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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 12/8/2011 12/7/2011   12/7/2011  
Hospital
Accredited 12/10/2011 12/9/2011   1/20/2012  


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 10/11/2012  10/10/2012  10/10/2012 




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


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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
Home Care
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.
*
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:
Oct  2011 -
Sep  2012
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.
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 similar to the target range/value.
This organization’s performance is similar to 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 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 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
   
  Survey of Patients' Hospital Experiences (see details)
 
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
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 Community Diabetes Education Program
        1318 Broadway
        Lubbock, TX  79401
          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 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 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)
                  • 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)
                  • Orthopedic Surgery (Surgical Services)
                  • Orthopedic/Spine Unit (Inpatient)
                  • Plastic Surgery (Surgical Services)
                  • Post Anesthesia Care Unit (PACU) (Inpatient)
                  • 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)
                    • Interventional Radiology (Imaging/Diagnostic Services)
                    • Labor & Delivery (Inpatient)
                    • Magnetic Resonance Imaging (Imaging/Diagnostic Services)
                    • Medical /Surgical Unit (Inpatient)
                    • Medical ICU (Intensive Care Unit)
                    • Neurosurgery (Surgical Services)
                    • Normal Newborn Nursery (Inpatient)
                    • Nuclear Medicine (Imaging/Diagnostic Services)
                    • Orthopedic Surgery (Surgical Services)
                    • Orthopedic/Spine Unit (Inpatient)
                    • Plastic Surgery (Surgical Services)
                    • Positron Emission Tomography (PET) (Imaging/Diagnostic Services)
                    • Post Anesthesia Care Unit (PACU) (Inpatient)
                    • 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 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)
                        Covenant Transplant Clinic
                        3506 21st Street, Suite 501
                        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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