The Joint Commission
Quality Check
Quality Report

Summary of Quality Information
Piedmont Hospital, Inc.
Org ID: 4277
1968 Peachtree Road, NW
Atlanta, GA  30309-1285
(404)605-3775
www.piedmonthospital.org


Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full Survey Date Last On-Site Survey Date
Hospital
Accredited 1/18/2013 8/10/2012   1/17/2013  


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
Primary Stroke Center
Certification 6/28/2013  6/27/2013  6/27/2013 
Ventricular Assist Device
Certification 5/22/2013  5/21/2013  5/21/2013 



Certified
Programs
Certification
Decision
Effective
Date
Last Full
Review Date
Last On-Site
Review Date
Chronic Obstructive Pulmonary Disease
Certification 9/28/2013  9/27/2013  9/27/2013 
Joint Replacement - Hip
Certification 9/25/2013  9/24/2013  9/24/2013 
Joint Replacement - Knee
Certification 9/25/2013  9/24/2013  9/24/2013 


Certification programs recognized by the Centers for Medicare and Medicaid Services (CMS)
Ventricular Assist Device



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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
2012 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 similar to the target range/value.
This organization’s performance is similar to 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 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 similar to the target range/value.
This organization’s performance is similar to 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
   
 
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
CV Imaging Rockdale
1301 Sigman Road Suite 210
Conyers, GA  30012
    Services:
    • Outpatient Clinics (Outpatient)
    Piedmont Cardiovascular Imaging
    1140 Hammond Drive
    Sandy Springs, GA  30328
      Services:
      • Outpatient Clinics (Outpatient)
      Piedmont Hospital Cardiovascular Imaging
      1357 Hembree Road, Suite 145
      Roswell, GA  30076
        Services:
        • Outpatient Clinics (Outpatient)
        Piedmont Hospital, Inc.  *
        1968 Peachtree Road, NW
        Atlanta, GA  30309-1285
        Joint Commission Advanced Certification Programs:
        • Primary Stroke Center
        • Ventricular Assist Device
        Joint Commission Certified Programs:
        • Chronic Obstructive Pulmonary Disease
        • Joint Replacement - Hip
        • Joint Replacement - Knee
          Services:
          • Brachytherapy (Imaging/Diagnostic 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)
          • 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 (Inpatient, Outpatient, 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)
          • Pediatric Ophthalmology (Outpatient - Child/Youth)
          • Pediatric Otolaryngology (Outpatient - Child/Youth)
          • 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)
          • Transplant Surgery (Surgical Services)
          • Ultrasound (Imaging/Diagnostic Services)
          • Urology (Surgical Services)
          • Vascular Surgery (Surgical Services)
          Piedmont Imaging at Atlantic Station
          232 19th Street Suite 7220
          Atlanta, GA  30309
            Services:
            • Outpatient Clinics (Outpatient)
            Piedmont Imaging at Howell Mill
            1800 Howell Mill Road Suite 100
            Atlanta, GA  30318
              Services:
              • Outpatient Clinics (Outpatient)
              • Perform Invasive Procedure (Outpatient)
              Piedmont Imaging Center at Kennesaw
              3525 Busbee Drive
              Kennesaw, GA  30144
                Services:
                • Outpatient Clinics (Outpatient)
                Piedmont Infusion Center at Piedmont West Medical Office Par
                1800 Howell Mill Road, Suite 750
                Atlanta, GA  30318
                  Services:
                  • Administration of High Risk Medications (Outpatient)
                  • Outpatient Clinics (Outpatient)
                  Radiation Oncology Clinic at Piedmont West
                  1800 Howell Mill Road Suite LL10
                  Atlanta, GA  30318
                    Services:
                    • Outpatient Clinics (Outpatient)
                    The Piedmont Atlanta Sleep Center
                    3820 Medical Park Drive, Suite #2100
                    Austell, GA  30106
                      Services:
                      • Outpatient Clinics (Outpatient)

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