The Joint Commission
Quality Check
Quality Report

Summary of Quality Information
Capital Health System, Inc.
DBA: Capital Health
Org ID: 208281
750 Brunswick Avenue
Trenton, NJ  08638
(609)537-6081
www.capitalhealth.org


Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full Survey Date Last On-Site Survey Date
Hospital
Accredited 5/18/2013 5/17/2013   5/17/2013  


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
Advanced Comprehensive Stroke Center
Certification 7/11/2013  6/4/2013  6/4/2013 



Certified
Programs
Certification
Decision
Effective
Date
Last Full
Review Date
Last On-Site
Review Date
Respiratory Distress Syndrome in Preterm Infants
Certification 6/22/2012  6/21/2012  6/21/2012 




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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
Hospital
2013 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 similar to the target range/value.
This organization’s performance is similar to 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.
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 similar to the target range/value.
This organization’s performance is similar to 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
Not displayed.
3
Not displayed.
3
  • Knee Replacement
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
Bordentown Family Medical Center
1 Third St.
Bordentown, NJ  08505
    Services:
    • Single Specialty Practitioner (Outpatient)
    Capital Health Regional Medical Center  *
    750 Brunswick Avenue
    Trenton, NJ  08638
    Joint Commission Advanced Certification Programs:
    • Advanced Comprehensive Stroke Center
    Joint Commission Certified Programs:
    • Respiratory Distress Syndrome in Preterm Infants
      Services:
      • Behavioral Health (Day Programs - Adult)
        (Non 24 Hour Care - Adult/Child/Youth)
        (24-hour Acute Care/Crisis Stabilization - Adult)
        (Partial - Adult)
      • Cardiovascular Unit (Inpatient)
      • CT Scanner (Imaging/Diagnostic Services)
      • Dialysis Unit (Inpatient)
      • 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)
      • In-Home Behavioral Health Services (Non 24 Hour Care - Adult/Child/Youth)
      • Inpatient Unit (Inpatient)
      • Interventional Radiology (Imaging/Diagnostic Services)
      • Labor & Delivery (Inpatient)
      • Magnetic Resonance Imaging (Imaging/Diagnostic Services)
      • Medical /Surgical Unit (Inpatient)
      • 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 (Surgical Services)
      • Outpatient Clinics (Outpatient)
      • Plastic Surgery (Surgical Services)
      • Post Anesthesia Care Unit (PACU) (Inpatient)
      • Sleep Laboratory (Sleep Laboratory)
      • Surgical ICU (Intensive Care Unit)
      • Surgical Unit (Inpatient)
      • Teleradiology (Imaging/Diagnostic Services)
      • Thoracic Surgery (Surgical Services)
      • Ultrasound (Imaging/Diagnostic Services)
      • Urology (Surgical Services)
      • Vascular Surgery (Surgical Services)
      Corporate Health
      832 Brunswick Ave
      Trenton, NJ  08638
        Services:
        • Single Specialty Practitioner (Outpatient)
        Family Health Center
        433 Bellevue Ave
        Trenton, NJ  08618
          Services:
          • Outpatient Clinics (Outpatient)

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