The Joint Commission
Quality Check
Quality Report

Summary of Quality Information
Medstar Harbor Hospital
DBA: MedStar Harbor Hospital
Org ID: 6261
3001 South Hanover Street
Baltimore, MD  21225
(410)350-3200
www.medstarharbor.org


Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full Survey Date Last On-Site Survey Date
Hospital
Accredited 4/13/2012 4/12/2012   4/12/2012  


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 8/14/2013  8/13/2013  8/13/2013 



Certified
Programs
Certification
Decision
Effective
Date
Last Full
Review Date
Last On-Site
Review Date
Asthma, Pediatrics
Certification 12/23/2013  12/10/2013  12/10/2013 
Heart Failure
Certification 12/24/2013  12/12/2013  12/12/2013 
Joint Replacement - Hip
Certification 8/15/2013  8/14/2013  8/14/2013 
Joint Replacement - Knee
Certification 8/15/2013  8/14/2013  8/14/2013 
Spine Surgery
Certification 12/12/2013  12/11/2013  12/11/2013 



Special Quality Awards


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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
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:
Jan  2013 -
Dec  2013
Heart Attack 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.
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 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
Not displayed.
3
Not displayed.
3
  • 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.
  • 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.
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
Harbor Primary Care
1414 N. Crain Highway, Suite 3A
Glen Burnie, MD  21061
    Services:
    • Single Specialty Practitioner (Outpatient)
    Harbor Primary Care
    901 E. Fort Avenue
    Baltimore, MD  21230
      Services:
      • Single Specialty Practitioner (Outpatient)
      Harbor Primary Care
      7566 North Point Road
      Baltimore, MD  21219
        Services:
        • Single Specialty Practitioner (Outpatient)
        Harbor Primary Care
        2825 Lodge Farm Road
        Baltimore, MD  21219
          Services:
          • Single Specialty Practitioner (Outpatient)
          Harbor Specialty Care
          2900 South Hanover Street
          Baltimore, MD  21225
            Services:
            • Outpatient Clinics (Outpatient)
            • Perform Invasive Procedure (Outpatient)
            Harbor Specialty Care
            2 West Rolling Road - Ste. 108
            Catonsville, MD  21228
              Services:
              • Urgent Care (Outpatient)
              Medstar Harbor Hospital  *
              DBA:  Medstar Harbor Hospital
              3001 South Hanover Street
              Baltimore, MD  21225
              Joint Commission Advanced Certification Programs:
              • Primary Stroke Center
              Joint Commission Certified Programs:
              • Asthma, Pediatrics
              • Heart Failure
              • Joint Replacement - Hip
              • Joint Replacement - Knee
              • Spine Surgery
                Services:
                • Cardiac Catheterization Lab (Surgical Services)
                • CT Scanner (Imaging/Diagnostic Services)
                • Dialysis Unit (Inpatient)
                • 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)
                • Hematology/Oncology 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)
                • 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)
                • Outpatient Clinics (Outpatient)
                • Pediatric Emergency Medicine (Inpatient - Child/Youth)
                  (Outpatient - Child/Youth)
                • Pediatric General Surgery (Inpatient - Child/Youth)
                  (Outpatient - Child/Youth)
                • Pediatric Unit (Inpatient)
                • Plastic Surgery (Surgical Services)
                • Positron Emission Tomography (PET) (Imaging/Diagnostic Services)
                • Post Anesthesia Care Unit (PACU) (Inpatient)
                • 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)
                MedStar Harbor Primary Care - Oakwood
                DBA:  Primary Care Providers
                7845 Oakwood Road Suite 300
                Glen Burnie, MD  21061
                  Services:
                  • Outpatient Clinics (Outpatient)
                  Medstar Harbor Surgical Associates
                  7310 Ritchie Highway, Suite 515
                  Glen Burnie, MD  21061
                    Services:
                    • Single Specialty Practitioner (Outpatient)
                    Parkway Medical Association
                    DBA:  Primary Care Clinic
                    1406 South Crain Highway, Suite 108
                    Glen Burnie, MD  21061
                      Services:
                      • Single Specialty Practitioner (Outpatient)
                      Sports Medicine
                      110 Old Padonia Road
                      Cockeysville, MD  21030
                        Services:
                        • Outpatient Clinics (Outpatient)

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