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 7/12/2014  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:
Jul  2014 -
Jun  2015
Emergency Department See Detail
Not displayed.
2
Not displayed.
2
Immunization See Detail
Not displayed.
2
Not displayed.
2
Perinatal 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.
Venous Thromboembolism (VTE) See Detail
Not displayed.
8
Not displayed.
8
 
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
Bordentown Family Medical Center
1 Third St.
Bordentown, NJ  08505
    Services:
    • Perform Invasive Procedure (Outpatient)
    • Single Specialty Practitioner (Outpatient)
    Capital Health Center for Digestive Health
    Two Capital Way, Suite 380
    Pennington, NJ  08534
      Services:
      • Single Specialty Practitioner (Outpatient)
      Capital Health Endocrinology Specialists
      1235 Whitehorse-Mercerville Road
      Hamilton, NJ  08619
        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)
          • 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:
            • Perform Invasive Procedure (Outpatient)
            • Single Specialty Practitioner (Outpatient)
            Capital Health Primary Care - Lower Makefield
            1050 Stoney Hill Road
            Yardley, PA  19067
              Services:
              • Perform Invasive Procedure (Outpatient)
              • Single Specialty Practitioner (Outpatient)
              Capital Health Primary Care - Mountainview
              850 Bear Tavern Road, Suite 309
              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)
                • Perform Invasive Procedure (Outpatient)
                • 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 - Princeton
                811 Executive Drive, Building 8
                Princeton, NJ  08540
                  Services:
                  • Perform Invasive Procedure (Outpatient)
                  • Single Specialty Practitioner (Outpatient)
                  Capital Health Primary Care - Quakerbridge
                  4056 Quakerbridge Road, Suite 101
                  Lawrence Township, NJ  08648
                    Services:
                    • Perform Invasive Procedure (Outpatient)
                    • Single Specialty Practitioner (Outpatient)
                    Capital Health Surgical Group
                    Two Capital Way, Suite 356
                    Pennington, NJ  08534
                      Services:
                      • Outpatient Clinics (Outpatient)
                      • Perform Invasive Procedure (Outpatient)
                      • Single Specialty Practitioner (Outpatient)
                      Capital Health System at Hamilton
                      1401/1445 Whitehorse-Mercerville Road
                      Trenton, NJ  08619
                        Services:
                        • Outpatient Clinics (Outpatient)
                        • Perform Invasive Procedure (Outpatient)
                        Capital Institute for Neurosciences
                        Two Capital Way, Suite 456
                        Pennington, NJ  08534
                          Services:
                          • Outpatient Clinics (Outpatient)
                          • Perform Invasive Procedure (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:
                              • Perform Invasive Procedure (Outpatient)
                              • Single Specialty Practitioner (Outpatient)

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