The Joint Commission
Quality Check
Quality Report

Summary of Quality Information
Brigham and Women's Hospital
Org ID: 5503
75 Francis Street
Boston, MA  02115
(617)732-5500
www.brighamandwomens.org


Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full Survey Date Last On-Site Survey Date  
Hospital
Accredited 2/6/2010 2/5/2010 2/5/2010  
Pathology and Clinical Laboratory
Accredited 2/14/2009 8/27/2010 8/27/2010  

Advanced Certification
Programs
Certification
Decision
Effective
Date
Last Full
Review Date
Last On-Site
Review Date
Ventricular Assist Device
Certification 11/5/2008  11/4/2008  11/4/2008 



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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 of patients 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.
National Patient Safety Goals and National Quality Improvement Goals
    Compared to other Joint Commission Accredited Organizations
    Nationwide Statewide
Hospital
2010 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  2009 -
Dec  2009
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 similar to the target range/value.
This organization’s performance is similar to the target range/value.
Pregnancy Care See Detail
Not displayed.
2
Not displayed.
2
Surgical Care Improvement Project (SCIP)    
SCIP - Cardiac See Detail
   
SCIP - Infection Prevention
For All Reported Procedures:
See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
  • Blood Vessel 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.
  • 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 similar to the target range/value.
This organization’s performance is similar to the target range/value.
  • Hysterectomy
See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
  • Knee Replacement
See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
  • Open Heart Surgery
See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is above the target range/value.
SCIP – Venous Thromboembolism (VTE) See Detail
   
  30 Day Risk Adjusted Mortality Rates (see details)
  30 Day Hospital Readmission Rates (see details)
  Survey of Patients' Hospital Experiences (see details)
Pathology and Clinical Laboratory
2010 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.
*
 
Hospitals voluntarily participate in the Survey of Patients' Hospital Experiences(HCAHPS).
Pediatric and psychiatric hospitals are not eligible to participate in the HCAHPS survey based on their patient population.

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
Brigham and Women's Hospital  *
75 Francis Street
Boston, MA  02115
Joint Commission Advanced Certification Programs:
  • Ventricular Assist Device
Services:
  • Allergy (Outpatient)
  • Audiology (Inpatient, Outpatient)
  • Blood Donor Center
  • Bone Marrow Transplant (Inpatient)
  • Cancer Center/Oncology (Inpatient)
  • Cardiac Catheterization Lab (Inpatient, Outpatient)
  • Cardiac Surgery (Inpatient, Outpatient)
  • Cardiac Unit/Cardiology (Inpatient, Outpatient)
  • CT Scanner (Inpatient, Outpatient)
  • Dentistry (Outpatient)
  • Dermatology (Inpatient, Outpatient)
  • Dialysis (Inpatient, Outpatient)
  • EEG/EKG/EMG Lab (Inpatient, Outpatient)
  • Emergency Room (Outpatient)
  • Endocrinology (Inpatient, Outpatient)
  • Gastroenterology (Inpatient, Outpatient)
  • General Laboratory Tests
  • General Medical Services (Inpatient, Outpatient)
  • General Surgery (Inpatient, Outpatient)
  • GI or Endoscopy Lab (Inpatient, Outpatient)
  • Gynecology (Inpatient, Outpatient)
  • Hematology/Blood Treatment (Inpatient, Outpatient)
  • Imaging/Radiology (Inpatient, Outpatient)
  • Infectious Diseases (Inpatient, Outpatient)
  • Infusion Therapy (Inpatient, Outpatient)
  • Intensive Care Unit (Inpatient)
  • Internal Medicine (Inpatient, Outpatient)
  • Labor & Delivery (Inpatient)
  • Lithotripsy/Kidney Stone Treatment (Inpatient)
  • Magnetic Resonance Imaging (Inpatient, Outpatient)
  • Mental Health (Outpatient)
  • Neonatal Intensive Care (Inpatient)
  • Nephrology (Inpatient, Outpatient)
  • Neurology (Inpatient, Outpatient)
  • Neurosurgery (Inpatient)
  • Nuclear Medicine (Inpatient, Outpatient)
  • Nursery (Inpatient)
  • Obstetrics (Inpatient, Outpatient)
  • Occupational Health (Outpatient)
  • Operating Room (Inpatient, Outpatient)
  • Ophthalmology/Eye Surgery (Inpatient)
  • Oral Maxillofacial Surgery (Inpatient, Outpatient)
  • Orthopedic Surgery (Inpatient, Outpatient)
  • Otolaryngology/Ear, Nose, and Throat (Inpatient, Outpatient)
  • Outpatient Surgery (Outpatient)
  • Pain Management (Inpatient, Outpatient)
  • Plastic Surgery (Inpatient, Outpatient)
  • Podiatry (Outpatient)
  • Post Anesthesia Care Unit (PACU) (Inpatient, Outpatient)
  • Pulmonary Function Lab (Inpatient, Outpatient)
  • Radiation Oncology (Inpatient, Outpatient)
  • Rehabilitation and Physical Medicine (Inpatient, Outpatient)
  • Respiratory Care (Ventilator) (Inpatient)
  • Rheumatology (Inpatient, Outpatient)
  • Sleep Center (Outpatient)
  • Telemetry (Inpatient)
  • Thoracic Surgery (Inpatient, Outpatient)
  • Toxicology
  • Trauma/Burn Unit (Inpatient)
  • Ultrasound (Inpatient, Outpatient)
  • Urology (Inpatient, Outpatient)
  • Vascular Surgery (Inpatient, Outpatient)
  • Wound Care (Inpatient, Outpatient)
Brigham and Women's Hospital
221 Longwood Avenue, 2nd Floor
Boston, MA  02115
  • General Laboratory Tests
  • General Outpatient Services (Outpatient)
Brigham and Women's Hospital Ambulatory Care Center
850 Boylston Street
Chestnut Hill, MA  02467-2401
  • Anesthesia (Outpatient)
  • General Laboratory Tests
  • General Outpatient Services (Outpatient)
Brigham and Women's Hospital MRI
1 Compass Way, Suite 108
East Bridgewater, MA  02333
  • General Laboratory Tests
  • General Outpatient Services (Outpatient)
Brigham and Women's/Mass General Healthcare Center
20 Patriot Place
Foxboro, MA  02035
  • Ambulatory Surgery Center (Outpatient)
  • Anesthesia (Outpatient)
  • General Laboratory Tests
  • General Outpatient Services (Outpatient)
Brigham Women Hospital Care Center
1153 Centre Street
Jamaica Plain, MA  02130
  • General Laboratory Tests
  • General Outpatient Services (Outpatient)
Brookside Community Health Center
3297 Washington Street
Jamaica Plain, MA  02130
  • General Laboratory Tests
  • General Outpatient Services (Outpatient)
Multiple Sclerosis Center
One Brookline Place
Brookline, MA  02445
  • General Outpatient Services (Outpatient)
Southern Jamaica Plain Health Center
640 Centre Street
Jamaica Plain, MA  02130
  • General Laboratory Tests
  • General Outpatient Services (Outpatient)
Teen Health Center
144 McBride Street
Jamaica Plain, MA  02130
  • General Laboratory Tests
  • General Outpatient Services (Outpatient)

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