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Quality Report

Summary of Quality Information
Wilkes-Barre General Hospital
Org ID: 6222
575 North River Street
Wilkes Barre, PA  18764
(570)552-1279
www.wvhcs.org

Accreditation
Programs 		Accreditation
Decision 		Effective
Date 		Last Full Survey Date Last On-Site Survey Date
Laboratory Accreditation Program
Accredited 6/11/2011 6/10/2011   6/10/2011  
Hospital
Accredited 7/21/2012 7/20/2012   7/20/2012  


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


Advanced Certification
Programs 		Certification
Decision 		Effective
Date 		Last Full
Review Date 		Last On-Site
Review Date
Primary Stroke Center
Certification 2/1/2013  1/31/2013  1/31/2013 





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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.
National Patient Safety Goals and National Quality Improvement Goals
    Compared to other Joint Commission Accredited Organizations
    Nationwide Statewide
Laboratory Accreditation Program
2011 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.
*
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:
Oct  2011 -
Sep  2012
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 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 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 below the target range/value.
This organization’s performance is below 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 below the target range/value.
This organization’s performance is below 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
   
  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
Back Mountain Medical Center
100 Upper Demunds Road
Dallas, PA  18612
    Services:
    • Outpatient Clinics (Outpatient)
    Carbondale Outpatient Center
    150 Brooklyn St.
    Carbondale, PA  18407
      Services:
      • Outpatient Clinics (Outpatient)
      Center for Diagnostic Imaging
      960 Welles St.
      Forty Fort, PA  18704
      Other Clinics/Practices located at this site:
      • Commonwealth Health Outpatient Center
      Services:
      • General Laboratory Tests
      • Outpatient Clinics (Outpatient)
      Center for Same Day Surgery at Wilkes Barre General Hospital
      545 N. River st.
      Wilkes Barre, PA  18764
        Services:
        • Ambulatory Surgery Center (Outpatient)
        • Anesthesia (Outpatient)
        • General Laboratory Tests
        • Perform Invasive Procedure (Outpatient)
        Commonwealth Health Outpatient
        Route 940 & 115,
        Blakeslee, PA  18610
          Services:
          • Laboratory Draw Station (Outpatient)
          Commonwealth Health Outpatient Center
          Rear 319 North State St.
          Clarks Summit, PA  18411
            Services:
            • Laboratory Draw Station (Outpatient)
            Commonwealth Health Outpatient Center
            Bill's Plaza, Route 435
            Moscow, PA  18444
              Services:
              • Single Specialty Practitioner (Outpatient)
              Commonwealth Health Outpatient Center
              605 Main St.
              Duryea, PA  18642
                Services:
                • Laboratory Draw Station (Outpatient)
                Commonwealth Health Outpatient Center
                1201 North Church St.
                Hazleton, PA  18202
                  Services:
                  • Laboratory Draw Station (Outpatient)
                  Commonwealth Health Outpatient Center
                  425 Tioga Ave
                  Kingston, PA  18704
                    Services:
                    • Laboratory Draw Station (Outpatient)
                    Commonwealth Health Outpatient Center
                    610 Wyoming Ave.
                    Kingston, PA  18704
                      Services:
                      • Laboratory Draw Station (Outpatient)
                      Commonwealth Health Outpatient Center
                      62 North Mountain Blvd
                      Mountain Top, PA  18707
                        Services:
                        • Laboratory Draw Station (Outpatient)
                        Commonwealth Health Outpatient Center
                        4 Main St.
                        Nanticoke, PA  18634
                          Services:
                          • Laboratory Draw Station (Outpatient)
                          Commonwealth Health Outpatient Center
                          201 N. Main St.
                          Wilkes Barre, PA  18705
                            Services:
                            • Laboratory Draw Station (Outpatient)
                            Commonwealth Health Outpatient Center
                            729 Siniawa Plaza II, Route 6
                            Scranton, PA  18501
                              Services:
                              • Laboratory Draw Station (Outpatient)
                              Commonwealth Health Outpatient Center
                              331 N. Washington Ave.
                              Scranton, PA  18502
                                Services:
                                • Ambulatory Surgery Center (Outpatient)
                                Commonwealth Health Outpatient Center
                                803 South Main St.
                                Taylor, PA  18517
                                  Services:
                                  • Laboratory Draw Station (Outpatient)
                                  Commonwealth Health Outpatient Center
                                  901 Wyoming Ave
                                  Pittston, PA  18640
                                    Services:
                                    • Laboratory Draw Station (Outpatient)
                                    Commonwealth Health Outpatient Center
                                    176 N. Main Street
                                    Shavertown, PA  18708
                                    Other Clinics/Practices located at this site:
                                    • Commonwealth Health Outpatient Center
                                    Services:
                                    • Laboratory Draw Station (Outpatient)
                                    Commonwealth Health Outpatient Clinic
                                    190 Welles Street, Suite 166
                                    Forty Fort, PA  18704
                                    Other Clinics/Practices located at this site:
                                    • Commonwealth Health Outpatient Clinic
                                    Services:
                                    • Laboratory Draw Station (Outpatient)
                                    Diabetes Management Center
                                    468 Northampton Street
                                    Edwardsville, PA  18704
                                    Other Clinics/Practices located at this site:
                                    • Commonwealth Health Diabetes Management Center
                                    Services:
                                    • General Laboratory Tests
                                    • Outpatient Clinics (Outpatient)
                                    Exeter Outpatient Testing Center
                                    1701 Wyoming Avenue
                                    Exeter, PA  18643
                                    Other Clinics/Practices located at this site:
                                    • Commonwealth Health Outpatient Center
                                    Services:
                                    • Outpatient Clinics (Outpatient)
                                    Pennant Lackawanna
                                    620 North Blakely Street
                                    Dunmore, PA  18512
                                      Services:
                                      • General Laboratory Tests
                                      Sleep Disorder Center at Cross Creek Pointe
                                      1065 Highway 315, Suite 202
                                      Wilkes Barre, PA  18702
                                        Services:
                                        • Outpatient Clinics (Outpatient)
                                        Thomas P. Saxton Medical Pavilion
                                        468 Northampton Street
                                        Edwardsville, PA  18704
                                        Other Clinics/Practices located at this site:
                                        • Commonwealth Health Outpatient Center
                                        Services:
                                        • General Laboratory Tests
                                        • Outpatient Clinics (Outpatient)
                                        Wilkes-Barre General Hospital
                                        575 River Street
                                        Wilkes Barre, PA  18764
                                          Services:
                                          • Cardiac Catheterization Lab (Surgical Services)
                                          • Cardiac Surgery (Surgical Services)
                                          • Cardiothoracic Surgery (Surgical Services)
                                          • Cardiovascular Unit (Inpatient)
                                          • Coronary Care Unit (Inpatient)
                                          • CT Scanner (Imaging/Diagnostic Services)
                                          • Dialysis Unit (Inpatient)
                                          • Ear/Nose/Throat Surgery (Surgical Services)
                                          • EEG/EKG/EMG Lab (Imaging/Diagnostic Services)
                                          • Gastroenterology (Surgical Services)
                                          • General Laboratory Tests
                                          • GI or Endoscopy Lab (Imaging/Diagnostic Services)
                                          • Gynecological Surgery (Surgical Services)
                                          • Gynecology (Inpatient)
                                          • Hematology/Oncology Unit (Inpatient)
                                          • Interventional Radiology (Imaging/Diagnostic Services)
                                          • Labor & Delivery (Inpatient)
                                          • Magnetic Resonance Imaging (Imaging/Diagnostic Services)
                                          • Medical /Surgical Unit (Inpatient)
                                          • Medical Detoxification (Inpatient)
                                          • Medical ICU (Intensive Care Unit)
                                          • Neurosurgery (Surgical Services)
                                          • Normal Newborn Nursery (Inpatient)
                                          • Nuclear Medicine (Imaging/Diagnostic 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)
                                          • Surgical ICU (Intensive Care Unit)
                                          • Surgical Unit (Inpatient)
                                          • Thoracic Surgery (Surgical Services)
                                          • Toxicology
                                          • Ultrasound (Imaging/Diagnostic Services)
                                          • Urology (Surgical Services)
                                          • Vascular Surgery (Surgical Services)
                                          Wilkes-Barre General Hospital POCT  *
                                          575 North River Street
                                          Wilkes Barre, PA  18764
                                          Joint Commission Advanced Certification Programs:
                                          • Primary Stroke Center
                                            Services:
                                            • General Laboratory Tests
                                            • Toxicology
                                            Wilkes-Barre General Hospital, Mountaintop Campus
                                            239 South Mountain Boulevard
                                            Mountain Top, PA  18707
                                              Services:
                                              • Outpatient Clinics (Outpatient)
                                              Wound Healing Center at Wilkes Barre General Hospital
                                              545 North River Street
                                              Wilkes Barre, PA  18702
                                                Services:
                                                • General Laboratory Tests
                                                • Outpatient Clinics (Outpatient)
                                                Wyoming Valley Imaging Center
                                                345 North Pennsylvania Avenue
                                                Wilkes Barre, PA  18702
                                                  Services:
                                                  • General Laboratory Tests
                                                  • Outpatient Clinics (Outpatient)

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