The Joint Commission
Quality Check
Quality Report

Summary of Accreditation Quality Information
Lahey Clinic Hospital, Inc.
DBA: Lahey Hospital & Medical Center, Burlington
Org ID: 5194
41 Mall Road
Burlington, MA  01805
(781)744-5100
www.Lahey.org


Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full Survey Date Last On-Site Survey Date
Hospital
Accredited 11/12/2011 11/11/2011   11/11/2011  


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






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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.
National Patient Safety Goals and National Quality Improvement Goals
    Compared to other Joint Commission Accredited Organizations
    Nationwide Statewide
Hospital
2011 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:
Jul  2012 -
Jun  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 similar to the target range/value.
This organization’s performance is similar to the target range/value.
Pneumonia 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
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
  • Colon/Large Intestine Surgery
See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to 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
Dermatology & Physical Therapy Outpatient Services
DBA:  Lahey Hospital & Medical Center, Burlington
20 Wall Street
Burlington, MA  01803
    Services:
    • Administration of High Risk Medications (Outpatient)
    • Outpatient Clinics (Outpatient)
    • Perform Invasive Procedure (Outpatient)
    Lahey Clinic Hospital, Inc.
    DBA:  Lahey Medical Center, Peabody
    One Essex Center Drive
    Peabody, MA  01960
      Services:
      • Behavioral Health (Non 24 Hour Care - Adult)
      • CT Scanner (Imaging/Diagnostic Services)
      • EEG/EKG/EMG Lab (Imaging/Diagnostic Services)
      • General Laboratory Tests
      • GI or Endoscopy Lab (Imaging/Diagnostic Services)
      • Gynecological Surgery (Surgical Services)
      • Magnetic Resonance Imaging (Imaging/Diagnostic Services)
      • Medical /Surgical Unit (Inpatient)
      • Ophthalmology (Surgical Services)
      • Orthopedic Surgery (Surgical Services)
      • Outpatient Clinics (Outpatient)
      • Plastic Surgery (Surgical Services)
      • Post Anesthesia Care Unit (PACU) (Inpatient)
      • Radiation Oncology (Imaging/Diagnostic Services)
      • Sleep Laboratory (Sleep Laboratory)
      • Ultrasound (Imaging/Diagnostic Services)
      • Urology (Surgical Services)
      • Vascular Surgery (Surgical Services)
      Lahey Clinic Hospital, Inc.  *
      DBA:  Lahey Hospital & Medical Center, Burlington
      41 Mall Road
      Burlington, MA  01805
        Services:
        • Behavioral Health (Non 24 Hour Care - Adult/Child/Youth)
        • Blood Donor Center
        • Brachytherapy (Imaging/Diagnostic Services)
        • Cardiac Catheterization Lab (Surgical Services)
        • Cardiac Surgery (Surgical Services)
        • Cardiothoracic Surgery (Surgical Services)
        • CT Scanner (Imaging/Diagnostic Services)
        • Ear/Nose/Throat Surgery (Surgical Services)
        • EEG/EKG/EMG Lab (Imaging/Diagnostic Services)
        • Gastroenterology (Surgical Services)
        • General Laboratory Tests
        • GI or Endoscopy Lab (Imaging/Diagnostic Services)
        • Gynecological Surgery (Surgical Services)
        • Interventional Radiology (Imaging/Diagnostic Services)
        • 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 Services)
        • Outpatient Clinics (Outpatient)
        • Plastic Surgery (Surgical Services)
        • Positron Emission Tomography (PET) (Imaging/Diagnostic Services)
        • Post Anesthesia Care Unit (PACU) (Inpatient)
        • Radiation Oncology (Imaging/Diagnostic Services)
        • Sleep Laboratory (Sleep Laboratory)
        • Surgical ICU (Intensive Care Unit)
        • Thoracic Surgery (Surgical Services)
        • Toxicology
        • Transplant Surgery (Surgical Services)
        • Ultrasound (Imaging/Diagnostic Services)
        • Urology (Surgical Services)
        • Vascular Surgery (Surgical Services)
        Lahey Clinic Hospital, Inc.
        DBA:  Lahey Outpatient Center, Lexington (MRI Services)
        16 Hayden Avenue
        Lexington, MA  02421
          Services:
          • Outpatient Clinics (Outpatient)
          Lahey Clinic Hospital, Inc. - 31 Mall Road
          DBA:  Lahey Hospital & Medical Center, Burlington
          31 Mall Road
          Burlington, MA  01805
            Services:
            • Administration of High Risk Medications (Outpatient)
            • Outpatient Clinics (Outpatient)
            • Perform Invasive Procedure (Outpatient)
            Lahey Hospital and Medical Center Medical Weight Loss
            50 Mall Road
            Burlington, MA  01805
              Services:
              • Outpatient Clinics (Outpatient)
              Outpatient Rehabilitation Services at Danvers
              DBA:  Lahey Hospital & Medical Center
              5 Federal Street
              Danvers, MA  01923
                Services:
                • Outpatient Clinics (Outpatient)

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