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
www.ughsystem.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.
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
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:
Jan  2014 -
Dec  2014
Emergency Department See Detail
Not displayed.
2
Not displayed.
2
Heart Attack Care See Detail
Not displayed.
3
Not displayed.
3
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
Not displayed.
3
Not displayed.
3
  • 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
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
  • Knee Replacement
See Detail
This organization’s performance is below the target range/value.
This organization’s performance is below 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 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)
          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)
            • Inpatient Unit (Inpatient)
            • 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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