The Joint Commission
Quality Check
Quality Report

Summary of Accreditation Quality Information
University General Hospital
Org ID: 440118
7501 Fannin Street
Houston, TX  77054
(713)375-7100
ughospital.com


Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full Survey Date Last On-Site Survey Date
Hospital
Accredited 10/13/2012 10/12/2012   3/28/2014  


Accreditation programs recognized by the Centers for Medicare and Medicaid Services (CMS)
Hospital





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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
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:
Oct  2012 -
Sep  2013
Heart Failure Care See Detail
Not displayed.
3
Not displayed.
3
Pneumonia Care See Detail
This organization’s performance is below the target range/value.
This organization’s performance is below 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 below the target range/value.
This organization’s performance is below the target range/value.
  • Blood Vessel Surgery
See Detail
This organization’s performance is below the target range/value.
This organization’s performance is below 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.
  • Hip Joint Replacement
See Detail
Not displayed.
3
Not displayed.
3
  • Knee 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.
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
UGH Baytown Endoscopy Center
910 N Highway 146
Baytown, TX  77520
    Services:
    • Ambulatory Surgery Center (Outpatient)
    • Anesthesia (Outpatient)
    • Perform Invasive Procedure (Outpatient)
    UGH Baytown Imaging
    2800 Garth Road
    Baytown, TX  77520
      Services:
      • Administration of High Risk Medications (Outpatient)
      • Outpatient Clinics (Outpatient)
      UGH Baytown Sleep
      910 N. Highway 146
      Baytown, TX  77520
        Services:
        • Outpatient Clinics (Outpatient)
        UGH C. Foster & Associates - Seabrook
        2100 Nasa Parkway
        Seabrook, TX  77586
          Services:
          • Outpatient Clinics (Outpatient)
          UGH C. Foster & Associates- Dickinson
          3750 Medical Park Drive # 200
          Dickinson, TX  77539
            Services:
            • Outpatient Clinics (Outpatient)
            UGH C. Foster & Associates- S.W. Houston
            6565 West Loop South # 820
            Bellaire, TX  77401
              Services:
              • Outpatient Clinics (Outpatient)
              UGH C. Foster & Asssociates - Pasadena
              5051 Crenshaw Rad
              Pasadena, TX  77505
                Services:
                • Outpatient Clinics (Outpatient)
                UGH KW Imaging
                22751 Professional Dr., Suite 2100
                Kingwood, TX  77339
                  Services:
                  • Outpatient Clinics (Outpatient)
                  UGH KW Physical Therapy
                  22751 Professional Dr., Suite 2100
                  Kingwood, TX  77339
                    Services:
                    • Outpatient Clinics (Outpatient)
                    UGH KW Sleep Center
                    22751 Professional Dr., Suite 2100
                    Kingwood, TX  77339
                      Services:
                      • Outpatient Clinics (Outpatient)
                      UGH Robert Horry Center for Sports & Physical Rehab
                      15591 CreekBend Drive Suite 200
                      Sugar Land, TX  77498
                        Services:
                        • Outpatient Clinics (Outpatient)
                        UGH Woodlands Physical Therapy
                        3101 College Park Drive
                        The Woodlands, TX  77384
                          Services:
                          • Outpatient Clinics (Outpatient)
                          University General Hospital  *
                          7501 Fannin Street
                          Houston, TX  77054
                            Services:
                            • Cardiac Catheterization Lab (Surgical Services)
                            • 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)
                            • Interventional Radiology (Imaging/Diagnostic Services)
                            • Magnetic Resonance Imaging (Imaging/Diagnostic Services)
                            • Medical /Surgical Unit (Inpatient)
                            • Medical ICU (Intensive Care Unit)
                            • Nuclear Medicine (Imaging/Diagnostic Services)
                            • Orthopedic Surgery (Surgical Services)
                            • Outpatient Clinics (Outpatient)
                            • Plastic Surgery (Surgical Services)
                            • Teleradiology (Imaging/Diagnostic Services)
                            • Thoracic Surgery (Surgical Services)
                            • Ultrasound (Imaging/Diagnostic Services)
                            • Urology (Surgical Services)
                            • Vascular Surgery (Surgical Services)
                            University General Hospital My Quest
                            7501 Fannin Street # 600
                            Houston, TX  77054
                              Services:
                              • Outpatient Clinics (Outpatient)
                              University General Hospital Wound Care
                              7501 Fannin Suite 600
                              Houston, TX  77054
                                Services:
                                • Outpatient Clinics (Outpatient)

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