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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 8/21/2010 8/20/2010   6/6/2013  


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




Certified
Programs 		Certification
Decision 		Effective
Date 		Last Full
Review Date 		Last On-Site
Review Date
Hip Fracture
Certification 7/11/2012  7/10/2012  7/10/2012 
Joint Replacement - Hip
Certification 7/12/2012  7/11/2012  7/11/2012 
Joint Replacement - Knee
Certification 7/12/2012  7/11/2012  7/11/2012 



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.
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:
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 similar to the target range/value.
This organization’s performance is similar to the target range/value.
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
This organization’s performance is similar to the target range/value.
This organization’s performance is above 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 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
Geisinger Northeast Urology
6 Wildflower Drive
Wilkes Barre, PA  18702
    Services:
    • Outpatient Clinics (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
      675 Baltimore Drive
      Wilkes Barre, PA  18702
        Services:
        • Anesthesia (Outpatient)
        • Outpatient Clinics (Outpatient)
        Geisinger Wyoming Valley Medical Center  *
        1000 East Mountain Drive
        Wilkes Barre, PA  18711-0001
        Joint Commission Certified Programs:
        • Hip Fracture
        • Joint Replacement - Hip
        • Joint Replacement - Knee
          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)
          • 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)
          • 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)
          • Surgical ICU (Intensive Care Unit)
          • Thoracic Surgery (Surgical Services)
          • Transplant Surgery (Surgical Services)
          • Ultrasound (Imaging/Diagnostic Services)
          • Urology (Surgical Services)
          • Vascular Surgery (Surgical Services)
          GWVMC Infusion Center at Mount Pocono
          126 Market Way
          Mount Pocono, PA  18344
            Services:
            • Administration of High Risk Medications (Outpatient)
            • Outpatient Clinics (Outpatient)
            GWVMC Infusion Center at Tunkhannock
            110 Trieble Road, Suite 1
            Tunkhannock, PA  18657
              Services:
              • Administration of High Risk Medications (Outpatient)
              • Outpatient Clinics (Outpatient)
              GWVMC Orthopaedics
              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
                114 Lt. Michael Cleary Drive
                Dallas, PA  18612
                  Services:
                  • Single Specialty Practitioner (Outpatient)
                  GWVMC Radiology at Mount Pocono
                  126 Market Way
                  Mount Pocono, PA  18344
                    Services:
                    • Single Specialty Practitioner (Outpatient)
                    GWVMC Specialty Outpatient Clinic
                    620 Baltimore Dr
                    Wilkes Barre, PA  18702
                      Services:
                      • Outpatient Clinics (Outpatient)
                      GWVMC Women's Health Services
                      1130 Highway 315
                      Wilkes Barre, PA  18702
                        Services:
                        • Single Specialty Practitioner (Outpatient)
                        Mountaintop Patient Service Center
                        Route 309
                        Mountain Top, PA  18707
                          Services:
                          • Single Specialty Practitioner (Outpatient)
                          Mt. Pocono Sleep Center
                          126 Market Way
                          Mount Pocono, PA  18344
                            Services:
                            • Single Specialty Practitioner (Outpatient)
                            Podiatry-Plains
                            270 South River Street
                            Wilkes Barre, PA  18705
                              Services:
                              • Single Specialty Practitioner (Outpatient)
                              Same Day Surgery, at GSWB a campus of GWV
                              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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