapel Hill, NC, 27517
Available Services
Single Specialty Practitioner(Outpatient )
UNC Hospitals Nutrition Clinic590 Manning DriveChapel Hill, NC, 27599
Available Services
Outpatient Clinics (Outpatient )
University of North CarolinaHospitals101 Manning DriveChapel Hill, NC, 27514
Available Services
Behavioral Health (24-hour AcuteCare/Crisis Stabilization - Adult )Brachytherapy (Imaging/DiagnosticServices )Burn Unit (Inpatient )Cardiac Catheterization Lab(Surgical Services )Cardiac Surgery (Surgical Services)Cardiothoracic Surgery (SurgicalServices )Cardiovascular Unit (Inpatient )Coronary Care Unit (Inpatient )CT Scanner (Imaging/DiagnosticServices )Dialysis Unit (Inpatient )Ear/Nose/Throat Surgery (SurgicalServices )Eating DisordersEating DisordersEating Disorders (Inpatient - Adult )Eating Disorders (Outpatient -Child/Youth )Eating Disorders (Non 24 Hour Care
© 2016 The Joint Commission, All Rights Reserved.
- Child/Youth )Eating Disorders (24-hour AcuteCare/Crisis Stabilization - Adult )EEG/EKG/EMG Lab(Imaging/Diagnostic Services )Gastroenterology (Surgical Services)GI or Endoscopy Lab(Imaging/Diagnostic Services )Gynecological Surgery (SurgicalServices )Gynecology (Inpatient )Hematology/Oncology Unit (Inpatient)Inpatient Unit (Inpatient )Interventional Radiology(Imaging/Diagnostic Services )Labor & Delivery (Inpatient )Magnetic Resonance Imaging(Imaging/Diagnostic Services )Medical /Surgical Unit (Inpatient )Medical ICU (Intensive Care Unit )Neuro/Spine ICU (Intensive Care Unit)Neuro/Spine Unit (Inpatient )Neurosurgery (Surgical Services )Normal Newborn Nursery (Inpatient)Nuclear Medicine(Imaging/Diagnostic Services )Ophthalmology (Surgical Services )Orthopedic Surgery (SurgicalServices )Orthopedic/Spine Unit (Inpatient )Outpatient Clinics (Outpatient )Pediatric Unit (Inpatient )Plastic Surgery (Surgical Services )Positron Emission Tomography (PET)(Imaging/Diagnostic Services )Post Anesthesia Care Unit (PACU)(Inpatient )Radiation Oncology(Imaging/Diagnostic Services )Rehabilitation Unit (Inpatient )Rehabilitation Unit (24-hour AcuteCare/Crisis Stabilization )Sleep Laboratory (Sleep Laboratory
© 2016 The Joint Commission, All Rights Reserved.
)Surgical ICU (Intensive Care Unit )Surgical Unit (Inpatient )Teleradiology (Imaging/DiagnosticServices )Thoracic Surgery (Surgical Services)Transplant Surgery (SurgicalServices )Ultrasound (Imaging/DiagnosticServices )Urology (Surgical Services )Vascular Surgery (SurgicalServices )
Certification Programs
Advanced Comprehensive StrokeCenterVentricular Assist Device
Urology Services, UNCHospitalsDBA: Urology Services, UNCHospitalsCarolina Point 1, 5915 FarringtonRd., Suite 102Durham, NC, 27705
Available Services
Single Specialty Practitioner(Outpatient )
Special Quality Awards
Due to our commitment to accurate data reporting, The Joint Commission is suspending the practice ofupdating Special Quality Awards until further notice
2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program2014 Gold Plus Get With The Guidelines - Stroke
© 2016 The Joint Commission, All Rights Reserved.
Cooperative Agreements
Hospital - Accredited by American College of Surgeons-Commission on Cancer (ACoS-COC)
Symbol Key
This organization achieved the best possible results
This organization's performance is above the target range/value
This organization's performance is similar to the target range/value
This organization's performance is below the target range/value
This measure is not applicable for this organization
Not displayed
Measures Footnote Key
The measure or measure set was not reported.1.
The measure set does not have an overall result.2.
The number is not enough for comparison purposes.3.
The measure meets the Privacy Disclosure Threshold rule.4.
The organization scored above 90% but was below most other organizations.5.
The measure results are not statistically valid.6.
The measure results are based on a sample of patients.7.
The number of months with measure data is below the reporting requirement.8.
The measure results are temporarily suppressed pending resubmission of updated data.9.
Test Measure: a measure being evaluated for reliability of the individual data elements or awaiting National
Quality Forum Endorsement.
10.
There were no eligible patients that met the denominator criteria.11.
The Joint Commission only reports measures endorsed by the National Quality Forum.
* This information can also be viewed at Hospital Compare.
** Indicates per 1000 hours of patient care.
*** The measure was not in effect for this quarter.
---- Null value or data not displayed.
National Patient Safety Goals and National Quality Improvement Goals Show Keys +
© 2016 The Joint Commission, All Rights Reserved.
New Changes to Quarterly Measure
Download Quarterly Measure Results
The Joint Commission only reports measures endorsed by the National Quality Forum.* State results are not calculated for the National Patient Safety Goals.
Hospital 2016 National PatientSafety Goals
NationwideComparison:
StatewideComparison:
Behavioral HealthCare
2016 National PatientSafety Goals
NationwideComparison:
StatewideComparison:
Home Care 2016 National PatientSafety Goals
NationwideComparison:
StatewideComparison:
Reporting Period: July 2015 - June 2016
National Quality Improvement Goals:
Emergency Department National Comparison:2
StatewideComparison: 2
Hospital-Based InpatientPsychiatric Services
National Comparison:2
StatewideComparison: 2
Immunization National Comparison:2
StatewideComparison: 2
Perinatal Care National Comparison:2
StatewideComparison: 2
Stroke Care National Comparison:2
StatewideComparison: 2
VenousThromboembolism (VTE)
National Comparison:2
StatewideComparison: 2
© 2016 The Joint Commission, All Rights Reserved.
National Quality Improvement Goals:
University of North Carolina HospitalsHCO ID: 6478101 Manning DriveChapel Hill , NC, 27514
Measure Area Nationwide Statewide
Hospital-BasedInpatientPsychiatricServicesRead More
Compared to Other Joint CommissionAccredited Organizations
2 2
Nationwide Statewide
MeasureHospitalResults
Top 10%Scored at
Least
AverageRate
Top 10%Scored at
Least
AverageRate
Assessment of violence risk, substance usedisorder, trauma and patient strengthscompleted - Overall RateRead MoreSee Quarterly Results
76% of782
EligiblePatients
100% 94% 100% 95%
© 2016 The Joint Commission, All Rights Reserved.
Quarterly Measure Results
Jul - Sep 2015
782
58%
94%
Oct - Dec 2015
782
83%
94%
Jan - Mar 2016
782
87%
94%
Apr - Jun 2016
782
76%
94%
Nationwide Statewide
MeasureHospitalResults
Top 10%Scored at
Least
AverageRate
Top 10%Scored at
Least
AverageRate
Assessment of violence risk, substance usedisorder, trauma and patient strengthscompleted - Children (1-12 years)Read MoreSee Quarterly Results
47% of141
EligiblePatients
100% 96% 100% 84%
Quarterly Measure Results
Jul - Sep 2015
141
32%
96%
Oct - Dec 2015
141
65%
96%
Jan - Mar 2016
141
52%
95%
Apr - Jun 2016
141
39%
96%
Number of Eligible Patients
Rate
Nationwide Average
Number of Eligible Patients
Rate
Nationwide Average
© 2016 The Joint Commission, All Rights Reserved.
Nationwide Statewide
MeasureHospitalResults
Top 10%Scored at
Least
AverageRate
Top 10%Scored at
Least
AverageRate
Assessment of violence risk, substance usedisorder, trauma and patient strengthscompleted - Adolescent (13-17 years)Read MoreSee Quarterly Results
81% of171
EligiblePatients
100% 97% 100% 95%
Quarterly Measure Results
Jul - Sep 2015
171
63%
97%
Oct - Dec 2015
171
83%
97%
Jan - Mar 2016
171
89%
97%
Apr - Jun 2016
171
88%
97%
Nationwide Statewide
MeasureHospitalResults
Top 10%Scored at
Least
AverageRate
Top 10%Scored at
Least
AverageRate
Assessment of violence risk, substance usedisorder, trauma and patient strengthscompleted - Adult (18-64 years)Read MoreSee Quarterly Results
85% of328
EligiblePatients
100% 94% 100% 96%
Number of Eligible Patients
Rate
Nationwide Average
© 2016 The Joint Commission, All Rights Reserved.
Quarterly Measure Results
Jul - Sep 2015
328
69%
94%
Oct - Dec 2015
328
93%
94%
Jan - Mar 2016
328
96%
93%
Apr - Jun 2016
328
83%
94%
Nationwide Statewide
MeasureHospitalResults
Top 10%Scored at
Least
AverageRate
Top 10%Scored at
Least
AverageRate
Assessment of violence risk, substance usedisorder, trauma and patient strengthscompleted - Older Adult (>= 65 years)Read MoreSee Quarterly Results
76% of142
EligiblePatients
100% 92% 100% 90%
Quarterly Measure Results
Jul - Sep 2015
142
53%
93%
Oct - Dec 2015
142
77%
92%
Jan - Mar 2016
142
94%
92%
Apr - Jun 2016
142
85%
93%
Number of Eligible Patients
Rate
Nationwide Average
Number of Eligible Patients
Rate
Nationwide Average
© 2016 The Joint Commission, All Rights Reserved.
Nationwide Statewide
MeasureHospitalResults
Top 10%Scored at
Least
AverageRate
Top 10%Scored at
Least
AverageRate
Multiple Antipsychotic Medications atDischarge with Appropriate JustificationOverall RateRead MoreSee Quarterly Results
3
39% of 23EligiblePatients
100% 62% 100% 81%
Quarterly Measure Results
Jul - Sep 2015
23
33%
63%
Oct - Dec 2015
23
36%
64%
Jan - Mar 2016
23
33%
62%
Apr - Jun 2016
23
67%
60%
Nationwide Statewide
MeasureHospitalResults
Top 10%Scored at
Least
AverageRate
Top 10%Scored at
Least
AverageRate
Multiple Antipsychotic Medications at Dischargewith Appropriate Justification Children Age 1 -12Read More(No Quarterly Result are available)
3
----100% 62% ____3 ____3
Number of Eligible Patients
Rate
Nationwide Average
© 2016 The Joint Commission, All Rights Reserved.
Quarterly Measure Results
Jul - Sep 2015
____1
____1
____1
Oct - Dec 2015
____1
____1
____1
Jan - Mar 2016
____1
____1
____1
Apr - Jun 2016
____1
____1
____1
Nationwide Statewide
MeasureHospitalResults
Top 10%Scored at
Least
AverageRate
Top 10%Scored at
Least
AverageRate
Multiple Antipsychotic Medications at Dischargewith Appropriate Justification Adolescents Age13 - 17Read More(No Quarterly Result are available)
4
----100% 61% ____3 ____3
Quarterly Measure Results
Jul - Sep 2015
____1
____1
____1
Oct - Dec 2015
____1
____1
____1
Jan - Mar 2016
____1
____1
____1
Apr - Jun 2016
____1
____1
____1
Number of Eligible Patients
Rate
Nationwide Average
Number of Eligible Patients
Rate
Nationwide Average
© 2016 The Joint Commission, All Rights Reserved.
Nationwide Statewide
MeasureHospitalResults
Top 10%Scored at
Least
AverageRate
Top 10%Scored at
Least
AverageRate
Multiple Antipsychotic Medications atDischarge with Appropriate JustificationAdults Age 18 - 64Read MoreSee Quarterly Results
3
35% of 17EligiblePatients
100% 63% 100% 82%
Quarterly Measure Results
Jul - Sep 2015
____4
____4
64%
Oct - Dec 2015
17
17%
65%
Jan - Mar 2016
17
33%
62%
Apr - Jun 2016
17
67%
62%
Nationwide Statewide
MeasureHospitalResults
Top 10%Scored at
Least
AverageRate
Top 10%Scored at
Least
AverageRate
Multiple Antipsychotic Medications atDischarge with Appropriate Justification OlderAdults Age 65 and OlderRead MoreSee Quarterly Results
3
60% of 5EligiblePatients
100% 56% 100% 75%
Number of Eligible Patients
Rate
Nationwide Average
© 2016 The Joint Commission, All Rights Reserved.
Quarterly Measure Results
Jul - Sep 2015
____4
____4
57%
Oct - Dec 2015
5
75%
58%
Jan - Mar 2016
____1
____1
58%
Apr - Jun 2016
____1
____1
53%
Nationwide Statewide
MeasureHospitalResults
Top 10%Scored at
Least
AverageRate
Top 10%Scored at
Least
AverageRate
Hours of Physical Restraint Use per1000 Patient Hours - Overall RateRead MoreSee Quarterly Results
0.1056(92 Total Hours in
Restraints)
N/A 0.4876 N/A 0.5467
Quarterly Measure Results
Jul - Sep 2015
208.0080
14.5333
0.0699
0.5156
Oct - Dec 2015
212.6880
47.3667
0.2227
0.4559
Jan - Mar 2016
211.6800
16.2000
0.0765
0.4618
Apr - Jun 2016
236.6640
13.6833
0.0578
0.5019
Number of Eligible Patients
Rate
Nationwide Average
Total Patient Hours/1000
Total Patient Hours in Restraint
Rate of Restraint Use**
Nationwide Rate**
© 2016 The Joint Commission, All Rights Reserved.
Nationwide Statewide
MeasureHospitalResults
Top 10%Scored at
Least
AverageRate
Top 10%Scored at
Least
AverageRate
Hours of Physical Restraint UseChildren Age 1 - 12Read MoreSee Quarterly Results
0.2476(16 Total Hours in
Restraints)
N/A 0.3128 N/A 0.354
Quarterly Measure Results
Jul - Sep 2015
15.4320
4.5833
0.2970
0.3423
Oct - Dec 2015
18.8160
2.7667
0.1470
0.3438
Jan - Mar 2016
15.3600
1.9667
0.1280
0.3122
Apr - Jun 2016
15.0000
6.6833
0.4456
0.2632
Nationwide Statewide
MeasureHospitalResults
Top 10%Scored at
Least
AverageRate
Top 10%Scored at
Least
AverageRate
Hours of Physical Restraint UseAdolescents Age 13 - 17Read MoreSee Quarterly Results
0.1286(17 Total Hours in
Restraints)
N/A 0.3159 N/A 0.175
Total Patient Hours/1000
Total Patient Hours in Restraint
Rate of Restraint Use**
Nationwide Rate**
© 2016 The Joint Commission, All Rights Reserved.
Quarterly Measure Results
Jul - Sep 2015
33.9120
3.0833
0.0909
0.3003
Oct - Dec 2015
33.1440
0.0500
0.0015
0.2326
Jan - Mar 2016
33.4800
11.7167
0.3500
0.2194
Apr - Jun 2016
33.7200
2.4167
0.0717
0.4930
Nationwide Statewide
MeasureHospitalResults
Top 10%Scored at
Least
AverageRate
Top 10%Scored at
Least
AverageRate
Hours of Physical Restraint UseAdults Age 18 - 64Read MoreSee Quarterly Results
0.0229(13 Total Hours in
Restraints)
N/A 0.5142 N/A 0.1433
Total Patient Hours/1000
Total Patient Hours in Restraint
Rate of Restraint Use**
Nationwide Rate**
© 2016 The Joint Commission, All Rights Reserved.
Quarterly Measure Results
Jul - Sep 2015
134.6160
4.1667
0.0310
0.5219
Oct - Dec 2015
135.3120
4.4167
0.0326
0.5053
Jan - Mar 2016
138.5040
1.5333
0.0111
0.4893
Apr - Jun 2016
168.8640
3.1000
0.0184
0.5258
Nationwide Statewide
MeasureHospitalResults
Top 10%Scored at
Least
AverageRate
Top 10%Scored at
Least
AverageRate
Hours of Physical Restraint UseOlder Adults Age 65 and OlderRead MoreSee Quarterly Results
0.4877(45 Total Hours in
Restraints)
N/A 0.4777 N/A 4.0872
Total Patient Hours/1000
Total Patient Hours in Restraint
Rate of Restraint Use**
Nationwide Rate**
© 2016 The Joint Commission, All Rights Reserved.
Quarterly Measure Results
Jul - Sep 2015
24.0480
2.7000
0.1123
0.6561
Oct - Dec 2015
25.4160
40.1333
1.5791
0.3105
Jan - Mar 2016
24.3360
0.9833
0.0404
0.5057
Apr - Jun 2016
19.0800
1.4833
0.0777
0.4039
Nationwide Statewide
MeasureHospitalResults
Top 10%Scored at
Least
AverageRate
Top 10%Scored at
Least
AverageRate
Hours of Seclusion Use per 1000Patient Hours - Overall RateRead MoreSee Quarterly Results
0.3243(282 Total Hours in
Seclusion)
N/A 0.3612 N/A 0.1022
Total Patient Hours/1000
Total Patient Hours in Restraint
Rate of Restraint Use**
Nationwide Rate**
© 2016 The Joint Commission, All Rights Reserved.
Quarterly Measure Results
Jul - Sep 2015
208.0080
71.2833
0.3427
0.3642
Oct - Dec 2015
212.6880
44.6333
0.2099
0.3719
Jan - Mar 2016
211.6800
31.3833
0.1483
0.3574
Apr - Jun 2016
236.6640
134.5167
0.5684
0.3446
Nationwide Statewide
MeasureHospitalResults
Top 10%Scored at
Least
AverageRate
Top 10%Scored at
Least
AverageRate
Hours of Seclusion UseChildren Age 1 - 12Read MoreSee Quarterly Results
0.7855(51 Total Hours in
Seclusion)
N/A 0.5425 N/A 0.353
Total Patient Hours/1000
Total Patient Hours in Seclusion
Rate of Seclusion Use**
Nationwide Rate**
© 2016 The Joint Commission, All Rights Reserved.
Quarterly Measure Results
Jul - Sep 2015
15.4320
11.1333
0.7214
0.5224
Oct - Dec 2015
18.8160
15.6500
0.8317
0.6198
Jan - Mar 2016
15.3600
8.4833
0.5523
0.5541
Apr - Jun 2016
15.0000
15.4833
1.0322
0.4847
Nationwide Statewide
MeasureHospitalResults
Top 10%Scored at
Least
AverageRate
Top 10%Scored at
Least
AverageRate
Hours of Seclusion UseAdolescents Age 13 - 17Read MoreSee Quarterly Results
0.324(43 Total Hours in
Seclusion)
N/A 0.2001 N/A 0.1279
Total Patient Hours/1000
Total Patient Hours in Seclusion
Rate of Seclusion Use**
Nationwide Rate**
© 2016 The Joint Commission, All Rights Reserved.
Quarterly Measure Results
Jul - Sep 2015
33.9120
24.2333
0.7146
0.2564
Oct - Dec 2015
33.1440
5.7500
0.1735
0.1732
Jan - Mar 2016
33.4800
7.5833
0.2265
0.1957
Apr - Jun 2016
33.7200
5.9333
0.1760
0.1852
Nationwide Statewide
MeasureHospitalResults
Top 10%Scored at
Least
AverageRate
Top 10%Scored at
Least
AverageRate
Hours of Seclusion Use AdultsAge 18 - 64Read MoreSee Quarterly Results
0.2869(166 Total Hours in
Seclusion)
N/A 0.4089 N/A 0.0966
Total Patient Hours/1000
Total Patient Hours in Seclusion
Rate of Seclusion Use**
Nationwide Rate**
© 2016 The Joint Commission, All Rights Reserved.
Quarterly Measure Results
Jul - Sep 2015
134.6160
17.6167
0.1309
0.4063
Oct - Dec 2015
135.3120
22.3500
0.1652
0.4171
Jan - Mar 2016
138.5040
12.5833
0.0909
0.4088
Apr - Jun 2016
168.8640
113.1000
0.6698
0.3962
Nationwide Statewide
MeasureHospitalResults
Top 10%Scored at
Least
AverageRate
Top 10%Scored at
Least
AverageRate
Hours of Seclusion Use OlderAdults Age 65 and OlderRead MoreSee Quarterly Results
0.236(22 Total Hours in
Seclusion)
N/A 0.0918 N/A 0.0382
Total Patient Hours/1000
Total Patient Hours in Seclusion
Rate of Seclusion Use**
Nationwide Rate**
© 2016 The Joint Commission, All Rights Reserved.
Quarterly Measure Results
Jul - Sep 2015
24.0480
18.3000
0.7610
0.0934
Oct - Dec 2015
25.4160
0.8833
0.0348
0.1371
Jan - Mar 2016
24.3360
2.7333
0.1123
0.0660
Apr - Jun 2016
19.0800
0
0
0.0684
Measure Area Nationwide Statewide
Stroke CareRead More
Compared to Other Joint CommissionAccredited Organizations
2 2
Nationwide Statewide
MeasureHospitalResults
Top 10%Scored at Least
AverageRate
Top 10%Scored at Least
AverageRate
Thrombolytic TherapyRead MoreSee Quarterly Results
100% of 11Eligible Patients
100% 89% 100% 91%
Total Patient Hours/1000
Total Patient Hours in Seclusion
Rate of Seclusion Use**
Nationwide Rate**
© 2016 The Joint Commission, All Rights Reserved.
Quarterly Measure Results
Jul - Sep 2015
____1
____1
87%
Oct - Dec 2015
____4
____4
89%
Jan - Mar 2016
11
100%
89%
Apr - Jun 2016
11
100%
90%
Measure Area Nationwide Statewide
VenousThromboembolism(VTE)Read More
Compared to Other Joint CommissionAccredited Organizations
2 2
Nationwide Statewide
MeasureHospitalResults
Top 10%Scored at Least
AverageRate
Top 10%Scored at Least
AverageRate
VTE Discharge InstructionsRead MoreSee Quarterly Results
100% of 62Eligible Patients
100% 93% 100% 95%
Number of Eligible Patients
Rate
Nationwide Average
© 2016 The Joint Commission, All Rights Reserved.
Quarterly Measure Results
Jul - Sep 2015
62
100%
93%
Oct - Dec 2015
62
100%
93%
Jan - Mar 2016
62
100%
93%
Apr - Jun 2016
62
100%
93%
Measure Area Nationwide Statewide
Perinatal CareRead More
Compared to Other Joint CommissionAccredited Organizations
2 2
Nationwide Statewide
MeasureHospitalResults
Top 10%Scored at Least
AverageRate
Top 10%Scored at Least
AverageRate
Elective DeliveryRead MoreSee Quarterly Results
0% of 46Eligible Patients
0% 2% 0% 1%
Number of Eligible Patients
Rate
Nationwide Average
© 2016 The Joint Commission, All Rights Reserved.
Quarterly Measure Results
Jul - Sep 2015
46
0%
2%
Oct - Dec 2015
46
0%
2%
Jan - Mar 2016
46
0%
2%
Apr - Jun 2016
46
0%
2%
Nationwide Statewide
MeasureHospitalResults
Top 10%Scored at Least
AverageRate
Top 10%Scored at Least
AverageRate
Exclusive Breast Milk FeedingRead MoreSee Quarterly Results
66% of 399Eligible Patients
75% 53% 66% 47%
Quarterly Measure Results
Jul - Sep 2015
399
75%
52%
Oct - Dec 2015
399
55%
52%
Jan - Mar 2016
399
66%
53%
Apr - Jun 2016
399
69%
55%
Number of Eligible Patients
Rate
Nationwide Average
Number of Eligible Patients
Rate
Nationwide Average
© 2016 The Joint Commission, All Rights Reserved.
Nationwide Statewide
MeasureHospitalResults
Top 10%Scored at Least
AverageRate
Top 10%Scored at Least
AverageRate
Antenatal SteroidsRead MoreSee Quarterly Results
100% of 33Eligible Patients
100% 98% 100% 98%
Quarterly Measure Results
Jul - Sep 2015
33
100%
97%
Oct - Dec 2015
33
100%
98%
Jan - Mar 2016
33
100%
98%
Apr - Jun 2016
33
100%
98%
Measure Area Nationwide Statewide
EmergencyDepartmentRead More
Compared to Other Joint CommissionAccredited Organizations
2 2
Number of Eligible Patients
Rate
Nationwide Average
© 2016 The Joint Commission, All Rights Reserved.
Nationwide Statewide
MeasureHospitalResults
Top 10%Scored at
Most
WeightedMedian
Top 10%Scored at
Most
WeightedMedian
Median Time from ED Arrival to EDDeparture for Admitted ED PatientsRead MoreSee Quarterly Results
2
406 minutes400 eligible
Patients
202 309 233 298
Quarterly Measure Results
Jul - Sep 2015
400
454
302
Oct - Dec 2015
400
411
301
Jan - Mar 2016
400
386
323
Apr - Jun 2016
400
384
309
Nationwide Statewide
MeasureHospitalResults
Top 10%Scored at
Most
WeightedMedian
Top 10%Scored at
Most
WeightedMedian
Admit Decision Time to ED DepartureTime for Admitted PatientsRead MoreSee Quarterly Results
2
246 minutes400 eligible
Patients
52 122 61 111
Number of Eligible Patients
Weighted Median Minutes
Nationwide Weighted Median Minutes
© 2016 The Joint Commission, All Rights Reserved.
Quarterly Measure Results
Jul - Sep 2015
400
214
116
Oct - Dec 2015
400
269
118
Jan - Mar 2016
400
261
132
Apr - Jun 2016
400
236
123
Measure Area Nationwide Statewide
ImmunizationRead More
Compared to Other Joint CommissionAccredited Organizations
2 2
Nationwide Statewide
MeasureHospitalResults
Top 10%Scored at Least
AverageRate
Top 10%Scored at Least
AverageRate
Influenza ImmunizationRead MoreSee Quarterly Results
98% of 503Eligible Patients
100% 94% 99% 96%
Number of Eligible Patients
Weighted Median Minutes
Nationwide Weighted Median Minutes
© 2016 The Joint Commission, All Rights Reserved.
Quarterly Measure Results
Jul - Sep 2015
____1
____1
____1
Oct - Dec 2015
503
97%
93%
Jan - Mar 2016
503
100%
95%
Apr - Jun 2016
____1
____1
____1
Number of Eligible Patients
Rate
Nationwide Average
© 2016 The Joint Commission, All Rights Reserved.