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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
Programs		 Accreditation
Decision		 Effective
Date		 Last Full Survey Date Last On-Site Survey Date  
Behavioral Health Care
Accredited 3/11/2010 3/10/2010 3/10/2010  
Home Care
Accredited 3/11/2010 3/10/2010 3/10/2010  
Hospital
Accredited 3/13/2010 3/12/2010 3/12/2010  
Long Term Care
Accredited 3/10/2010 3/9/2010 3/9/2010  
Pathology and Clinical Laboratory
Accredited 10/30/2008 10/29/2008 10/29/2008  



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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 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
2010 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
2010 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
2010 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  2009 -
Dec  2009
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.
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 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 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.
SCIP – Venous Thromboembolism (VTE) See Detail
   
Long Term Care
2010 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.

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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
Baldo Mero Lopez State Veterans Nursing Home
6919 Parkway Boulevard
Land O Lakes, FL  34639
  • Pharmacy, Clinical Consulting Services
  • Pharmacy, Long Term Care
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, Non-Hospice Services
  • Imaging/Radiology (Inpatient, Outpatient)
  • Infectious Diseases (Inpatient, Outpatient)
  • Infusion Therapy (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/Dispensary,General Services
  • Plastic Surgery (Inpatient, Outpatient)
  • Podiatry (Outpatient)
  • Post Anesthesia Care Unit (PACU) (Inpatient, Outpatient)
  • Pulmonary Function Lab (Inpatient, Outpatient)
  • Rehabilitation and Physical Medicine (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
  • Pharmacy, Clinical Consulting Services
  • Pharmacy, Long Term Care
Emery L. Bennett State Veterans Nursing Home
1920 Mason Avenue
Daytona Beach, FL  32117
  • Pharmacy, Clinical Consulting Services
  • Pharmacy, Long Term Care
VA Clinic Bradenton
5520 SR 64 Suite 101
Bradenton, FL  34208
  • Behavioral Health (Non 24 Hour Care - Adult)
  • General Outpatient Services (Outpatient)
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, Non-Hospice 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
4161 Tamiami Trail, Unit 4
Port Charlotte, FL  33952
  • Behavioral Health (Non 24 Hour Care - Adult)
  • General Outpatient Services (Outpatient)
  • Home Health, Non-Hospice 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
3760 US Highway 27 South
Sebring, FL  33870
  • 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)

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