The Joint Commission
Quality Check
Quality Report

Summary of Quality Information
Bryn Mawr Hospital
DBA: Bryn Mawr Hospital
Org ID: 6030
130 South Bryn Mawr Avenue
Bryn Mawr, PA  19010
(484)337-3000
www.mainlinehealth.org


Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full Survey Date Last On-Site Survey Date
Hospital
Accredited 7/18/2013 7/17/2013   7/17/2013  


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 3/2/2013  3/1/2013  3/1/2013 



Certified
Programs
Certification
Decision
Effective
Date
Last Full
Review Date
Last On-Site
Review Date
Breast Cancer
Certification 2/6/2013  2/5/2013  2/5/2013 
Joint Replacement - Hip
Certification 2/2/2013  2/1/2013  2/1/2013 
Joint Replacement - Knee
Certification 2/2/2013  2/1/2013  2/1/2013 




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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:
Apr  2013 -
Mar  2014
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.
Perinatal Care See Detail
Not displayed.
2
Not displayed.
2
Pneumonia Care See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
Stroke Care See Detail
Not displayed.
8
Not displayed.
8
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
This organization’s performance is above the target range/value.
This organization’s performance is above 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 above 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 above the target range/value.
This organization’s performance is above 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 above the target range/value.
SCIP – Venous Thromboembolism (VTE) See Detail
   
 
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
American Day Treatment Center
DBA:  American Day Treatment Center
401 Pilgrim Lane, Suite 100
Drexel Hill, PA  19026
    Services:
    • Behavioral Health (Non 24 Hour Care - Adult)
      (24-hour Acute Care/Crisis Stabilization - Adult)
    Bryn Mawr Hospital  *
    DBA:  Bryn Mawr Hospital
    130 South Bryn Mawr Avenue
    Bryn Mawr, PA  19010
    Joint Commission Advanced Certification Programs:
    • Primary Stroke Center
    Joint Commission Certified Programs:
    • Breast Cancer
    • Joint Replacement - Hip
    • Joint Replacement - Knee
      Services:
      • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult)
      • Cardiac Catheterization Lab (Surgical Services)
      • Cardiac Surgery (Surgical Services)
      • Cardiothoracic Surgery (Surgical Services)
      • Coronary Care 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)
      • Neuro/Spine ICU (Intensive Care Unit)
      • Neuro/Spine Unit (Inpatient)
      • Neurosurgery (Surgical Services)
      • Normal Newborn Nursery (Inpatient)
      • Nuclear Medicine (Imaging/Diagnostic Services)
      • Ophthalmology (Surgical Services)
      • Orthopedic Surgery (Surgical Services)
      • Orthopedic/Spine Unit (Inpatient)
      • Pediatric Unit (Inpatient)
      • Plastic Surgery (Surgical Services)
      • Post Anesthesia Care Unit (PACU) (Inpatient)
      • Radiation Oncology (Imaging/Diagnostic Services)
      • Sleep Laboratory (Sleep Laboratory)
      • Surgical ICU (Intensive Care Unit)
      • Surgical Unit (Inpatient)
      • Teleradiology (Imaging/Diagnostic Services)
      • Thoracic Surgery (Surgical Services)
      • Ultrasound (Imaging/Diagnostic Services)
      • Urology (Surgical Services)
      • Vascular Surgery (Surgical Services)
      BRYN MAWR HOSPITAL HEALTH CENTER
      DBA:  Bryn Mawr Hospital Health Center
      3855 West Chester Pike
      Newtown Square, PA  19073
        Services:
        • Outpatient Clinics (Outpatient)
        Founders Medical Building
        DBA:  Founders Medical Building Bryn Mawr Hospital
        101 Bryn Mawr Ave
        Bryn Mawr, PA  19010
          Services:
          • Outpatient Clinics (Outpatient)
          • Perform Invasive Procedure (Outpatient)

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