The Joint Commission
Quality Check
Quality Report

Summary of Accreditation Quality Information
Culpeper Memorial Hospital, Inc.
DBA: Culpeper Regional Hospital
Org ID: 6334
501 Sunset Lane
Culpeper, VA  22701
(540)829-4100
www.culpeperhospital.com


Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full Survey Date Last On-Site Survey Date
Hospital
Accredited 8/1/2014 7/31/2014   9/12/2014  


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





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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
2014 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:
Apr  2013 -
Mar  2014
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.
Perinatal Care See Detail
Not displayed.
2
Not displayed.
2
Pneumonia Care See Detail
This organization’s performance is similar to 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
Not displayed.
3
Not displayed.
3
  • 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 above the target range/value.
This organization’s performance is above the target range/value.
  • Hysterectomy
See Detail
Not displayed.
3
Not displayed.
3
  • 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
Culpeper Memorial Hospital, Inc.  *
DBA:  Culpeper Regional Hospital
501 Sunset Lane
Culpeper, VA  22701
    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)
    • Gynecological Surgery (Surgical Services)
    • Gynecology (Inpatient)
    • Inpatient Unit (Inpatient)
    • Labor & Delivery (Inpatient)
    • Magnetic Resonance Imaging (Imaging/Diagnostic Services)
    • Medical /Surgical Unit (Inpatient)
    • Medical ICU (Intensive Care Unit)
    • Normal Newborn Nursery (Inpatient)
    • Nuclear Medicine (Imaging/Diagnostic Services)
    • Orthopedic Surgery (Surgical Services)
    • Post Anesthesia Care Unit (PACU) (Inpatient)
    • Radiation Oncology (Imaging/Diagnostic Services)
    • Surgical Unit (Inpatient)
    • Teleradiology (Imaging/Diagnostic Services)
    • Ultrasound (Imaging/Diagnostic Services)
    • Urology (Surgical Services)
    Madison Physical Therapy and Rehab
    DBA:  Culpeper Regional Hospital
    1480 North Main Street, Suite B
    Madison, VA  22727
      Services:
      • Outpatient Clinics (Outpatient)
      Powell Wellness Center Physical Therapy & Outpatient
      DBA:  Culpeper Regional Hospital
      1005 Golf Drive
      Culpeper, VA  22701
        Services:
        • Outpatient Clinics (Outpatient)

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