The Joint Commission
Quality Check
Quality Report

Summary of Quality Information
Memorial Hospital West
Org ID: 5091
703 North Flamingo Road
Pembroke Pines, FL  33028
(954)436-5000
www.mhs.net


Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full Survey Date Last On-Site Survey Date  
Hospital
Accredited 4/19/2008 4/18/2008 9/18/2009  
Pathology and Clinical Laboratory
Accredited 2/1/2008 1/28/2010 1/28/2010  

Advanced Certification
Programs
Certification
Decision
Effective
Date
Last Full
Review Date
Last On-Site
Review Date
Primary Stroke Center
Certification 12/2/2008  12/1/2008  12/1/2008 


Special Quality Awards


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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
Hospital
2009 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 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 above the target range/value.
This organization’s performance is above the target range/value.
Pneumonia 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 similar to the target range/value.
  • 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.
  • Hysterectomy
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 similar to the target range/value.
This organization’s performance is similar to the target range/value.
SCIP – Venous Thromboembolism (VTE) See Detail
   
  30 Day Risk Adjusted Mortality Rates (see details)
  30 Day Hospital Readmission Rates (see details)
  Survey of Patients' Hospital Experiences (see details)
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
Breast Cancer Center Laboratory at Memorial Hospital West
603 N.Flamingo Road, Suite 157
Hollywood, FL  33028
  • General Laboratory Tests
Memorial Hospital West  *
703 North Flamingo Road
Pembroke Pines, FL  33028
Joint Commission Advanced Certification Programs:
  • Primary Stroke Center
Services:
  • Abdominal Aortic Aneurysm (Inpatient)
  • Acute Coronary Syndrome (Inpatient)
  • Asthma (Inpatient)
  • Asthma, Pediatrics (Inpatient)
  • Cancer Center/Oncology (Inpatient, Outpatient)
  • Cardiac Catheterization Lab (Inpatient, Outpatient)
  • Cardiac Unit/Cardiology (Inpatient)
  • Cellulitis (Inpatient)
  • Chronic Obstructive Pulmonary Disease (Inpatient)
  • CT Scanner (Inpatient, Outpatient)
  • Diabetes Mellitus (Inpatient)
  • Dialysis (Inpatient)
  • EEG/EKG/EMG Lab (Inpatient, Outpatient)
  • Emergency Room (Outpatient)
  • End Stage Renal Disease (Inpatient)
  • Endocrinology (Inpatient, Outpatient)
  • Family Practice (Inpatient)
  • Gastroenterology (Inpatient)
  • Gastroesophageal Reflux Disease (Inpatient)
  • General Laboratory Tests
  • General Medical Services (Inpatient)
  • General Surgery (Inpatient)
  • GI or Endoscopy Lab (Inpatient, Outpatient)
  • Gynecology (Inpatient)
  • Head Injury (Inpatient)
  • Heart Failure (Inpatient)
  • Hematology/Blood Treatment (Inpatient, Outpatient)
  • Hip Joint Replacement (Inpatient)
  • Hodgkin's disease (Inpatient)
  • Hyperlipidemia (Inpatient)
  • Imaging/Radiology (Inpatient, Outpatient)
  • Infectious Diseases (Inpatient)
  • Infusion Services (Inpatient, Outpatient)
  • Inpatient Diabetes (Inpatient)
  • Intensive Care Unit (Inpatient)
  • Internal Medicine (Inpatient)
  • Intraventricular hemorrhage (Inpatient)
  • Joint Replacement - Knee (Inpatient)
  • Labor & Delivery (Inpatient)
  • Leukemia (Inpatient)
  • Lithotripsy/Kidney Stone Treatment (Inpatient)
  • Lung Cancer (Inpatient)
  • Magnetic Resonance Imaging (Inpatient, Outpatient)
  • Neonatal Intensive Care (Inpatient)
  • Neonatology (Inpatient)
  • Nephrology (Inpatient)
  • Neurology (Inpatient)
  • Neurosurgery (Inpatient)
  • Nuclear Medicine (Inpatient, Outpatient)
  • Nursery (Inpatient)
  • Obstetrics (Inpatient, Outpatient)
  • Operating Room (Inpatient, Outpatient)
  • Oral Maxillofacial Surgery (Inpatient)
  • Orthopedic Surgery (Inpatient)
  • Otolaryngology/Ear, Nose, and Throat (Inpatient)
  • Outpatient Surgery (Outpatient)
  • Pain Management (Outpatient)
  • Pancreatitis (Inpatient)
  • Pediatric Emergency Department (Outpatient - Child/Youth)
  • Pelvic Inflammatory Disease (Inpatient)
  • Pneumonia (Inpatient)
  • Podiatry (Inpatient)
  • Post Anesthesia Care Unit (PACU) (Inpatient, Outpatient)
  • Prostate Cancer (Inpatient)
  • Pulmonary Function Lab (Inpatient, Outpatient)
  • Radiation Oncology (Inpatient, Outpatient)
  • Rehabilitation (Outpatient)
  • Respiratory Care (Ventilator) (Inpatient)
  • Rheumatology (Inpatient)
  • Self Injury (Inpatient)
  • Sports Medicine (Outpatient)
  • Telemetry (Inpatient)
  • Thoracic Surgery (Inpatient)
  • Toxicology
  • Ulcerative Colitis (Inpatient)
  • Ultrasound (Inpatient, Outpatient)
  • Urology (Inpatient)
  • Vascular Surgery (Inpatient)
  • Wound Care (Outpatient)
Memorial Hospital West Cancer Institute, Pembroke Pines, FL
801 N Flamingo Rd Ste 11
Pembroke Pines, FL  33028
  • General Laboratory Tests
  • General Outpatient Services (Outpatient)

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