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Quality Report
Summary of Accreditation Quality Information |
 DeKalb Medical at North Decatur
Org ID: 3735 2701 North Decatur Rd Decatur, GA 30033(404)501-1000 www.dekalbmedical.org
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Accreditation
Programs
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Accreditation
Decision
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Effective
Date
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Last Full Survey Date |
Last On-Site Survey Date |
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Accredited
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11/17/2012 |
11/16/2012
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12/28/2012
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Accreditation programs recognized by the Centers for Medicare and Medicaid Services (CMS)
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Symbol Key |
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This organization
achieved the best possible results
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This organization’s performance is above the target range/value. |
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This organization’s performance is similar to the target range/value. |
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This organization’s performance is below the target range/value. |
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This measure is not applicable for this organization.
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Not displayed |
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Footnote Key |
| 1. |
The measure or measure set was not reported. |
| 2. |
The measure set does not have
an overall result.
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| 3. |
The number is not
enough for comparison
purposes.
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The measure meets the Privacy Disclosure Threshold
rule.
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The organization scored above
90% but was below most other
organizations.
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The measure results are not
statistically valid.
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| 7. |
The measure results are based
on a sample of patients.
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| 8. |
The number of months with
measure data is below the reporting requirement.
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| 9. |
The measure results are temporarily suppressed pending resubmission of updated data. |
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Test Measure: a measure being evaluated for reliability of the individual data elements or awaiting National Quality Forum Endorsement. |
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| National Patient Safety Goals and National Quality Improvement Goals |
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Compared to
other Joint Commission Accredited Organizations
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Nationwide
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Statewide
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*
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National Quality Improvement Goals: |
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Reporting Period:
Oct
2011
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Sep
2012 |
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| Surgical Care Improvement Project (SCIP) |
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| SCIP - Infection Prevention For All Reported Procedures:
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See Detail
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Survey of Patients' Hospital Experiences (see details)
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Hospitals voluntarily participate in the Survey of Patients' Hospital Experiences(HCAHPS).
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Pediatric and psychiatric hospitals are not eligible to participate in the HCAHPS survey based on their patient population.
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The Joint Commission only reports measures endorsed by the National Quality Forum.
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State results are not calculated for the National Patient Safety Goals. |
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* Primary Location
An organization may provide services not listed here. For more information refer to the
Quality Report User Guide
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| Locations of Care |
Available Services |
DeKalb Medical. North Decatur Campus *
2701 N. Decatur Road
Decatur, GA 30033
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Services:
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- Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult)
- Brachytherapy (Imaging/Diagnostic Services)
- Cardiac Catheterization Lab (Surgical Services)
- Coronary Care Unit (Inpatient)
- CT Scanner (Imaging/Diagnostic Services)
- Ear/Nose/Throat Surgery (Surgical Services)
- EEG/EKG/EMG Lab (Imaging/Diagnostic Services)
- Gastroenterology (Surgical Services)
- General Laboratory Tests
- 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)
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- 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)
- 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)
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