QualityReport

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

Quality Report

Summary of Accreditation Quality Information

Beth Israel Deaconess Hospital - Needham, Inc.
Org ID: 5586
148 Chestnut Street
Needham, MA 02492
(781)453-3000
www.bidneedham.org

Accreditation Decision: Accredited	Decision Effective Date: September 27, 2008
This organization is in full compliance with all applicable standards.

Accredited Programs	Last Full Survey Date	Last On-Site Survey Date
Hospital	9/26/2008	9/26/2008

Special Quality Awards

2009 Gold Get With The Guidelines - Stroke

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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

2008 National Patient Safety Goals

See Detail

National Quality Improvement Goals:

Reporting Period:
Jan 2009 -
Dec 2009

Heart Attack Care

See Detail

Heart Failure Care

See Detail

Pneumonia Care

See Detail

Surgical Care Improvement Project (SCIP)

SCIP - Cardiac

See Detail

SCIP - Infection Prevention

For All Reported Procedures:

See Detail

Colon/Large Intestine Surgery

See Detail

Hip Joint Replacement

See Detail

Hysterectomy

See Detail

Knee Replacement

See Detail

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)

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.
	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

Beth Israel Deaconess Hospital - Needham, Inc. *
148 Chestnut Street
Needham, MA 02492

Allergy (Outpatient)
Cancer Center/Oncology (Outpatient)
Cardiac Unit/Cardiology (Outpatient)
CT Scanner (Inpatient, Outpatient)
Emergency Room (Outpatient)
Endocrinology (Outpatient)
General Medical Services (Inpatient)
General Surgery (Inpatient)
GI or Endoscopy Lab (Outpatient)
Hematology/Blood Treatment (Outpatient)
Imaging/Radiology (Inpatient, Outpatient)
Infectious Diseases (Inpatient)
Infusion Therapy (Outpatient)
Intensive Care Unit (Inpatient)

Lithotripsy/Kidney Stone Treatment (Outpatient)
Neurology (Outpatient)
Nuclear Medicine (Inpatient, Outpatient)
Occupational Health (Outpatient)
Operating Room (Inpatient, Outpatient)
Outpatient Surgery (Outpatient)
Post Anesthesia Care Unit (PACU) (Inpatient, Outpatient)
Pulmonary Function Lab (Outpatient)
Rehabilitation and Physical Medicine (Outpatient)
Sleep Center (Outpatient)
Telemetry (Inpatient)
Ultrasound (Inpatient, Outpatient)
Wound Care (Outpatient)

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