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Quality Report

Summary of Quality Information
MedStar Georgetown University Medical Center
Org ID: 6309
3800 Reservoir Road, Northwest
Washington, DC  20007
(202)444-3294
www.georgetownuniversityhospital.org

Accreditation
Programs		 Accreditation
Decision		 Effective
Date		 Last Full Survey Date Last On-Site Survey Date  
Hospital
Accredited 4/26/2008 4/25/2008 4/25/2008  

Advanced Certification
Programs		 Certification
Decision		 Effective
Date		 Last Full
Review Date		 Last On-Site
Review Date
Primary Stroke Center
Certification 10/8/2009  10/7/2009  10/7/2009 


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

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 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
2009 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
Children's Asthma 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 Attack Care See Detail
Not displayed.
3
Not displayed.
3
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.
Pregnancy Care See Detail
Not displayed.
2
Not displayed.
2
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
Not displayed.
3
Not displayed.
3
  • 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 similar to the target range/value.
  • Open Heart Surgery
 See Detail
Not displayed.
3
Not displayed.
3
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
Georgetown University Hospital  *
3800 Reservoir Road, Northwest
Washington, DC  20007
Joint Commission Advanced Certification Programs:
  • Primary Stroke Center
Services:
  • Abdominal Aortic Aneurysm (Inpatient)
  • Acquired Brain Injury (Inpatient, 24-hour Acute Care/Crisis Stabilization)
  • Acute Coronary Syndrome (Inpatient)
  • Acute Myocardial Infarction (Inpatient, Outpatient)
  • Adolescent medicine (Inpatient, Outpatient)
  • Advanced Fetal Care (Inpatient)
  • Allergy (Outpatient)
  • Alzheimers Disease (Inpatient)
  • Amyotrophic Lateral Sclerosis (Inpatient, Outpatient)
  • Anxiety/panic disorders (Inpatient, Outpatient)
  • Arthritis (Outpatient)
  • Asthma (Inpatient, Outpatient)
  • Asthma, Pediatrics (Inpatient, Outpatient)
  • Atrial Fibrillation (Inpatient, Outpatient)
  • Attention Deficit Disorder (Outpatient)
  • Audiology (Inpatient, Outpatient)
  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult)
  • Benign prostatic hyperplasia (BPH) (Inpatient, Outpatient)
  • Bipolar disorder (Inpatient, Outpatient)
  • Brain Injury Rehabilitation (Outpatient)
  • Breast Cancer (Inpatient, Outpatient)
  • Cancer Center/Oncology (Inpatient, Outpatient)
  • Cardiac Catheterization Lab (Inpatient, Outpatient)
  • Cardiac Unit/Cardiology (Inpatient, Outpatient)
  • Carotid Stenosis (Inpatient, Outpatient)
  • Cellulitis (Inpatient, Outpatient)
  • Cerebral Bleeding (Inpatient, Outpatient)
  • Cervical Spine Treatment (Inpatient, Outpatient)
  • Chronic Kidney Disease (Inpatient, Outpatient)
  • Chronic Obstructive Pulmonary Disease (Inpatient, Outpatient)
  • Coagulopathy Treatment (Inpatient, Outpatient)
  • Colon/Rectal Cancer (Inpatient, Outpatient)
  • Congenital Anomalies (Inpatient, Outpatient)
  • Coronary Artery Disease (Inpatient, Outpatient)
  • Crohn's Disease (Inpatient, Outpatient)
  • CT Scanner (Inpatient, Outpatient)
  • Cystic Fibrosis (Inpatient, Outpatient)
  • Depression (Inpatient, Outpatient)
  • Dermatology (Inpatient, Outpatient)
  • Developmental Pediatrics (Outpatient)
  • Diabetes Mellitus (Inpatient, Outpatient)
  • Dialysis (Inpatient, Outpatient)
  • Eating Disorders (Inpatient, Outpatient)
  • EEG/EKG/EMG Lab (Inpatient, Outpatient)
  • Emergency Room (Outpatient)
  • Emphysema (Inpatient, Outpatient)
  • End Stage Renal Disease (Inpatient, Outpatient)
  • Endocrinology (Inpatient, Outpatient)
  • Epilepsy (Inpatient, Outpatient)
  • Esophageal Cancer (Inpatient, Outpatient)
  • Extracorporeal Membrane Oxygenation (Inpatient)
  • Fetal Surgery (Inpatient)
  • Finger Joint Replacement (Inpatient)
  • Gastroenterology (Inpatient, Outpatient)
  • Gastroesophageal Reflux Disease (Inpatient, Outpatient)
  • General Laboratory Tests
  • General Medical Services (Inpatient, Outpatient)
  • General Surgery (Inpatient, Outpatient)
  • Genetic Testing / Counseling (Outpatient)
  • Genetics (Outpatient)
  • GI or Endoscopy Lab (Inpatient, Outpatient)
  • Gynecology (Inpatient, Outpatient)
  • Head Injury (Inpatient, Outpatient)
  • Health and Wellness (Outpatient)
  • Heart Failure (Inpatient, Outpatient)
  • Hematology/Blood Treatment (Inpatient, Outpatient)
  • Hemophilia (Inpatient, Outpatient)
  • Hepatitis B/C (Inpatient, Outpatient)
  • High Risk Neonatal (Inpatient)
  • High Risk Obstetrics (Inpatient)
  • Hip Joint Replacement (Inpatient, Outpatient)
  • HIV Clinic (Outpatient)
  • HIV/AIDS (Inpatient, Outpatient)
  • Hodgkin's disease (Inpatient, Outpatient)
  • Hyperbilirubinemia (Inpatient, Outpatient)
  • Hyperlipidemia (Inpatient, Outpatient)
  • Hypertension (Inpatient, Outpatient)
  • Hyperthyroidism/Hypothyroidism (Inpatient, Outpatient)
  • Imaging/Radiology (Inpatient, Outpatient)
  • Infectious Diseases (Inpatient, Outpatient)
  • Infusion Therapy (Inpatient, Outpatient)
  • Inpatient Diabetes (Inpatient)
  • Intensive Care Unit (Inpatient)
  • Internal Medicine (Inpatient, Outpatient)
  • Interventional Radiology (Inpatient, Outpatient)
  • Intraventricular hemorrhage (Inpatient, Outpatient)
  • Irritable Bowel Syndrome (Inpatient, Outpatient)
  • Ischemic Heart Disease (Inpatient, Outpatient)
  • Joint Replacement - Ankle (Inpatient)
  • Joint Replacement - Finger (Inpatient)
  • Joint Replacement - Knee (Inpatient, Outpatient)
  • Joint Replacement - Shoulder (Inpatient)
  • Labor & Delivery (Inpatient)
  • Laminectomy (Inpatient, Outpatient)
  • Leukemia (Inpatient, Outpatient)
  • Liver Diseases (Inpatient, Outpatient)
  • Lumbar Spine Treatment (Inpatient, Outpatient)
  • Lung Cancer (Inpatient, Outpatient)
  • Magnetic Resonance Imaging (Inpatient, Outpatient)
  • Maternal Child (Inpatient, Outpatient)
  • Mental Health (Inpatient, Outpatient, 24-hour Acute Care/Crisis Stabilization)
  • Migraine Headache (Inpatient, Outpatient)
  • Multiple Sclerosis (Inpatient, Outpatient)
  • Necrotizing Enteral Colitis (Inpatient, Outpatient)
  • Neonatal Intensive Care (Inpatient)
  • Neonatology (Inpatient, Outpatient)
  • Nephrology (Inpatient, Outpatient)
  • Neurology (Inpatient, Outpatient)
  • Neurosurgery (Inpatient)
  • Nuclear Medicine (Inpatient, Outpatient)
  • Nursery (Inpatient)
  • Obstetrics (Inpatient, Outpatient)
  • Occupational Health (Inpatient, Outpatient)
  • Operating Room (Inpatient, Outpatient)
  • Ophthalmology/Eye Surgery (Inpatient, Outpatient)
  • Oral Maxillofacial Surgery (Inpatient, Outpatient)
  • Organ Transplant - Intestine (Inpatient)
  • Organ Transplant - Kidney (Inpatient)
  • Organ Transplant - Kidney/Pancreas (Inpatient)
  • Organ Transplant - Liver (Inpatient)
  • Organ Transplant - Pancreas (Inpatient)
  • Orthopedic Surgery (Inpatient, Outpatient)
  • Osgood-Schlatter (Inpatient, Outpatient)
  • Osteoporosis (Inpatient, Outpatient)
  • Otolaryngology/Ear, Nose, and Throat (Inpatient, Outpatient)
  • Outpatient Surgery (Outpatient)
  • Pain Management (Inpatient)
  • Pancreatic Cancer (Inpatient, Outpatient)
  • Pancreatitis (Inpatient, Outpatient)
  • Parkinsons Disease (Inpatient, Outpatient)
  • Pathology (Inpatient, Outpatient)
  • Pediatric Allergy/Immunology (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Cardiology (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Care (Inpatient, Outpatient)
  • Pediatric Emergency Medicine (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Endocrinology (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Gastroenterology (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric General Surgery (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Hematology/Oncology (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Intensivists (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Nephrology (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Neurology (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Neurosurgery (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Ophthalmology (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Oral/Maxofacial Surgery (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Orthopedics (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Otolaryngology (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Pathology (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Physical Medicine and Rehab (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Plastic Surgery (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Pulmonology (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Radiology (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Urology (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pelvic Inflammatory Disease (Inpatient, Outpatient)
  • Perimenopause (Inpatient, Outpatient)
  • Peripheral Vascular Disease (Inpatient, Outpatient)
  • Plastic Surgery (Inpatient, Outpatient)
  • Pneumonia (Inpatient, Outpatient)
  • Podiatry (Inpatient, Outpatient)
  • Post Anesthesia Care Unit (PACU) (Inpatient, Outpatient)
  • Prematurity (Inpatient, Outpatient)
  • Prostate Cancer (Inpatient, Outpatient)
  • Pulmonary Function Lab (Inpatient, Outpatient)
  • Radiation Oncology (Inpatient, Outpatient)
  • Recovery/Infirmary (Outpatient)
  • Rehabilitation and Physical Medicine (Inpatient, Outpatient)
  • Respiratory Care (Ventilator) (Inpatient)
  • Respiratory Failure (Inpatient, Outpatient)
  • Rheumatology (Inpatient, Outpatient)
  • Schizophrenia (Inpatient, Outpatient)
  • Self Injury (Inpatient, Outpatient)
  • Sexually Transmitted Disease (Inpatient, Outpatient)
  • Sickle Cell Disease (Inpatient, Outpatient)
  • Sleep Center (Outpatient)
  • Sleeping Disorder (Inpatient, Outpatient)
  • Solid Organ Transplant (Inpatient)
  • Spinal Fusion (Inpatient, Outpatient)
  • Spine Care (Inpatient, Outpatient)
  • Sports Medicine (Inpatient, Outpatient)
  • Stroke Rehabilitation (Inpatient, Outpatient)
  • Stroke (Primary Stroke Center) (Inpatient, Outpatient)
  • Subacute Care (Inpatient)
  • Systemic Lupus Erythematosis (Inpatient, Outpatient)
  • Telemetry (Inpatient)
  • Thoracic Spine (Inpatient, Outpatient)
  • Thoracic Surgery (Inpatient, Outpatient)
  • Tobacco Treatment / Cessation (Outpatient)
  • Traumatic Brain Injury (Inpatient)
  • Tuberculosis (Inpatient, Outpatient)
  • Ulcerative Colitis (Inpatient, Outpatient)
  • Ultrasound (Inpatient, Outpatient)
  • Urgent Care/Emergency Medicine (Outpatient)
  • Urology (Inpatient, Outpatient)
  • Vascular Disease (Inpatient, Outpatient)
  • Vascular Surgery (Inpatient, Outpatient)
  • Women's Health (Inpatient, Outpatient)
  • Wound Care (Inpatient, Outpatient)
Georgetown University Hospital Neurosurgery
10401 Hospital Drive, Suite 101
Clinton, MD  20735
  • Cervical Spine Treatment (Outpatient)
  • Single Specialty Group Practice (Outpatient)
Georgetown University Hospital Wisconsin Ave. Multispecialty
2115 Wisconsin Avenue
Washington, DC  20007
  • Behavioral Health (Day Programs - Adult)
    (Non 24 Hour Care - Adult/Child/Youth)
  • Multi Specialty Group Practice (Outpatient)
Georgetown University Neurosurgery
117 Boscawen Street, Suite 4
Winchester, VA  22601
  • Single Specialty Practitioner (Outpatient)
  • Spine Care (Outpatient)
Georgetown Vascular Associates
1830 Town Center Dr., Ste 401
Reston, VA  20190
  • Breast Cancer (Outpatient)
  • Multi Specialty Group Practice (Outpatient)
  • Peripheral Vascular Disease (Outpatient)
  • Vascular Disease (Outpatient)
GUH Multispecialty Satellite
3833 N. Fairfax Drive
Arlington, VA  22203
  • Multi Specialty Group Practice (Outpatient)
GUMC at Chevy Chase Multispecialty (Dermatology/Urology)
5530 Wisconsin Avenue Suites 950
Chevy Chase, MD  20815-4390
  • Multi Specialty Group Practice (Outpatient)
GUMC Radiology Associates GUMC at Foxhall
3301 New Mexico Avenue, Suite 324
Washington, DC  20016
  • Single Specialty Group Practice (Outpatient)
GUMC Student Primary Care Clinic at the Law Center
Gewirz Building - Lower Lever 120 F Street, Northwest
Washington, DC  20001
  • General Outpatient Services (Outpatient)
HOYA Clinic
1900 Massachusetts Avenue, SE
Washington, DC  20003
  • Adolescent medicine (Outpatient)
  • General Outpatient Services (Outpatient)
  • Health and Wellness (Outpatient)
  • Women's Health (Outpatient)

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