The Joint Commission
Quality Check
Accreditation Quality Report
 > Summary of Accreditation Quality Information
 > Accredited Programs
 > Accreditation National Patient Safety Goals
 > Sites and Services
 > Accreditation History
 > Download Accreditation PDF Report
 > Download Accreditation PDF Report - Include Quarterly Data
 > Accreditation Quality Report User Guide
Additional Links
 > The Joint Commission
 > International Center for Patient Safety
 > Joint Commission International
Quality Report

Summary of Accreditation Quality Information
Bay Pines VA Healthcare System
Org ID: 4536
10000 Bay Pines Boulevard
Bay Pines, FL  33744
(727)398-6661
152.130.80.105
Accreditation Decision: Accredited
Decision Effective Date: April 14, 2007
This organization is in full compliance with all applicable standards.  


Accredited Programs Last Full Survey Date Last On-Site Survey Date  
Behavioral Health Care 4/13/2007 4/13/2007  
Home Care 4/13/2007 4/13/2007  
Hospital 4/13/2007 4/13/2007  
Long Term Care 4/13/2007 4/13/2007  
Pathology and Clinical Laboratory 10/29/2008 10/29/2008  



- Top -
  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 of patients 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.
National Patient Safety Goals and National Quality Improvement Goals
    Compared to other Joint Commission Accredited Organizations
    Nationwide Statewide
Behavioral Health Care
2007 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.
*
Home Care
2007 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
2007 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:
Jul  2008 -
Jun  2009
Heart Attack 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.
Heart Failure Care See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
Pneumonia 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.
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.
  • 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 above the target range/value.
This organization’s performance is above the target range/value.
SCIP – Venous Thromboembolism (VTE) See Detail
   
Long Term Care
2007 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.
*
Pathology and Clinical Laboratory
2008 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.
*
 
Hospitals voluntarily participate in the Survey of Patients' Hospital Experiences(HCAHPS).
Pediatric and psychiatric hospitals are not eligible to participate in the HCAHPS survey based on their patient population.
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.

- Top -
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
Baldo Mero Lopez State Veterans Nursing Home
6919 Parkway Boulevard
Land O Lakes, FL  34639
  • Clinical Consultant Pharmacist Services
  • Pharmacy Services
Bay Pines VA Healthcare System  *
10000 Bay Pines Boulevard
Bay Pines, FL  33744
  • Addiction Care (Outpatient)
  • Allergy (Outpatient)
  • Audiology (Outpatient)
  • Behavioral Health (Day Programs - Adult)
    (Residential / Group Homes - Adult)
    (Non 24 Hour Care - Adult)
    (24-hour Acute Care/Crisis Stabilization - Adult)
  • Cancer Center/Oncology (Inpatient, Outpatient)
  • Cardiac Catheterization Lab (Inpatient, Outpatient)
  • Cardiac Unit/Cardiology (Inpatient, Outpatient)
  • Care Coordination (Non 24 Hour Care)
  • Case Management (Non 24 Hour Care - Adult)
  • Chemical Dependency (Residential / Group Homes - Adult)
    (Non 24 Hour Care - Adult)
  • Community Integration (Non 24 Hour Care)
  • CT Scanner (Inpatient, Outpatient)
  • Dentistry (Inpatient, Outpatient)
  • Dermatology (Inpatient, Outpatient)
  • Dialysis (Inpatient, Outpatient)
  • EEG/EKG/EMG Lab (Inpatient, Outpatient)
  • Electroconvulsive Therapy (Inpatient, Outpatient)
  • Emergency Room (Outpatient)
  • Employment Services (Non 24 Hour Care)
  • Endocrinology (Inpatient, Outpatient)
  • Family Support (Non 24 Hour Care)
  • Gastroenterology (Inpatient, Outpatient)
  • General Medical Services (Inpatient, Outpatient)
  • General Surgery (Inpatient, Outpatient)
  • GI or Endoscopy Lab (Inpatient, Outpatient)
  • Gynecology (Inpatient, Outpatient)
  • Hematology/Blood Treatment (Inpatient, Outpatient)
  • Home Health Services
  • Imaging/Radiology (Inpatient, Outpatient)
  • Infectious Diseases (Inpatient, Outpatient)
  • Infusion Services (Inpatient, Outpatient)
  • Intensive Care Unit (Inpatient)
  • Internal Medicine (Inpatient, Outpatient)
  • Long Term Care
  • Magnetic Resonance Imaging (Inpatient, Outpatient)
  • Mental Health (Inpatient, Outpatient, 24-hour Acute Care/Crisis Stabilization)
  • Nephrology (Inpatient, Outpatient)
  • Neurology (Inpatient, Outpatient)
  • Nuclear Medicine (Inpatient, Outpatient)
  • On Site Pharmacy
  • Operating Room (Inpatient, Outpatient)
  • Ophthalmology/Eye Surgery (Inpatient, Outpatient)
  • Oral Maxillofacial Surgery (Inpatient, Outpatient)
  • Orthopedic Surgery (Inpatient, Outpatient)
  • Otolaryngology/Ear, Nose, and Throat (Inpatient, Outpatient)
  • Outpatient Surgery (Outpatient)
  • Pain Management (Inpatient, Outpatient)
  • Peer Support (Non 24 Hour Care)
  • Pharmacy Services
  • Plastic Surgery (Inpatient, Outpatient)
  • Podiatry (Outpatient)
  • Post Anesthesia Care Unit (PACU) (Inpatient, Outpatient)
  • Pulmonary Function Lab (Inpatient, Outpatient)
  • Rehabilitation (Inpatient, Outpatient)
  • Rehabilitation Services
  • Respiratory Care (Ventilator) (Inpatient)
  • Respite Care (Inpatient)
  • Rheumatology (Outpatient)
  • Services Supporting Rehabilitation and Resilience (Non 24 Hour Care - Adult)
  • Skilled Nursing Care
  • Skilled Nursing Facility (Inpatient)
  • Sleep Center (Outpatient)
  • Telemetry (Inpatient)
  • Thoracic Surgery (Inpatient, Outpatient)
  • Ultrasound (Inpatient, Outpatient)
  • Urgent Care/Emergency Medicine (Outpatient)
  • Urology (Inpatient, Outpatient)
  • Vascular Surgery (Inpatient, Outpatient)
  • Vocational Rehabilitation (Non 24 Hour Care - Adult)
  • Wound Care (Inpatient, Outpatient)
Douglas T. Jacobson State Veteran's Nursing Home
21281 Grayton Terrace
Port Charlotte, FL  33954
  • Clinical Consultant Pharmacist Services
  • Pharmacy Services
Emery L. Bennett State Veterans Nursing Home
1920 Mason Avenue
Daytona Beach, FL  32117
  • Clinical Consultant Pharmacist Services
  • Pharmacy Services
VA Clinic - Ellenton
5283 Office Park Boulevard
Bradenton, FL  34203
  • Behavioral Health (Non 24 Hour Care - Adult)
VA Outpatient Clinic
3033 Winkler Extension
Fort Myers, FL  33916
  • Anesthesia (Outpatient)
  • Behavioral Health (Non 24 Hour Care - Adult)
  • General Laboratory Tests
  • General Outpatient Services (Outpatient)
  • Home Health Services
  • Toxicology
VA Primary Care Clinic
5682 Bee Ridge Rd, Suite 100
Sarasota, FL  34233
  • Behavioral Health (Non 24 Hour Care - Adult)
  • General Outpatient Services (Outpatient)
VA Primary Care Clinic
4333 N U.S.Hwy 301
Ellenton, FL  34222
  • General Outpatient Services (Outpatient)
VA Primary Care Clinic
4161 Tamiami Trail, Unit 4
Port Charlotte, FL  33952
  • Behavioral Health (Non 24 Hour Care - Adult)
  • General Outpatient Services (Outpatient)
  • Home Health Services
VA Primary Care Clinic
2685 Horseshoe Drive South Suite 101
Naples, FL  34101
  • Behavioral Health (Non 24 Hour Care - Adult)
  • General Outpatient Services (Outpatient)
VA Primary Care Clinic
35209 US Hwy 19 North
Palm Harbor, FL  34684
  • Behavioral Health (Non 24 Hour Care - Adult)
  • General Outpatient Services (Outpatient)
VA Primary Care Clinic
840 Dr. MLK Jr. Street North
Saint Petersburg, FL  33705
  • Behavioral Health (Non 24 Hour Care - Adult)
  • General Outpatient Services (Outpatient)
  • In-Home Behavioral Health Services (Non 24 Hour Care - Adult)
VA Primary Care Clinic
3760 US Highway 27 South
Sebring, FL  33870
  • Behavioral Health (Non 24 Hour Care - Adult)
  • General Outpatient Services (Outpatient)

- Top -
The Joint Commission obtains information about accredited/certified organizations not only through direct observations by its employees …Read more.
Search | About Quality Check | Take Our Survey | Advanced Search | Certified Organizations | Quality Data Download | Contact Us | Help | Privacy Policy
 © 2010 The Joint Commission, All Rights Reserved
HONcode We subscribe to the HONcode principles of the Health On the Net Foundation