The Joint Commission
Quality Check
Quality Report

Summary of Quality Information
Covenant Med Ctr/Covenant Med Ctr - Lakeside
Org ID: 266567
3615 19th Street
Lubbock, TX  79410
(806)725-1011
www.covenanthealth.org


Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full Survey Date Last On-Site Survey Date
Home Care
Accredited 11/14/2014 11/13/2014   11/13/2014  
Hospital
Accreditation with Follow-up Survey 11/15/2014 11/14/2014   12/29/2014  
The following standard(s) were found to be out of compliance:
  • A pharmacist reviews the appropriateness of all medication orders for medications to be dispensed in the hospital.
  • Before the hospital discharges or transfers a patient, it informs and educates the patient about his or her follow-up care, treatment, and services.
  • Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.
  • Maintain and communicate accurate patient medication information.
  • Medical staff bylaws address self-governance and accountability to the governing body.
  • Medication orders are clear and accurate.
  • Ongoing professional practice evaluation information is factored into the decision to maintain existing privilege(s), to revise existing privilege(s), or to revoke an existing privilege prior to or at the time of renewal.
  • Qualified staff receive and record verbal orders.
  • The governing body is ultimately accountable for the safety and quality of care, treatment, and services.
  • The hospital designs and manages the physical environment to comply with the Life Safety Code.
  • The hospital effectively manages its programs, services, sites, or departments.
  • The hospital establishes and maintains a safe, functional environment. Note: The environment is constructed, arranged, and maintained to foster patient safety, provide facilities for diagnosis and treatment, and provide for special services appropriate to the needs of the community.
  • The hospital honors the patient's right to give or withhold informed consent.
  • The hospital inspects, tests, and maintains medical gas and vacuum systems. Note: This standard does not require hospitals to have the medical gas and vacuum systems discussed below. However, if a hospital has these types of systems, then the following inspection, testing, and maintenance requirements apply.
  • The hospital inspects, tests, and maintains utility systems. Note: At times, maintenance is performed by an external service. In these cases, hospitals are not required to possess maintenance documentation but must have access to such documentation during survey and as needed.
  • The hospital maintains complete and accurate medical records for each individual patient.
  • The hospital maintains fire safety equipment and fire safety building features. Note: This standard does not require hospitals to have the types of fire safety equipment and building features described below. However, if these types of equipment or features exist within the building, then the following maintenance, testing, and inspection requirements apply.
  • The hospital maintains the integrity of the means of egress.
  • The hospital makes food and nutrition products available to its patients.
  • The hospital manages fire risks.
  • The hospital manages risks associated with its utility systems.
  • The hospital manages risks related to hazardous materials and waste.
  • The hospital plans the patient’s care.
  • The hospital protects occupants during periods when the Life Safety Code is not met or during periods of construction.
  • The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.
  • The hospital provides care, treatment, and services as ordered or prescribed, and in accordance with law and regulation.
  • The hospital reduces the risk of infections associated with medical equipment, devices, and supplies.
  • The hospital respects, protects, and promotes patient rights.
  • The hospital safely manages high-alert and hazardous medications.
  • The organized medical staff defines the circumstances requiring monitoring and evaluation of a practitioner’s professional performance.
  • The patient’s medical record documents operative or other high-risk procedures and the use of moderate or deep sedation or anesthesia.
Advanced Certification
Programs
Certification
Decision
Effective
Date
Last Full
Review Date
Last On-Site
Review Date
Primary Stroke Center
Certification 10/11/2012  1/13/2015  1/13/2015 





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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
2014 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
2014 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  2013 -
Jun  2014
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 below the target range/value.
This organization’s performance is below the target range/value.
Perinatal Care See Detail
Not displayed.
2
Not displayed.
2
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.
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
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 below the target range/value.
This organization’s performance is below 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
   
Venous Thromboembolism (VTE) See Detail
Not displayed.
8
Not displayed.
8
 
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
Consultants in Infectious Diseases
4404 C 19th St.
Lubbock, TX  79407
    Services:
    • Outpatient Clinics (Outpatient)
    Convenant Neuroscience Patient Resource and Rehab Center
    3610 22nd St, Ste 301
    Lubbock, TX  79410
      Services:
      • Outpatient Clinics (Outpatient)
      Covenant Center for Wound Care and Hyperbaric Medicine
      4000 22nd Place Ste. 100
      Lubbock, TX  79410
        Services:
        • Outpatient Clinics (Outpatient)
        Covenant Children's Dental Clinic
        4122 22nd Place
        Lubbock, TX  79410
          Services:
          • Outpatient Clinics (Outpatient)
          Covenant Counseling Center
          1302 Broadway
          Lubbock, TX  79401
            Services:
            • Behavioral Health (Non 24 Hour Care - Adult/Child/Youth)
            Covenant Gamma Southwest
            3603 21st Street
            Lubbock, TX  79410
              Services:
              • Anesthesia (Outpatient)
              • Outpatient Clinics (Outpatient)
              Covenant Health Pulmonary
              3621 22nd St. Ste 400
              Lubbock, TX  79410
                Services:
                • Outpatient Clinics (Outpatient)
                Covenant Home Infusion
                4002 22nd Place
                Lubbock, TX  79410
                  Services:
                  • Durable Medical Equipment
                  • Enteral Equipment and/or Supplies
                  • Enteral Nutrients
                  • External Infusion Pumps and/or Supplies
                  • Parenteral Equipment and/or Supplies
                  • Parenteral Nutrients
                  • Pharmacy, Clinical Consulting Services
                  • Pharmacy/Dispensary,General Services
                  • Supplies
                  Covenant Horizons Clinic
                  4001 22nd Place, Building 66
                  Lubbock, TX  79410
                    Services:
                    • Behavioral Health (Non 24 Hour Care - Adult)
                    • Chemical Dependency (Non 24 Hour Care - Adult)
                    Covenant Medical Center  *
                    3615 19th Street
                    Lubbock, TX  79410
                    Joint Commission Advanced Certification Programs:
                    • Primary Stroke Center
                      Services:
                      • Cardiac Catheterization Lab (Surgical Services)
                      • Cardiac Surgery (Surgical Services)
                      • Cardiothoracic Surgery (Surgical Services)
                      • Cardiovascular Unit (Inpatient)
                      • Coronary Care 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)
                      • Inpatient Unit (Inpatient)
                      • Interventional Radiology (Inpatient, Outpatient, Imaging/Diagnostic Services)
                      • Magnetic Resonance Imaging (Imaging/Diagnostic Services)
                      • Medical /Surgical Unit (Inpatient)
                      • Medical ICU (Intensive Care Unit)
                      • Neuro/Spine Unit (Inpatient)
                      • Neurosurgery (Surgical Services)
                      • Nuclear Medicine (Imaging/Diagnostic Services)
                      • Ophthalmology (Surgical Services)
                      • Orthopedic Surgery (Surgical Services)
                      • Orthopedic/Spine Unit (Inpatient)
                      • Plastic Surgery (Surgical Services)
                      • Post Anesthesia Care Unit (PACU) (Inpatient)
                      • Rehabilitation Unit (Inpatient, 24-hour Acute Care/Crisis Stabilization)
                      • 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)
                      Covenant Medical Center - Lakeside
                      4000 24th Street
                      Lubbock, TX  79410
                        Services:
                        • Behavioral Health (Day Programs - Adult)
                          (24-hour Acute Care/Crisis Stabilization - Adult)
                          (Partial - Adult)
                        • Cardiac Catheterization Lab (Surgical Services)
                        • Cardiac Surgery (Surgical Services)
                        • Cardiothoracic Surgery (Surgical Services)
                        • Chemical Dependency (Day Programs - Adult)
                          (24-hour Acute Care/Crisis Stabilization - Adult)
                          (Partial - Adult)
                        • CT Scanner (Imaging/Diagnostic Services)
                        • Ear/Nose/Throat Surgery (Surgical Services)
                        • Family Support (Non 24 Hour Care)
                        • Gastroenterology (Surgical Services)
                        • GI or Endoscopy Lab (Imaging/Diagnostic Services)
                        • Gynecological Surgery (Surgical Services)
                        • 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)
                        • Neurosurgery (Surgical Services)
                        • Normal Newborn Nursery (Inpatient)
                        • Nuclear Medicine (Imaging/Diagnostic Services)
                        • Ophthalmology (Surgical Services)
                        • Orthopedic Surgery (Surgical Services)
                        • Plastic Surgery (Surgical Services)
                        • Positron Emission Tomography (PET) (Imaging/Diagnostic Services)
                        • Post Anesthesia Care Unit (PACU) (Inpatient)
                        • Surgical Unit (Inpatient)
                        • Teleradiology (Imaging/Diagnostic Services)
                        • Thoracic Surgery (Surgical Services)
                        • Ultrasound (Imaging/Diagnostic Services)
                        • Urology (Surgical Services)
                        • Vascular Surgery (Surgical Services)
                        Covenant Outpatient Infusion Center
                        4000 22nd Place, Ste. 100
                        Lubbock, TX  79410
                          Services:
                          • Outpatient Clinics (Outpatient)
                          Covenant Sleep Disorder Center
                          36102 22nd Street, Suite 200
                          Lubbock, TX  79410
                            Services:
                            • Outpatient Clinics (Outpatient)
                            Joe Arrington Cancer Research and Treatment Center
                            4101 22nd Place
                            Lubbock, TX  79410
                              Services:
                              • Administration of Blood Product (Outpatient)
                              • Administration of High Risk Medications (Outpatient)
                              • Anesthesia (Outpatient)
                              • Outpatient Clinics (Outpatient)
                              • Perform Invasive Procedure (Outpatient)
                              Southwest Medical Park
                              9812 Slide Road
                              Lubbock, TX  79424
                                Services:
                                • Outpatient Clinics (Outpatient)

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