The Joint Commission
Quality Check
Quality Report

Summary of Quality Information
Doylestown Hospital
Org ID: 4565
595 West State Street
Doylestown, PA  18901
(215)345-2200
dh.org


Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full Survey Date Last On-Site Survey Date
Home Care
Accredited 9/1/2012 8/31/2012   8/31/2012  
Hospital
Accredited 9/1/2012 8/31/2012   10/11/2012  


Accreditation programs recognized by the Centers for Medicare and Medicaid Services (CMS)
Hospital


Advanced Certification
Programs
Certification
Decision
Effective
Date
Last Full
Review Date
Last On-Site
Review Date
Primary Stroke Center
Certification 10/18/2012  10/17/2012  10/17/2012 



Certified
Programs
Certification
Decision
Effective
Date
Last Full
Review Date
Last On-Site
Review Date
Heart Failure
Certification 12/7/2012  12/6/2012  12/6/2012 
Joint Replacement - Hip
Certification 11/9/2012  11/8/2012  11/8/2012 
Joint Replacement - Knee
Certification 11/9/2012  11/8/2012  11/8/2012 



Other Accredited Programs / Services
Hospital  -  Accredited by American College of Surgeons-Commission on Cancer (ACoS-COC)

Special Quality Awards


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  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
  Footnote Key
1. The measure or measure set was not reported.
2. The measure set does not have an overall result.
3. The number is not enough for comparison purposes.
4. The measure meets the Privacy Disclosure Threshold rule.
5. The organization scored above 90% but was below most other organizations.
6. The measure results are not statistically valid.
7. The measure results are based on a sample of patients.
8. The number of months with measure data is below the reporting requirement.
9. The measure results are temporarily suppressed pending resubmission of updated data.
10. Test Measure: a measure being evaluated for reliability of the individual data elements or awaiting National Quality Forum Endorsement.
11. There were no eligible patients that met the denominator criteria.
National Patient Safety Goals and National Quality Improvement Goals
    Compared to other Joint Commission Accredited Organizations
    Nationwide Statewide
Home Care
2012 National Patient Safety Goals See Detail
This organization’s performance is similar to the target range/value.
This Goal is not applicable for this organization.
*
Hospital
2012 National Patient Safety Goals See Detail
This organization’s performance is similar to the target range/value.
This Goal is not applicable for this organization.
*
National Quality Improvement Goals:    
Reporting Period:
Jan  2013 -
Dec  2013
Heart Attack Care See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
Heart Failure Care See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
Perinatal Care See Detail
Not displayed.
2
Not displayed.
2
Pneumonia Care See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
Stroke Care See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
Surgical Care Improvement Project (SCIP)    
SCIP - Cardiac See Detail
   
SCIP - Infection Prevention
For All Reported Procedures:
See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
  • Blood Vessel Surgery
See Detail
Not displayed.
3
Not displayed.
3
  • Colon/Large Intestine Surgery
See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
  • Coronary Artery Bypass Graft
See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
  • Hip Joint Replacement
See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
  • Hysterectomy
See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
  • Knee Replacement
See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
  • Open Heart Surgery
See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
SCIP – Venous Thromboembolism (VTE) See Detail
   
 
National Quality Forum The Joint Commission only reports measures endorsed by the National Quality Forum.
 
* State results are not calculated for the National Patient Safety Goals.

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Sites and Services
* Primary Location

An organization may provide services not listed here. For more information refer to the Quality Report User Guide .

Locations of Care Available Services
Doylestown Hospital  *
595 West State Street
Doylestown, PA  18901
Joint Commission Advanced Certification Programs:
  • Primary Stroke Center
Joint Commission Certified Programs:
  • Heart Failure
  • Joint Replacement - Hip
  • Joint Replacement - Knee
    Services:
    • Cardiac Catheterization Lab (Surgical Services)
    • Cardiac Surgery (Surgical Services)
    • Cardiothoracic Surgery (Surgical Services)
    • Coronary Care Unit (Inpatient)
    • CT Scanner (Imaging/Diagnostic Services)
    • Ear/Nose/Throat Surgery (Surgical Services)
    • EEG/EKG/EMG Lab (Imaging/Diagnostic Services)
    • Gastroenterology (Surgical Services)
    • GI or Endoscopy Lab (Imaging/Diagnostic Services)
    • Gynecological Surgery (Surgical Services)
    • Gynecology (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)
    • Normal Newborn Nursery (Inpatient)
    • Nuclear Medicine (Imaging/Diagnostic Services)
    • Orthopedic Surgery (Surgical Services)
    • Orthopedic/Spine Unit (Inpatient)
    • Outpatient Clinics (Outpatient)
    • Pediatric Unit (Inpatient)
    • Plastic Surgery (Surgical Services)
    • Post Anesthesia Care Unit (PACU) (Inpatient)
    • Teleradiology (Imaging/Diagnostic Services)
    • Thoracic Surgery (Surgical Services)
    • Ultrasound (Imaging/Diagnostic Services)
    • Urology (Surgical Services)
    • Vascular Surgery (Surgical Services)
    Doylestown Hospital Home Care / Visiting Nurse
    875 North Easton Road
    Doylestown, PA  18901
      Services:
      • Home Health Aides
      • Home Health, Non-Hospice Services
      • Hospice Care
      • Medical Social Services
      • Occupational Therapy
      • Physical Therapy
      • Skilled Nursing Services
      • Speech Language Pathology
      Doylestown Hospital Cardiac Services
      599 West State Street, Suite 200
      Doylestown, PA  18901
        Services:
        • Outpatient Clinics (Outpatient)
        Doylestown Hospital Cardiac Services
        315 West State Street
        Doylestown, PA  18901
          Services:
          • Outpatient Clinics (Outpatient)
          Doylestown Hospital Surgery Center
          847 Easton Road, Suite 1400
          Warrington, PA  18976
          Other Clinics/Practices located at this site:
          • Doylestown Hospital Cardiac Services, Suite 2800
          • Health and Wellness Center
          • The Vein and Laser Center
          Services:
          • Administration of High Risk Medications (Outpatient)
          • Ambulatory Surgery Center (Outpatient)
          • Anesthesia (Outpatient)
          • Perform Invasive Procedure (Outpatient)

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