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Quality Report

Summary of Quality Information
The Miriam Hospital
Org ID: 5649
164 Summit Avenue
Providence, RI  02906
(401)793-2012
www.lifespan.org

Accreditation
Programs		 Accreditation
Decision		 Effective
Date		 Last Full Survey Date Last On-Site Survey Date  
Hospital
Accredited 7/12/2008 7/11/2008 7/11/2008  

Advanced Certification
Programs		 Certification
Decision		 Effective
Date		 Last Full
Review Date		 Last On-Site
Review Date
Primary Stroke Center
Certification 5/7/2010  5/6/2010  5/6/2010 



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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
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 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.
  • Coronary Artery Bypass Graft
 See Detail
This organization’s performance is above 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 above the target range/value.
This organization’s performance is above 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 above the target range/value.
This organization’s performance is above the target range/value.
  • Open Heart Surgery
 See Detail
This organization’s performance is above 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)
 
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
Behavioral Medicine Clinic Serv and Weight Mgmt Program
146 West River Street
Providence, RI  02904
  • Alzheimers Disease (Outpatient)
  • Anxiety/panic disorders (Outpatient)
  • Bariatric Surgery (Outpatient)
  • Behavioral Health (Non 24 Hour Care - Adult)
  • Depression (Outpatient)
  • General Outpatient Services (Outpatient)
  • Health and Wellness (Outpatient)
  • Morbid Obesity (Outpatient)
  • Nutrition Programs (Outpatient)
  • Tobacco Treatment / Cessation (Outpatient)
  • Weight Loss (Outpatient)
Center for Cardiac Fitness
208 Collyer Street, 2nd Floor
Providence, RI  02904
  • Acute Coronary Syndrome (Outpatient)
  • Acute Myocardial Infarction (Outpatient)
  • Coronary Artery Disease (Outpatient)
  • General Outpatient Services (Outpatient)
  • Health and Wellness (Outpatient)
  • Heart Failure (Outpatient)
  • Hyperlipidemia (Outpatient)
  • Ischemic Heart Disease (Outpatient)
  • Nutrition Programs (Outpatient)
  • Tobacco Treatment / Cessation (Outpatient)
  • Weight Loss (Outpatient)
Department of Rehabilitation Services
195 Collyer Street
Providence, RI  02904
  • General Outpatient Services (Outpatient)
  • Hip Joint Replacement (Outpatient)
  • Sports Medicine (Outpatient)
  • Stroke Rehabilitation (Outpatient)
Dr. Wing Behavioral Health & Research
196 Richmond Street
Providence, RI  02906
Joint Commission Advanced Certification Programs:
  • Primary Stroke Center
Services:
  • General Outpatient Services (Outpatient)
  • Weight Loss (Outpatient)
Immunology Research Center
1125 North Main Street
Providence, RI  02904
  • General Outpatient Services (Outpatient)
  • HIV Clinic (Outpatient)
  • HIV/AIDS (Outpatient)
Preadmission Testing
208 Collyer Street, 3rd floor, Room 300
Providence, RI  02904
  • General Outpatient Services (Outpatient)
RISE TB Clinic
14 Third St.
Providence, RI  02906
  • General Outpatient Services (Outpatient)
  • Tuberculosis (Outpatient)
The Miriam Hospital (Main Site), Providence RI  *
164 Summit Avenue
Providence, RI  02906
Joint Commission Advanced Certification Programs:
  • Primary Stroke Center
Services:
  • Abdominal Aortic Aneurysm (Inpatient)
  • Acute Coronary Syndrome (Inpatient)
  • Acute Myocardial Infarction (Inpatient)
  • Anxiety/panic disorders (Outpatient)
  • Atrial Fibrillation (Inpatient)
  • Bariatric Surgery (Inpatient)
  • Benign prostatic hyperplasia (BPH) (Inpatient, Outpatient)
  • Breast Cancer (Inpatient, Outpatient)
  • Cancer Center/Oncology (Inpatient, Outpatient)
  • Cardiac Catheterization Lab (Inpatient, Outpatient)
  • Cardiac Surgery (Inpatient)
  • Cardiac Unit/Cardiology (Inpatient)
  • Cellulitis (Inpatient)
  • Cerebral Bleeding (Inpatient)
  • Chronic Obstructive Pulmonary Disease (Inpatient)
  • Colon/Rectal Cancer (Inpatient)
  • Coronary Artery Disease (Inpatient)
  • Crohn's Disease (Inpatient)
  • CT Scanner (Inpatient, Outpatient)
  • Depression (Outpatient)
  • Dermatology (Outpatient)
  • Diabetes Mellitus (Inpatient)
  • Dialysis (Inpatient)
  • EEG/EKG/EMG Lab (Inpatient, Outpatient)
  • Emergency Room (Outpatient)
  • Emphysema (Inpatient)
  • End Stage Renal Disease (Inpatient)
  • Endocrinology (Inpatient)
  • Esophageal Cancer (Inpatient)
  • Family Practice (Inpatient)
  • Gastroenterology (Inpatient, Outpatient)
  • General Medical Services (Inpatient, Outpatient)
  • General Surgery (Inpatient, Outpatient)
  • GI or Endoscopy Lab (Inpatient, Outpatient)
  • Heart Failure (Inpatient)
  • Hematology/Blood Treatment (Inpatient, Outpatient)
  • Hip Joint Replacement (Inpatient, Outpatient)
  • HIV Clinic (Outpatient)
  • HIV/AIDS (Inpatient, Outpatient)
  • Hyperlipidemia (Inpatient, Outpatient)
  • Hypertension (Inpatient, Outpatient)
  • Imaging/Radiology (Inpatient)
  • Infectious Diseases (Inpatient)
  • Infusion Therapy (Inpatient)
  • Inpatient Diabetes (Inpatient)
  • Intensive Care Unit (Inpatient)
  • Internal Medicine (Inpatient, Outpatient)
  • Interventional Cardiac Catheterization (Inpatient, Outpatient)
  • Interventional Radiology (Inpatient)
  • Irritable Bowel Syndrome (Inpatient)
  • Ischemic Heart Disease (Inpatient)
  • Joint Replacement - Knee (Inpatient, Outpatient)
  • Laminectomy (Inpatient)
  • Leukemia (Inpatient, Outpatient)
  • Lung Cancer (Inpatient, Outpatient)
  • Magnetic Resonance Imaging (Inpatient, Outpatient)
  • Mental Health (Outpatient)
  • Morbid Obesity (Inpatient)
  • Nephrology (Inpatient)
  • Neurology (Inpatient, Outpatient)
  • Nuclear Medicine (Inpatient, Outpatient)
  • Occupational Health (Outpatient)
  • Operating Room (Inpatient, Outpatient)
  • Ophthalmology/Eye Surgery (Outpatient)
  • Oral Maxillofacial Surgery (Inpatient, Outpatient)
  • Orthopedic Surgery (Inpatient, Outpatient)
  • Otolaryngology/Ear, Nose, and Throat (Outpatient)
  • Outpatient Surgery (Outpatient)
  • Pancreatic Cancer (Inpatient)
  • Pancreatitis (Inpatient)
  • Pathology (Inpatient, Outpatient)
  • Plastic Surgery (Outpatient)
  • Pneumonia (Inpatient)
  • Podiatry (Outpatient)
  • Post Anesthesia Care Unit (PACU) (Inpatient, Outpatient)
  • Prostate Cancer (Inpatient)
  • Pulmonary Function Lab (Inpatient, Outpatient)
  • Respiratory Care (Ventilator) (Inpatient)
  • Respiratory Failure (Inpatient)
  • Sleep Center (Outpatient)
  • Sleeping Disorder (Outpatient)
  • Spine Care (Inpatient, Outpatient)
  • Telemetry (Inpatient)
  • Thoracic Surgery (Inpatient)
  • Tuberculosis (Outpatient)
  • Ulcerative Colitis (Inpatient)
  • Ultrasound (Inpatient, Outpatient)
  • Urgent Care/Emergency Medicine (Outpatient)
  • Urology (Inpatient, Outpatient)
  • Vascular Surgery (Inpatient, Outpatient)
  • Women's Health (Outpatient)
The Miriam Hospital's Diagnostic Imaging Center, Prov., RI
195 Collyer Street, Suite 101
Providence, RI  02904
  • General Outpatient Services (Outpatient)
  • Osteoporosis (Outpatient)
  • Spine Care (Outpatient)

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