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Quality Report

Summary of Quality Information
University of Maryland Medical Center
Org ID: 6264
22 South Greene Street
Baltimore, MD  21201-1595
(410)328-6027
www.umm.edu
Accreditation Decision: Accredited
Decision Effective Date: November 15, 2008
This organization is in full compliance with all applicable standards.  


Accredited Programs Last Full Survey Date Last On-Site Survey Date  
Behavioral Health Care 11/14/2008 11/14/2008  
Hospital 11/14/2008 11/14/2008  

Advanced Certification
Programs		 Certification
Decision		 Effective
Date		 Last Full
Review Date		 Last On-Site
Review Date
Primary Stroke Center
Certification 11/14/2008  11/13/2008  11/13/2008 
Ventricular Assist Device
Certification 12/11/2008  8/25/2010  8/25/2010 


Certified
Programs		 Certification
Decision		 Effective
Date		 Last Full
Review Date		 Last On-Site
Review Date
Asthma, Pediatrics
Certification 11/15/2008  11/14/2008  11/14/2008 


Other Accredited Programs / Services
Laboratory  -  Accredited by College of American Pathologists


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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
Behavioral Health Care
2008 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
2008 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 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 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 similar to the target range/value.
This organization’s performance is similar to 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 similar to the target range/value.
This organization’s performance is similar to the target range/value.
  • Hip Joint Replacement
 See Detail
This organization’s performance is above the target range/value.
This organization’s performance is similar to 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
1020 A Hollins Street - Residential
1020 A Hollins Street
Baltimore, MD  21223
  • Behavioral Health (Transitional Living - Adult)
1020 B Hollins Street - Residential
1020 B Hollins Street
Baltimore, MD  21223
  • Behavioral Health (Transitional Living - Adult)
1024 Hollins Street - Residential
1024 Hollins Street
Baltimore, MD  21223
  • Behavioral Health (Transitional Living - Adult)
1030 (2nd) Hollins Street - Residential
1030 (2nd) Hollins Street
Baltimore, MD  21201
  • Behavioral Health (Transitional Living - Adult)
1030 (3rd) Hollins Street - Residential
1030 (3rd) Hollins Street
Baltimore, MD  21201
  • Behavioral Health (Transitional Living - Adult)
110 Stricker Street - Intensive
110 Stricker Street
Baltimore, MD  21201
  • Behavioral Health (Transitional Living - Adult)
1319 W. Lombard Street - Intensive Residential
1319 W. Lombard Street
Baltimore, MD  21223
  • Behavioral Health (Transitional Living - Child/Youth)
1322 W. Hollins Street - Intensive
1322 W. Hollins Street
Baltimore, MD  21201
  • Behavioral Health (Transitional Living - Adult)
1324-A Hollins Street - Residential
1324-A Hollins Street
Baltimore, MD  21223
  • Behavioral Health (Transitional Living - Adult)
1324-B Hollins Street - Residential
1324-B Hollins Street
Baltimore, MD  21223
  • Behavioral Health (Transitional Living - Adult)
1338 Hollins Street - Residential
1338 Hollins Street
Baltimore, MD  21201
  • Behavioral Health (Transitional Living - Adult)
1408 W. Lombard Street - Residential
1408 W. Lombard Street
Baltimore, MD  21201
  • Behavioral Health (Transitional Living - Adult)
302 S. Calhoun Street - Intensive
302 S. Calhoun Street
Baltimore, MD  21201
  • Behavioral Health (Transitional Living - Adult)
835 1/2 W. Lombard Street - Intensive Residential
835 1/2 W. Lombard Street
Baltimore, MD  21201
  • Behavioral Health (Transitional Living - Adult)
850 W. Pratt Street - Intensive Residential
850 W. Pratt Street
Baltimore, MD  21201
  • Behavioral Health (Transitional Living - Adult)
854 W. Pratt Street - Intensive Residential
854 W. Pratt Street
Baltimore, MD  21201
  • Behavioral Health (Transitional Living - Adult)
864 W. Lombard Street (F) - Intensive Residential
864 W. Lombard Street (F)
Baltimore, MD  21201
  • Behavioral Health (Transitional Living - Adult)
864 W. Lombard Street (R) - Intensive Residential
864 W. Lombard Street (R)
Baltimore, MD  21201
  • Behavioral Health (Transitional Living - Adult)
916 W. Lombard Street - Intensive Residential
916 W. Lombard Street
Baltimore, MD  21223
  • Behavioral Health (Transitional Living - Adult)
Central Maryland Oncology Center
11065 Little Patuxent Parkway
Columbia, MD  21044
  • General Outpatient Services (Outpatient)
Community Support Program
701 West Pratt Street
Baltimore, MD  21201
  • Case Management (Non 24 Hour Care - Adult)
Comprehensive Recovery Program
645 W. Redwood Street
Baltimore, MD  21201
  • Chemical Dependency (Non 24 Hour Care - Adult)
Frenkil Building
16 S. Eutaw
Baltimore, MD  21201
  • General Outpatient Services (Outpatient)
Harbor City Unlimited
1227 W. Pratt Street
Baltimore, MD  21223
  • Behavioral Health (Non 24 Hour Care - Adult)
  • Vocational Rehabilitation (Non 24 Hour Care - Adult)
Program of Assertive Community Treatment (PACT)
701 W. Pratt Street
Baltimore, MD  21201
  • Assertive Community Treatment (Non 24 Hour Care - Adult/Child/Youth)
University of Maryland Medical System Corporation  *
22 South Greene Street
Baltimore, MD  21201
Joint Commission Advanced Certification Programs:
  • Primary Stroke Center
  • Ventricular Assist Device
Joint Commission Certified Programs:
  • Asthma, Pediatrics
Services:
  • Addiction Care (Outpatient)
  • Assertive Community Treatment (Non 24 Hour Care - Adult/Child/Youth)
  • Behavioral Health (Day Programs - Adult/Child/Youth)
    (Transitional Living - Adult)
    (Non 24 Hour Care - Adult/Child/Youth)
    (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)
  • Case Management (Non 24 Hour Care - Adult)
  • Chemical Dependency (Day Programs - Adult)
    (Non 24 Hour Care - Adult)
  • CT Scanner (Inpatient, Outpatient)
  • Dentistry (Outpatient)
  • Dermatology (Outpatient)
  • Dialysis (Inpatient, Outpatient)
  • EEG/EKG/EMG Lab (Inpatient, Outpatient)
  • Electroconvulsive Therapy (Inpatient, Outpatient)
  • Emergency Room (Outpatient)
  • Endocrinology (Inpatient, Outpatient)
  • Family Practice (Inpatient, Outpatient)
  • Gastroenterology (Inpatient)
  • General Medical Services (Inpatient, Outpatient)
  • General Surgery (Inpatient, Outpatient)
  • GI or Endoscopy Lab (Inpatient, Outpatient)
  • Gynecology (Inpatient, Outpatient)
  • Hematology/Blood Treatment (Inpatient, Outpatient)
  • Imaging/Radiology (Inpatient, Outpatient)
  • Infectious Diseases (Inpatient, Outpatient)
  • Infusion Therapy (Outpatient)
  • Intensive Care Unit (Inpatient)
  • Internal Medicine (Inpatient, Outpatient)
  • Labor & Delivery (Inpatient)
  • Magnetic Resonance Imaging (Inpatient, Outpatient)
  • Medical Detoxification (Inpatient)
  • Mental Health (Inpatient, Outpatient, 24-hour Acute Care/Crisis Stabilization)
  • Neonatal Intensive Care (Inpatient)
  • Nephrology (Inpatient)
  • Neurology (Inpatient, Outpatient)
  • Neurosurgery (Inpatient)
  • Nuclear Medicine (Inpatient, Outpatient)
  • Nursery (Inpatient)
  • Obstetrics (Inpatient, Outpatient)
  • Operating Room (Inpatient, Outpatient)
  • Ophthalmology/Eye Surgery (Outpatient)
  • Oral Maxillofacial Surgery (Outpatient)
  • Orthopedic Surgery (Inpatient, Outpatient)
  • Otolaryngology/Ear, Nose, and Throat (Inpatient, Outpatient)
  • Outpatient Surgery (Outpatient)
  • Pain Management (Inpatient, Outpatient)
  • Pediatric Care (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)
  • Telemetry (Inpatient)
  • Thoracic Surgery (Inpatient)
  • Trauma/Burn Unit (Inpatient)
  • Ultrasound (Inpatient, Outpatient)
  • Urgent Care/Emergency Medicine (Outpatient)
  • Urology (Inpatient, Outpatient)
  • Vascular Surgery (Inpatient)
  • Vocational Rehabilitation (Non 24 Hour Care - Adult)
  • Wound Care (Inpatient)
Walter P. Carter Clinic
701 W. Pratt Street
Baltimore, MD  21201
  • Behavioral Health (Non 24 Hour Care - Adult/Child/Youth)
  • Case Management (Non 24 Hour Care - Adult/Child/Youth)
Walter P. Carter Carruthers Clinic
611 S. Charles St.
Baltimore, MD  21230
  • Behavioral Health (Non 24 Hour Care - Adult/Child/Youth)

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