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Quality Report

Summary of Quality Information
Thomas Jefferson University Hospitals, Inc.
Org ID: 6132
111 South 11th Street
Philadelphia, PA  19107
(215)955-6000
www.jeffersonhospital.org

Accreditation
Programs		 Accreditation
Decision		 Effective
Date		 Last Full Survey Date Last On-Site Survey Date  
Hospital
Accredited 12/12/2009 12/11/2009 12/11/2009  

Advanced Certification
Programs		 Certification
Decision		 Effective
Date		 Last Full
Review Date		 Last On-Site
Review Date
Primary Stroke Center
Certification 7/31/2009  7/30/2009  7/30/2009 
Ventricular Assist Device
Certification 8/5/2009  7/9/2009  7/9/2009 


Certified
Programs		 Certification
Decision		 Effective
Date		 Last Full
Review Date		 Last On-Site
Review Date
Joint Replacement - Hip
Certification 8/1/2009  7/31/2009  7/31/2009 
Joint Replacement - Knee
Certification 8/1/2009  7/31/2009  7/31/2009 


Other Accredited Programs / Services
Pathology and Clinical Laboratory  -  Accredited by American Society for Histocompatibility and Immuniogenetics


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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
2010 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 above the target range/value.
This organization’s performance is above the target range/value.
Pneumonia Care See Detail
This organization’s performance is below the target range/value.
This organization’s performance is below 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.
  • 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 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 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)
 
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
Healthmark Inc.
1 Cresent Drive, Suite 100
Philadelphia, PA  19112
  • General Outpatient Services (Outpatient)
Jefferson Hospital of Neuroscience
900 Walnut Street
Philadelphia, PA  19107
  • CT Scanner (Inpatient, Outpatient)
  • EEG/EKG/EMG Lab (Inpatient)
  • Endocrinology (Inpatient)
  • Family Practice (Inpatient)
  • General Medical Services (Inpatient)
  • General Surgery (Inpatient)
  • Imaging/Radiology (Inpatient, Outpatient)
  • Intensive Care Unit (Inpatient)
  • Internal Medicine (Inpatient)
  • Magnetic Resonance Imaging (Inpatient, Outpatient)
  • Mental Health (Inpatient, 24-hour Acute Care/Crisis Stabilization)
  • Neurology (Inpatient)
  • Neurosurgery (Inpatient)
  • Nuclear Medicine (Inpatient, Outpatient)
  • Operating Room (Inpatient)
  • Pain Management (Inpatient)
  • Post Anesthesia Care Unit (PACU) (Inpatient)
  • Rehabilitation and Physical Medicine (Inpatient)
  • Respiratory Care (Ventilator) (Inpatient)
  • Telemetry (Inpatient)
  • Urgent Care/Emergency Medicine (Outpatient)
Jefferson Methodist Heart Center, PHiladelphia
2422-24 S Broad Street
Philadelphia, PA  19145
  • General Outpatient Services (Outpatient)
Jefferson Outpatient Imaging at 925 Chestnut Street
925 Chestnut Street
Philadelphia, PA  19107
  • General Outpatient Services (Outpatient)
Jefferson Outpatient Rehabilitation Medicine
25 S. 9th Street
Philadelphia, PA  19107
  • General Outpatient Services (Outpatient)
Jefferson Radiation Therapy at Riddle Memorial Hospital
1078 West Baltimore Pike, Ste 2
Media, PA  19063
  • General Outpatient Services (Outpatient)
Jefferson Surgical Center
1100 Walnut Street, 2nd Floor
Philadelphia, PA  19107
  • Anesthesia (Outpatient)
  • General Outpatient Services (Outpatient)
Methodist Radiology at St. Agnes
1900 S. Broad Street
Philadelphia, PA  19145
  • General Outpatient Services (Outpatient)
MRI at Novacare
1 Novacare Way
Philadelphia, PA  19107
  • General Outpatient Services (Outpatient)
Pain Center
Ben Franklin Building
Philadelphia, PA  19107
  • General Outpatient Services (Outpatient)
Thomas Jefferson University Hospital  *
111 South 11th Street
Philadelphia, PA  19107
Joint Commission Advanced Certification Programs:
  • Primary Stroke Center
  • Ventricular Assist Device
Joint Commission Certified Programs:
  • Joint Replacement - Hip
  • Joint Replacement - Knee
Services:
  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult/Child/Youth)
  • Bone Marrow Transplant (Inpatient)
  • Cancer Center/Oncology (Inpatient, Outpatient)
  • Cardiac Catheterization Lab (Inpatient, Outpatient)
  • Cardiac Surgery (Inpatient)
  • Cardiac Unit/Cardiology (Inpatient)
  • CT Scanner (Inpatient, Outpatient)
  • Dermatology (Inpatient)
  • Dialysis (Inpatient)
  • EEG/EKG/EMG Lab (Inpatient, Outpatient)
  • Electroconvulsive Therapy (Inpatient, Outpatient)
  • Emergency Room (Outpatient)
  • Endocrinology (Inpatient)
  • Family Practice (Inpatient, Outpatient)
  • Gastroenterology (Inpatient)
  • General Medical Services (Inpatient, Outpatient)
  • General Surgery (Inpatient, Outpatient)
  • GI or Endoscopy Lab (Inpatient, Outpatient)
  • Gynecology (Inpatient)
  • Hematology/Blood Treatment (Inpatient)
  • Imaging/Radiology (Inpatient, Outpatient)
  • Infectious Diseases (Inpatient)
  • Infusion Therapy (Inpatient, Outpatient)
  • Intensive Care Unit (Inpatient)
  • Internal Medicine (Inpatient, Outpatient)
  • Labor & Delivery (Inpatient)
  • Magnetic Resonance Imaging (Inpatient, Outpatient)
  • Mental Health (Inpatient, 24-hour Acute Care/Crisis Stabilization)
  • Neonatal Intensive Care (Inpatient)
  • Nephrology (Inpatient, Outpatient)
  • Neurology (Inpatient)
  • Neurosurgery (Inpatient)
  • Nuclear Medicine (Inpatient, Outpatient)
  • Nursery (Inpatient)
  • Obstetrics (Inpatient)
  • Occupational Health (Outpatient)
  • Operating Room (Inpatient, Outpatient)
  • Ophthalmology/Eye Surgery (Inpatient, Outpatient)
  • Oral Maxillofacial Surgery (Inpatient, Outpatient)
  • Orthopedic Surgery (Inpatient, Outpatient)
  • Otolaryngology/Ear, Nose, and Throat (Inpatient, Outpatient)
  • Outpatient Surgery (Outpatient)
  • Pain Management (Inpatient, Outpatient)
  • Pediatric Care (Inpatient)
  • Plastic Surgery (Inpatient, Outpatient)
  • Podiatry (Inpatient, Outpatient)
  • Post Anesthesia Care Unit (PACU) (Inpatient, Outpatient)
  • Pulmonary Function Lab (Inpatient, Outpatient)
  • Radiation Oncology (Inpatient, Outpatient)
  • Rehabilitation and Physical Medicine (Inpatient, Outpatient)
  • Respiratory Care (Ventilator) (Inpatient)
  • Rheumatology (Inpatient)
  • Telemetry (Inpatient)
  • Thoracic Surgery (Inpatient, Outpatient)
  • Trauma/Burn Unit (Inpatient)
  • Ultrasound (Inpatient, Outpatient)
  • Urgent Care/Emergency Medicine (Outpatient)
  • Urology (Inpatient)
  • Vascular Surgery (Inpatient)
  • Wound Care (Inpatient, Outpatient)
TJUH/Methodist Hospital Division
2301 S. Broad Street
Philadelphia, PA  19148
  • Cancer Center/Oncology (Inpatient, Outpatient)
  • Cardiac Unit/Cardiology (Inpatient)
  • CT Scanner (Inpatient, Outpatient)
  • Dermatology (Inpatient)
  • Dialysis (Inpatient)
  • EEG/EKG/EMG Lab (Inpatient, Outpatient)
  • Emergency Room (Outpatient)
  • Endocrinology (Inpatient, Outpatient)
  • Family Practice (Inpatient)
  • Gastroenterology (Inpatient)
  • General Medical Services (Inpatient)
  • General Surgery (Inpatient)
  • GI or Endoscopy Lab (Inpatient, Outpatient)
  • Gynecology (Inpatient, Outpatient)
  • Hematology/Blood Treatment (Inpatient)
  • Imaging/Radiology (Inpatient, Outpatient)
  • Infectious Diseases (Inpatient)
  • Infusion Therapy (Inpatient)
  • Intensive Care Unit (Inpatient)
  • Internal Medicine (Inpatient)
  • Magnetic Resonance Imaging (Inpatient, Outpatient)
  • Nephrology (Inpatient, Outpatient)
  • Neurology (Inpatient)
  • Nuclear Medicine (Inpatient, Outpatient)
  • Occupational Health (Outpatient)
  • Operating Room (Inpatient, Outpatient)
  • Ophthalmology/Eye Surgery (Inpatient, Outpatient)
  • Orthopedic Surgery (Inpatient, Outpatient)
  • Otolaryngology/Ear, Nose, and Throat (Inpatient, Outpatient)
  • Outpatient Surgery (Outpatient)
  • Pain Management (Inpatient, Outpatient)
  • Plastic Surgery (Inpatient, Outpatient)
  • Podiatry (Inpatient, Outpatient)
  • Post Anesthesia Care Unit (PACU) (Inpatient, Outpatient)
  • Pulmonary Function Lab (Inpatient, Outpatient)
  • Radiation Oncology (Inpatient, Outpatient)
  • Rehabilitation and Physical Medicine (Inpatient, Outpatient)
  • Respiratory Care (Ventilator) (Inpatient)
  • Rheumatology (Inpatient)
  • Sleep Center (Outpatient)
  • Telemetry (Inpatient)
  • Thoracic Surgery (Inpatient)
  • Ultrasound (Inpatient, Outpatient)
  • Urgent Care/Emergency Medicine (Outpatient)
  • Urology (Inpatient, Outpatient)
  • Vascular Surgery (Inpatient)
  • Wound Care (Inpatient, Outpatient)
Ultrasound / Breast Imaging Center
909 Walnut Street
Philadelphia, PA  19107
  • General Outpatient Services (Outpatient)

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