The Joint Commission
Quality Check
Quality Report

Summary of Quality Information
Geisinger Wyoming Valley Medical Center
Org ID: 6223
1000 East Mountain Drive
Wilkes Barre, PA  18711
(570)808-7300
www.geisinger.org


Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full Survey Date Last On-Site Survey Date
Hospital
Accredited 8/17/2013 8/16/2013   8/16/2013  


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 11/19/2013  11/5/2013  11/5/2013 
Ventricular Assist Device
Certification 2/26/2014  2/25/2014  2/25/2014 



Certified
Programs
Certification
Decision
Effective
Date
Last Full
Review Date
Last On-Site
Review Date
Hip Fracture
Certification 8/21/2014  8/20/2014  8/20/2014 
Joint Replacement - Hip
Certification 8/20/2014  8/19/2014  8/19/2014 
Joint Replacement - Knee
Certification 8/20/2014  8/19/2014  8/19/2014 



Other Accredited Programs / Services
Hospital  -  Accredited by American College of Surgeons-Commission on Cancer (ACoS-COC)


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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
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 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
Geisinger Maternal Fetal Medicine, a service of GWVMC
190 Welles Street, Suite 114
Kingston, PA  18704
    Services:
    • Single Specialty Practitioner (Outpatient)
    Geisinger Mount Pocono
    126 Market Way
    Mount Pocono, PA  18344
    Other Clinics/Practices located at this site:
    • GWVMC Infusion Center at Mount Pocono, a service of GWVMC
    • GWVMC Radiology at Mount Pocono, a service of GWVMC
    • GWVMC Sleep Center at Mount Pocono, a service of GWVMC
    Services:
    • Administration of High Risk Medications (Outpatient)
    • Outpatient Clinics (Outpatient)
    Geisinger Northeast Urology, a service of GWVMC
    6 Wildflower Drive
    Wilkes Barre, PA  18702
      Services:
      • Single Specialty Practitioner (Outpatient)
      Geisinger South Wilkes Barre, a campus of GWV
      25 Church Street
      Wilkes Barre, PA  18765
        Services:
        • Anesthesia (Outpatient)
        • Outpatient Clinics (Outpatient)
        Geisinger Specialty Clinic, a service of GWVMC
        675 Baltimore Drive
        Wilkes Barre, PA  18702
          Services:
          • Anesthesia (Outpatient)
          • Outpatient Clinics (Outpatient)
          Geisinger Tunkhannock
          110 Trieble Road, Suite 1
          Tunkhannock, PA  18657
          Other Clinics/Practices located at this site:
          • GWVMC Infusion Center at Tunkhannock, a service of GWVMC
          • GWVMC Radiology at Tunkhannock, a service of GWVMC
          Services:
          • Administration of High Risk Medications (Outpatient)
          • Outpatient Clinics (Outpatient)
          Geisinger Wyoming Valley Medical Center  *
          1000 East Mountain Drive
          Wilkes Barre, PA  18711-0001
          Joint Commission Advanced Certification Programs:
          • Primary Stroke Center
          • Ventricular Assist Device
          Joint Commission Certified Programs:
          • Hip Fracture
          • Joint Replacement - Hip
          • Joint Replacement - Knee
          Other Clinics/Practices located at this site:
          • GWVMC Cancer Center
          • GWVMC Specialty Clinic-Outpatient Departments
          Services:
          • Brachytherapy (Imaging/Diagnostic Services)
          • Cardiac Catheterization Lab (Surgical Services)
          • Cardiac Surgery (Surgical Services)
          • Cardiothoracic Surgery (Surgical Services)
          • 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 (Inpatient, Outpatient, Imaging/Diagnostic Services)
          • Labor & Delivery (Inpatient)
          • Magnetic Resonance Imaging (Imaging/Diagnostic Services)
          • Medical /Surgical Unit (Inpatient)
          • Medical ICU (Intensive Care Unit)
          • Neurosurgery (Surgical Services)
          • Normal Newborn Nursery (Inpatient)
          • Nuclear Medicine (Imaging/Diagnostic Services)
          • Orthopedic Surgery (Surgical Services)
          • Outpatient Clinics (Outpatient)
          • Pediatric Cardiology (Outpatient - Child/Youth)
          • Pediatric Unit (Inpatient)
          • Plastic Surgery (Surgical Services)
          • Positron Emission Tomography (PET) (Imaging/Diagnostic Services)
          • Post Anesthesia Care Unit (PACU) (Inpatient)
          • Radiation Oncology (Imaging/Diagnostic Services)
          • Rehabilitation Unit (Inpatient, 24-hour Acute Care/Crisis Stabilization)
          • Sleep Laboratory (Sleep Laboratory)
          • Surgical ICU (Intensive Care Unit)
          • Teleradiology (Imaging/Diagnostic Services)
          • Thoracic Surgery (Surgical Services)
          • Ultrasound (Imaging/Diagnostic Services)
          • Urology (Surgical Services)
          • Vascular Surgery (Surgical Services)
          GWVMC Orthopaedics, a service of GWVMC
          1175 East Mountain Drive
          Wilkes Barre, PA  18702
          Joint Commission Certified Programs:
          • Hip Fracture
          • Joint Replacement - Hip
          • Joint Replacement - Knee
            Services:
            • Single Specialty Practitioner (Outpatient)
            GWVMC Radiology at Dallas, a service of GWVMC
            114 Lt. Michael Cleary Drive
            Dallas, PA  18612
              Services:
              • Single Specialty Practitioner (Outpatient)
              GWVMC Specialty Outpatient Clinic, a service of GWVMC
              620 Baltimore Dr
              Wilkes Barre, PA  18702
                Services:
                • Single Specialty Practitioner (Outpatient)
                GWVMC Women's Health Services, a service of GWVMC
                1130 Highway 315
                Wilkes Barre, PA  18702
                  Services:
                  • Single Specialty Practitioner (Outpatient)
                  Mountaintop Patient Service Center, a service of GWVMC
                  Route 309
                  Mountain Top, PA  18707
                    Services:
                    • Outpatient Clinics (Outpatient)
                    Podiatry-Plains, a service of GWVMC
                    270 South River Street
                    Wilkes Barre, PA  18705
                      Services:
                      • Single Specialty Practitioner (Outpatient)
                      Same Day Surgery at GSWB, a service of GWVMC
                      25 Church St
                      Wilkes Barre, PA  18711
                        Services:
                        • Administration of High Risk Medications (Outpatient)
                        • Ambulatory Surgery Center (Outpatient)
                        • Anesthesia (Outpatient)
                        • Perform Invasive Procedure (Outpatient)

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