The Joint Commission
Quality Check
Quality Report

Summary of Accreditation Quality Information
Massena Memorial Hospital
Org ID: 5799
One Hospital Drive
Massena, NY  13662
(315)769-4320
www.massenahospital.org


Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full Survey Date Last On-Site Survey Date
Hospital
Accredited 3/23/2012 3/22/2012   3/22/2012  
Laboratory Accreditation Program
Accredited 7/4/2013 7/3/2013   7/3/2013  


Accreditation programs recognized by the Centers for Medicare and Medicaid Services (CMS)
Hospital





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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
2012 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 similar to the target range/value.
This organization’s performance is similar to the target range/value.
Heart Failure Care See Detail
Not displayed.
3
Not displayed.
3
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
Not displayed.
3
Not displayed.
3
  • Colon/Large Intestine Surgery
See Detail
Not displayed.
3
Not displayed.
3
  • 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.
SCIP – Venous Thromboembolism (VTE) See Detail
   
Laboratory Accreditation Program
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 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
Brasher Falls Health Center
Box 285
Brasher Falls, NY  13613
    Services:
    • General Laboratory Tests
    • Outpatient Clinics (Outpatient)
    Louisville Family Health Center
    10 State Highway 37B
    Massena, NY  13662
      Services:
      • Outpatient Clinics (Outpatient)
      Massena Memorial Hospital  *
      One Hospital Drive
      Massena, NY  13662
        Services:
        • CT Scanner (Imaging/Diagnostic Services)
        • Ear/Nose/Throat Surgery (Surgical Services)
        • EEG/EKG/EMG Lab (Imaging/Diagnostic Services)
        • Gastroenterology (Surgical Services)
        • General Laboratory Tests
        • Gynecological Surgery (Surgical Services)
        • Labor & Delivery (Inpatient)
        • Magnetic Resonance Imaging (Imaging/Diagnostic Services)
        • Medical /Surgical Unit (Inpatient)
        • Medical ICU (Intensive Care Unit)
        • Nuclear Medicine (Imaging/Diagnostic Services)
        • Ophthalmology (Surgical Services)
        • Orthopedic Surgery (Surgical Services)
        • Outpatient Clinics (Outpatient)
        • Positron Emission Tomography (PET) (Imaging/Diagnostic Services)
        • Post Anesthesia Care Unit (PACU) (Inpatient)
        • Surgical ICU (Intensive Care Unit)
        • Toxicology
        • Ultrasound (Imaging/Diagnostic Services)
        • Urology (Surgical Services)
        MMH Dialysis Center
        290 Main Street
        Massena, NY  13662
          Services:
          • Dialysis (Outpatient)
          • General Laboratory Tests
          • Outpatient Clinics (Outpatient)
          MMH OUTPATIENT CENTER
          DBA:  MMH OUTPATIENT CENTER
          269-271 Andrews Street, Massena, NY
          Massena, NY  13662
            Services:
            • Outpatient Clinics (Outpatient)
            Norfolk Family Health Center
            42 West Main Street
            Norfolk, NY  13667
              Services:
              • General Laboratory Tests
              • Outpatient Clinics (Outpatient)

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