The Joint Commission
Quality Check
Accreditation Quality Report
 > Summary of Accreditation Quality Information
 > Accredited Programs
 > Accreditation National Patient Safety Goals
 > Sites and Services
 > Accreditation History
 > Download Accreditation PDF Report
 > Download Accreditation PDF Report - Include Quarterly Data
 > Accreditation Quality Report User Guide
Quality Report

Summary of Accreditation Quality Information
Shady Grove Adventist Hospital
Org ID: 6297
9901 Medical Center Drive
Rockville, MD  20850
(240)826-6000
www.shadygroveadventisthospital.com

Accreditation
Programs		 Accreditation
Decision		 Effective
Date		 Last Full Survey Date Last On-Site Survey Date  
Hospital
Accredited 9/15/2007 9/14/2007 10/16/2008  
Pathology and Clinical Laboratory
Accredited 7/3/2009 7/2/2009 7/2/2009  



- Top -
  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
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 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 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.
  • Hip Joint Replacement
 See Detail
This organization’s performance is similar to 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 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)
Pathology and Clinical Laboratory
2010 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.
*
 
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.

- Top -
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
Shady Grove Adventist Emergency Center
19735 Germantown Road
Rockville, MD  20850
  • Anesthesia (Outpatient)
  • General Outpatient Services (Outpatient)
Shady Grove Adventist Hospital  *
9901 Medical Center Drive
Rockville, MD  20850
  • Abdominal Aortic Aneurysm (Inpatient)
  • Acute Coronary Syndrome (Inpatient)
  • Acute Myocardial Infarction (Inpatient)
  • Adolescent medicine (Inpatient)
  • Advanced Fetal Care (Inpatient)
  • Alzheimers Disease (Inpatient)
  • Amyotrophic Lateral Sclerosis (Inpatient)
  • Arthritis (Inpatient)
  • Asthma (Inpatient)
  • Asthma, Pediatrics (Inpatient)
  • Atrial Fibrillation (Inpatient)
  • Bariatric Surgery (Inpatient, Outpatient)
  • Benign prostatic hyperplasia (BPH) (Inpatient)
  • Breast Cancer (Inpatient, Outpatient)
  • Burn Treatment (Inpatient)
  • Cancer Center/Oncology (Inpatient)
  • Cardiac Catheterization Lab (Inpatient)
  • Cardiac Rehabilitation (Outpatient)
  • Cardiac Unit/Cardiology (Inpatient)
  • Carotid Stenosis (Inpatient)
  • Cellulitis (Inpatient)
  • Cerebral Bleeding (Inpatient)
  • Chronic Kidney Disease (Inpatient)
  • Chronic Obstructive Pulmonary Disease (Inpatient)
  • Coagulopathy Treatment (Inpatient)
  • Colon/Rectal Cancer (Inpatient)
  • Congenital Anomalies (Inpatient)
  • Coronary Artery Disease (Inpatient)
  • Crohn's Disease (Inpatient)
  • CT Scanner (Inpatient)
  • Cystic Fibrosis (Inpatient)
  • Developmental Pediatrics (Inpatient)
  • Diabetes Mellitus (Inpatient)
  • Dialysis (Inpatient)
  • EEG/EKG/EMG Lab (Inpatient)
  • Emergency Room (Outpatient)
  • Emphysema (Inpatient)
  • End Stage Renal Disease (Inpatient)
  • Epilepsy (Inpatient)
  • Esophageal Cancer (Inpatient)
  • Family Practice (Inpatient)
  • Fetal Surgery (Inpatient)
  • Gastroenterology (Inpatient)
  • Gastroesophageal Reflux Disease (Inpatient, Outpatient)
  • General Laboratory Tests
  • General Medical Services (Inpatient)
  • General Surgery (Inpatient)
  • Genetic Testing / Counseling (Inpatient)
  • Genetics (Inpatient)
  • GI or Endoscopy Lab (Inpatient)
  • Gynecology (Inpatient)
  • Head Injury (Inpatient)
  • Health and Wellness (Inpatient)
  • Health Social Work (Inpatient)
  • Heart Failure (Inpatient, Outpatient)
  • Hematology/Blood Treatment (Inpatient, Outpatient)
  • Hemophilia (Inpatient)
  • Hepatitis B/C (Inpatient)
  • High Risk Obstetrics (Inpatient)
  • Hip Joint Replacement (Inpatient)
  • HIV/AIDS (Inpatient)
  • Hodgkin's disease (Inpatient)
  • Hyperbilirubinemia (Inpatient)
  • Hyperlipidemia (Inpatient)
  • Hypertension (Inpatient)
  • Hyperthyroidism/Hypothyroidism (Inpatient)
  • Imaging/Radiology (Inpatient, Outpatient)
  • Inpatient Diabetes (Inpatient)
  • Intensive Care Unit (Inpatient)
  • Internal Medicine (Inpatient)
  • Interventional Cardiac Catheterization (Inpatient)
  • Interventional Radiology (Inpatient, Outpatient)
  • Intraventricular hemorrhage (Inpatient)
  • Irritable Bowel Syndrome (Inpatient)
  • Ischemic Heart Disease (Inpatient, Outpatient)
  • Joint Replacement - Knee (Inpatient)
  • Labor & Delivery (Inpatient)
  • Laminectomy (Inpatient)
  • Leukemia (Inpatient)
  • Lithotripsy/Kidney Stone Treatment (Outpatient)
  • Liver Diseases (Inpatient)
  • Low Back Pain (Inpatient)
  • Lumbar Spine Treatment (Inpatient)
  • Lung Cancer (Inpatient)
  • Magnetic Resonance Imaging (Inpatient, Outpatient)
  • Maternal Child (Inpatient, Outpatient)
  • Microdiscectomy (Inpatient)
  • Migraine Headache (Inpatient)
  • Morbid Obesity (Inpatient)
  • Multiple Sclerosis (Inpatient)
  • Necrotizing Enteral Colitis (Inpatient)
  • Neonatal Intensive Care (Inpatient)
  • Neonatology (Inpatient)
  • Nephrology (Inpatient)
  • Neurology (Inpatient)
  • Neurosurgery (Inpatient)
  • Nuclear Medicine (Inpatient)
  • Nursery (Inpatient)
  • Nutrition Programs (Inpatient, Outpatient)
  • Obstetrics (Inpatient)
  • Operating Room (Inpatient, Outpatient)
  • Ophthalmology/Eye Surgery (Inpatient)
  • Oral Maxillofacial Surgery (Inpatient)
  • Orthopedic Surgery (Inpatient)
  • Osteopathic Care (Inpatient)
  • Osteoporosis (Inpatient)
  • Otolaryngology/Ear, Nose, and Throat (Inpatient)
  • Outpatient Surgery (Outpatient)
  • Pain Management (Inpatient)
  • Pancreatic Cancer (Inpatient, Outpatient)
  • Pancreatitis (Inpatient)
  • Parkinsons Disease (Inpatient)
  • Pathology (Inpatient, Outpatient)
  • Pediatric Allergy/Immunology (Inpatient - Child/Youth)
  • Pediatric Cardiology (Inpatient - Child/Youth)
  • Pediatric Care (Inpatient)
  • Pediatric Dentistry (Inpatient - Child/Youth)
  • Pediatric Dermatology (Inpatient - Child/Youth)
  • Pediatric Emergency Department (Outpatient - Child/Youth)
  • Pediatric Emergency Medicine (Inpatient - Child/Youth)
  • Pediatric Endocrinology (Inpatient - Child/Youth)
  • Pediatric Gastroenterology (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric General Surgery (Inpatient - Child/Youth)
  • Pediatric Hematology/Oncology (Inpatient - Child/Youth)
  • Pediatric Intensivists (Inpatient - Child/Youth)
  • Pediatric Nephrology (Inpatient - Child/Youth)
  • Pediatric Neurology (Inpatient - Child/Youth)
  • Pediatric Neurosurgery (Inpatient - Child/Youth)
  • Pediatric Ophthalmology (Inpatient - Child/Youth)
  • Pediatric Oral/Maxofacial Surgery (Inpatient - Child/Youth)
  • Pediatric Orthopedics (Inpatient - Child/Youth)
  • Pediatric Otolaryngology (Inpatient - Child/Youth)
  • Pediatric Pathology (Inpatient - Child/Youth)
  • Pediatric Physical Medicine and Rehab (Inpatient - Child/Youth)
  • Pediatric Pulmonology (Inpatient - Child/Youth)
  • Pediatric Radiology (Inpatient - Child/Youth)
  • Pediatric Urology (Inpatient - Child/Youth)
  • Pelvic Inflammatory Disease (Inpatient, Outpatient)
  • Perimenopause (Inpatient)
  • Peripheral Vascular Disease (Inpatient, Outpatient)
  • Plastic Surgery (Inpatient)
  • Pneumonia (Inpatient)
  • Podiatry (Inpatient)
  • Post Anesthesia Care Unit (PACU) (Inpatient, Outpatient)
  • Prematurity (Inpatient)
  • Prostate Cancer (Inpatient)
  • Pulmonary Function Lab (Inpatient, Outpatient)
  • Radiation Oncology (Inpatient, Outpatient)
  • Rehabilitation and Physical Medicine (Inpatient, Outpatient)
  • Respiratory Care (Ventilator) (Inpatient)
  • Respiratory Failure (Inpatient, Outpatient)
  • Sexually Transmitted Disease (Inpatient, Outpatient)
  • Sickle Cell Disease (Inpatient)
  • Sleep Center (Outpatient)
  • Sleeping Disorder (Outpatient)
  • Spinal Fusion (Inpatient)
  • Spine Care (Inpatient)
  • Sports Medicine (Inpatient)
  • Stroke Rehabilitation (Inpatient)
  • Stroke (Primary Stroke Center) (Inpatient)
  • Subacute Care (Inpatient)
  • Systemic Lupus Erythematosis (Inpatient)
  • Telemetry (Inpatient)
  • Thoracic Spine (Inpatient)
  • Thoracic Surgery (Inpatient)
  • Tobacco Treatment / Cessation (Inpatient, Outpatient)
  • Toxicology
  • Trauma (Inpatient)
  • Tuberculosis (Inpatient)
  • Ulcerative Colitis (Inpatient, Outpatient)
  • Ultrasound (Inpatient, Outpatient)
  • Urgent Care/Emergency Medicine (Outpatient)
  • Urology (Inpatient)
  • Vascular Disease (Inpatient)
  • Vascular Surgery (Inpatient)
  • Ventricular Assist Device (Inpatient)
  • Weight Loss (Inpatient)
  • Women's Health (Inpatient, Outpatient)
  • Wound Care (Inpatient, Outpatient)
Shady Grove Adventist Hospital Maternity Center
19735 Germantown Rd. # 270
Germantown, MD  20874
  • General Outpatient Services (Outpatient)

- Top -
The Joint Commission obtains information about accredited/certified organizations not only through direct observations by its employees …Read more.
Search | About Quality Check | Take Our Survey | Advanced Search | Certified Organizations | Quality Data Download | Contact Us | Help | Privacy Policy
 © 2010 The Joint Commission, All Rights Reserved

This website is certified by Health On the Net Foundation. Click to verify. This site complies with the HONcode standard for trustworthy health information:
verify here.