The Joint Commission
Quality Check
Quality Report

Summary of Quality Information
Capital Health Medical Center - Hopewell
Org ID: 502836
One Capital Way
Pennington, NJ  08534
(609)537-6081
www.capitalhealth.org


Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full Survey Date Last On-Site Survey Date
Hospital
Accredited 5/18/2013 5/17/2013   5/17/2013  


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 6/15/2012  7/11/2014  7/11/2014 



Certified
Programs
Certification
Decision
Effective
Date
Last Full
Review Date
Last On-Site
Review Date
Joint Replacement - Hip
Certification 12/4/2013  12/3/2013  12/3/2013 



Other Accredited Programs / Services
Hospital  -  Accredited by American College of Surgeons-Commission on Cancer (ACoS-COC)


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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
2013 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  2013 -
Dec  2013
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.
Stroke Care See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above 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 above the target range/value.
  • Colon/Large Intestine 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.
  • 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.
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
Capital Health Center for Digestive Health
Two Capital Way, Suite 380
Pennington, NJ  08534
    Services:
    • Single Specialty Practitioner (Outpatient)
    Capital Health Medical Center - Hopewell  *
    One Capital Way
    Pennington, NJ  08534
    Joint Commission Advanced Certification Programs:
    • Primary Stroke Center
    Joint Commission Certified Programs:
    • Joint Replacement - Hip
      Services:
      • Brachytherapy (Imaging/Diagnostic 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)
      • Gynecology (Inpatient)
      • Inpatient Unit (Inpatient)
      • Interventional Radiology (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)
      • Neurosurgery (Surgical Services)
      • Normal Newborn Nursery (Inpatient)
      • Nuclear Medicine (Imaging/Diagnostic Services)
      • Ophthalmology (Surgical Services)
      • Orthopedic Surgery (Surgical Services)
      • Outpatient Clinics (Outpatient)
      • Pediatric Unit (Inpatient)
      • Plastic Surgery (Surgical Services)
      • Positron Emission Tomography (PET) (Imaging/Diagnostic Services)
      • Post Anesthesia Care Unit (PACU) (Inpatient)
      • Radiation Oncology (Imaging/Diagnostic Services)
      • Surgical Unit (Inpatient)
      • Teleradiology (Imaging/Diagnostic Services)
      • Thoracic Surgery (Surgical Services)
      • Ultrasound (Imaging/Diagnostic Services)
      • Urology (Surgical Services)
      • Vascular Surgery (Surgical Services)
      Capital Health Primary Care - Ewing
      1230 Parkway Ave, Suite 203
      Ewing, NJ  08628
        Services:
        • Single Specialty Practitioner (Outpatient)
        Capital Health Primary Care - Lower Makefield
        1050 Stoney Hill Road
        Yardley, PA  19067
          Services:
          • Single Specialty Practitioner (Outpatient)
          Capital Health Primary Care - Mountainview
          850 Bear Tavern Road
          Trenton, NJ  08628
            Services:
            • Brachytherapy (Imaging/Diagnostic Services)
            • Cardiac Catheterization Lab (Surgical Services)
            • Cardiovascular 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)
            • Inpatient Unit (Inpatient)
            • Interventional Radiology (Imaging/Diagnostic Services)
            • Labor & Delivery (Inpatient)
            • Magnetic Resonance Imaging (Imaging/Diagnostic Services)
            • Medical /Surgical Unit (Inpatient)
            • Medical ICU (Intensive Care Unit)
            • Neurosurgery (Surgical Services)
            • Normal Newborn Nursery (Inpatient)
            • Nuclear Medicine (Imaging/Diagnostic Services)
            • Orthopedic Surgery (Surgical Services)
            • Outpatient Clinics (Outpatient)
            • Pediatric Unit (Inpatient)
            • Plastic Surgery (Surgical Services)
            • Positron Emission Tomography (PET) (Imaging/Diagnostic Services)
            • Post Anesthesia Care Unit (PACU) (Inpatient)
            • Radiation Oncology (Imaging/Diagnostic Services)
            • Single Specialty Practitioner (Outpatient)
            • Surgical Unit (Inpatient)
            • Teleradiology (Imaging/Diagnostic Services)
            • Thoracic Surgery (Surgical Services)
            • Ultrasound (Imaging/Diagnostic Services)
            • Urology (Surgical Services)
            • Vascular Surgery (Surgical Services)
            Capital Health Primary Care - Pennington
            2480 Pennington Road
            Pennington, NJ  08534
              Services:
              • Single Specialty Practitioner (Outpatient)
              Capital Health Primary Care - Princeton
              811 Executive Drive, Building 8
              Princeton, NJ  08540
                Services:
                • Single Specialty Practitioner (Outpatient)
                Capital Health Primary Care - Quakerbridge
                4056 Quakerbridge Road, Suite 101
                Lawrence Township, NJ  08648
                  Services:
                  • Single Specialty Practitioner (Outpatient)
                  Capital Health Surgical Group
                  Two Capital Way, Suite 356
                  Pennington, NJ  08534
                    Services:
                    • Single Specialty Practitioner (Outpatient)
                    Capital Health System at Hamilton
                    1401/1445 Whitehorse-Mercerville Road
                    Trenton, NJ  08619
                      Services:
                      • Outpatient Clinics (Outpatient)
                      Capital Institute for Neurosciences
                      Two Capital Way, Suite 456
                      Pennington, NJ  08534
                        Services:
                        • Outpatient Clinics (Outpatient)
                        Heart Care Associates at Capital Health
                        Two Capital Way, Suite 357
                        Pennington, NJ  08534
                          Services:
                          • Single Specialty Practitioner (Outpatient)
                          Plastic Surgery Associates of NJ
                          Two Capital Way, Suite 505
                          Pennington, NJ  08534
                            Services:
                            • Single Specialty Practitioner (Outpatient)

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