The Joint Commission
Quality Check
Quality Report

Summary of Quality Information
Grady Memorial Hospital Corporation
Org ID: 3506
80 Jesse Hill, Jr., Drive, S.E.
Atlanta, GA  30303
(404)616-4252
www.gradyhealth.org


Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full Survey Date Last On-Site Survey Date
Behavioral Health Care
Accredited 7/10/2013 7/9/2013   7/9/2013  
Hospital
Accredited 7/13/2013 7/12/2013   7/12/2013  


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 6/13/2013  4/10/2013  4/10/2013 




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.
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
Behavioral Health Care
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.
*
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:
Apr  2013 -
Mar  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 similar to the target range/value.
This organization’s performance is similar to the target range/value.
Perinatal Care See Detail
Not displayed.
2
Not displayed.
2
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
Not displayed.
8
Not displayed.
8
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
Not displayed.
3
Not displayed.
3
  • 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
Not displayed.
3
Not displayed.
3
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
Adult Outpatient Behavioral Health
10 Park Place South, SE
Atlanta, GA  30303
    Services:
    • Assertive Community Treatment/Community Support Services (Non 24 Hour Care - Adult)
    • Behavioral Health (Day Programs - Adult)
      (Non 24 Hour Care - Adult)
      (Partial - Adult)
    • Community Integration (Non 24 Hour Care)
    • Peer Support (Non 24 Hour Care)
    Asa G. Yancey Health Center
    1247 Donald Lee Hollowell Pkwy. NW
    Atlanta, GA  30318
      Services:
      • Outpatient Clinics (Outpatient)
      Children's Healthcare of Atlanta Hughes Spalding Hospital
      35 Jesse Hill Dr.
      Atlanta, GA  30303
        Services:
        • Inpatient Unit (Inpatient)
        • Outpatient Clinics (Outpatient)
        • Pediatric Unit (Inpatient)
        • Ultrasound (Imaging/Diagnostic Services)
        East Point Health Center
        1595 West Cleveland Avenue
        East Point, GA  30344
          Services:
          • Outpatient Clinics (Outpatient)
          Edward C. Loughlin Radiation - Oncology Center
          145 Edgewood Avenue, S.E.
          Atlanta, GA  30303
            Services:
            • Outpatient Clinics (Outpatient)
            Grady Memorial Hospital  *
            80 Jesse Hill Jr. Drive S.E.
            Atlanta, GA  30303
            Joint Commission Advanced Certification Programs:
            • Advanced Comprehensive Stroke Center
              Services:
              • Behavioral Health (Non 24 Hour Care - Adult)
                (24-hour Acute Care/Crisis Stabilization - Adult)
              • Brachytherapy (Imaging/Diagnostic Services)
              • Burn Unit (Inpatient)
              • Cardiac Catheterization Lab (Surgical Services)
              • Cardiac Surgery (Surgical Services)
              • Cardiothoracic Surgery (Surgical Services)
              • Cardiovascular Unit (Inpatient)
              • CT Scanner (Imaging/Diagnostic Services)
              • 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)
              • 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)
              • Medical ICU (Intensive Care Unit)
              • 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)
              • Orthopedic/Spine Unit (Inpatient)
              • 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)
              • Surgical Unit (Inpatient)
              • Thoracic Surgery (Surgical Services)
              • Ultrasound (Imaging/Diagnostic Services)
              • Urology (Surgical Services)
              • Vascular Surgery (Surgical Services)
              Grady Walk-In Center
              56 Jesse Hill Jr. Drive
              Atlanta, GA  30303
                Services:
                • Outpatient Clinics (Outpatient)
                Kirkwood Family Medicine
                1863 Memorial Dr. SE
                Atlanta, GA  30317
                  Services:
                  • Outpatient Clinics (Outpatient)
                  Lindbergh Health Center
                  2695 Buford Highway, N.E., Suite 200
                  Atlanta, GA  30324
                    Services:
                    • Outpatient Clinics (Outpatient)
                    North Dekalb Health Center
                    3807 Clairmont Road, N.E.
                    Chamblee, GA  30341
                      Services:
                      • Outpatient Clinics (Outpatient)
                      North Fulton Health Center
                      7741 Roswell Road
                      Sandy Springs, GA  30350
                        Services:
                        • Outpatient Clinics (Outpatient)
                        Ponce de Leon Center
                        341 Ponce de Leon Avenue
                        Atlanta, GA  30308
                          Services:
                          • Administration of High Risk Medications (Outpatient)
                          • Outpatient Clinics (Outpatient)

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