The Joint Commission
Quality Check
Quality Report

Summary of Quality Information
West Virginia University Hospitals, Inc.
Org ID: 6444
1 Medical Center Drive
Morgantown, WV  26506
(304)598-4200
http://wvuhealthcare.com/wvuh


Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full Survey Date Last On-Site Survey Date
Behavioral Health Care
Accredited 8/22/2015 8/21/2015   8/21/2015  
Hospital
Accreditation with Follow-up Survey 8/22/2015 8/21/2015   9/30/2015  
The following standard(s) were found to be out of compliance:
  • A time-out is performed before the procedure.
  • Before the hospital discharges or transfers a patient, it informs and educates the patient about his or her follow-up care, treatment, and services.
  • For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital documents the use of restraint or seclusion.
  • Maintain and communicate accurate patient medication information.
  • Medical staff bylaws address self-governance and accountability to the governing body.
  • Medication orders are clear and accurate.
  • Report critical results of tests and diagnostic procedures on a timely basis.
  • Resuscitation services are available throughout the hospital.
  • Staff and licensed independent practitioners are familiar with their roles and responsibilities relative to the environment of care.
  • The governing body is ultimately accountable for the safety and quality of care, treatment, and services.
  • The hospital assesses and manages the patient's risks for falls.
  • The hospital designs and manages the physical environment to comply with the Life Safety Code.
  • The hospital establishes and maintains a safe, functional environment. Note: The environment is constructed, arranged, and maintained to foster patient safety, provide facilities for diagnosis and treatment, and provide for special services appropriate to the needs of the community.
  • The hospital has policies and procedures that guide and support patient care, treatment, and services.
  • The hospital identifies risks for acquiring and transmitting infections.
  • The hospital implements its infection prevention and control plan.
  • The hospital inspects, tests, and maintains medical equipment.
  • The hospital inspects, tests, and maintains medical gas and vacuum systems. Note: This standard does not require hospitals to have the medical gas and vacuum systems discussed below. However, if a hospital has these types of systems, then the following inspection, testing, and maintenance requirements apply.
  • The hospital maintains complete and accurate medical records for each individual patient.
  • The hospital maintains the integrity of the means of egress.
  • The hospital makes food and nutrition products available to its patients.
  • The hospital manages risks associated with its utility systems.
  • The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.
  • The hospital provides and maintains systems for extinguishing fires.
  • The hospital provides care, treatment, and services as ordered or prescribed, and in accordance with law and regulation.
  • The hospital provides care, treatment, and services for each patient.
  • The hospital provides the patient with care before initiating operative or other high-risk procedures, including those that require the administration of moderate or deep sedation or anesthesia.
  • The hospital reduces the risk of infections associated with medical equipment, devices, and supplies.
  • The hospital safely stores medications.
  • The patient and his or her family have the right to have complaints reviewed by the hospital.
  • The patient’s medical record documents operative or other high-risk procedures and the use of moderate or deep sedation or anesthesia.
Laboratory Accreditation Program
Accredited 12/7/2013 11/5/2015   11/5/2015  


Accreditation programs recognized by the Centers for Medicare and Medicaid Services (CMS)
Pathology and Clinical Laboratory


Advanced Certification
Programs
Certification
Decision
Effective
Date
Last Full
Review Date
Last On-Site
Review Date
Primary Stroke Center
Certification 7/19/2014  7/18/2014  7/18/2014 



Certified
Programs
Certification
Decision
Effective
Date
Last Full
Review Date
Last On-Site
Review Date
Joint Replacement - Hip
Certification 10/18/2014  10/17/2014  10/17/2014 
Joint Replacement - Knee
Certification 10/18/2014  10/17/2014  10/17/2014 



Other Accredited Programs / Services
Hospital  -  Accredited by American College of Surgeons-Commission on Cancer (ACoS-COC)


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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
Behavioral Health Care
2015 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
2015 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  2014 -
Mar  2015
Hospital-Based Inpatient Psychiatric Services See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
Immunization See Detail
Not displayed.
2
Not displayed.
2
Perinatal 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.
Stroke Care See Detail
Not displayed.
8
Not displayed.
8
Venous Thromboembolism (VTE) See Detail
Not displayed.
8
Not displayed.
8
Laboratory Accreditation Program
2013 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 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
University Town Centre Clinic operated by WVU Hospitals, Inc
6040 University Town Centre Drive
Morgantown, WV  26501
Other Clinics/Practices located at this site:
  • University Town Centre Clark K. Sleeth Family Medicine Cente
  • University Town Centre Dermatology
  • University Town Centre Geriatrics
  • University Town Centre Imaging
  • University Town Centre Laboratory
  • University Town Centre Medicine
  • University Town Centre MGP
  • University Town Centre Obstetrics and Gynecology
  • University Town Centre Orthopaedics
  • University Town Centre Pediatric and Adolescent Practice
  • University Town Centre Podiatry
  • University Town Centre Pre-admission Testing
Services:
  • Administration of Blood Product (Outpatient)
  • Administration of High Risk Medications (Outpatient)
  • General Laboratory Tests
  • Outpatient Clinics (Outpatient)
  • Perform Invasive Procedure (Outpatient)
West Virginia University Hospitals, Inc.
DBA:  Fairmont Regional Cancer Center
1325 Locust Avenue
Fairmont, WV  26554-1435
    Services:
    • Outpatient Clinics (Outpatient)
    West Virginia University Hospitals, Inc.  *
    One Medical Center Drive
    Morgantown, WV  26506-8242
    Joint Commission Advanced Certification Programs:
    • Primary Stroke Center
    Joint Commission Certified Programs:
    • Joint Replacement - Hip
    • Joint Replacement - Knee
    Other Clinics/Practices located at this site:
    • Betty Puskar Breast Care Center
    • Bonnie's Bus
    • Mary Babb Randolph Cancer Center
    • Neurology Clinic
    • Neurosurgery Clinic
    • Physician Office Center Clark K. Sleeth Family Medicine Clin
    • Physician Office Center EEG/EMG
    • Physician Office Center Endocrinology Clinic
    • Physician Office Center ENT Clinic
    • Physician Office Center Lab
    • Physician Office Center Medical Center Pharmacy
    • Physician Office Center Medical Group Practice
    • Physician Office Center Medical Specialties Clinic
    • Physician Office Center Obstetrics and Gynecology Clinic
    • Physician Office Center Orthopedics Clinic
    • Physician Office Center Pediatric Specialties Clinic
    • Physician Office Center Pre-admission Testing
    • Physician Office Center Radiology
    • Physician Office Center Surgical Specialties Clinic
    • Physician Office Center Ultrasound
    • Radiation Oncology
    • West Virginia University Eye Institute
    Services:
    • Assertive Community Treatment/Community Support Services (Non 24 Hour Care - Adult)
    • Behavioral Health (Day Programs - Adult)
      (24-hour Acute Care/Crisis Stabilization - Adult/Child/Youth)
      (Residential Care - Child/Youth)
      (Partial - Adult)
    • Brachytherapy (Imaging/Diagnostic Services)
    • Cardiac Catheterization Lab (Surgical Services)
    • Cardiac Surgery (Surgical Services)
    • Cardiothoracic Surgery (Surgical Services)
    • Cardiovascular Unit (Inpatient)
    • Community Integration (Non 24 Hour Care)
    • Coronary Care Unit (Inpatient)
    • CT Scanner (Imaging/Diagnostic Services)
    • Dialysis Unit (Inpatient)
    • Ear/Nose/Throat Surgery (Surgical Services)
    • EEG/EKG/EMG Lab (Imaging/Diagnostic Services)
    • Gastroenterology (Surgical Services)
    • General Laboratory Tests
    • GI or Endoscopy Lab (Imaging/Diagnostic Services)
    • Gynecological Surgery (Surgical Services)
    • Gynecology (Inpatient)
    • Hematology/Oncology Unit (Inpatient)
    • Inpatient Unit (Inpatient)
    • Interventional Radiology (Imaging/Diagnostic Services)
    • Labor & Delivery (Inpatient)
    • Medical /Surgical Unit (Inpatient)
    • Medical ICU (Intensive Care Unit)
    • Neuro/Spine Unit (Inpatient)
    • Neurosurgery (Surgical Services)
    • Nuclear Medicine (Imaging/Diagnostic Services)
    • Ophthalmology (Surgical Services)
    • Orthopedic Surgery (Surgical Services)
    • Orthopedic/Spine Unit (Inpatient)
    • Outpatient Clinics (Outpatient)
    • Pediatric Unit (Inpatient)
    • Plastic Surgery (Surgical Services)
    • Post Anesthesia Care Unit (PACU) (Inpatient)
    • Radiation Oncology (Imaging/Diagnostic Services)
    • Surgical ICU (Intensive Care Unit)
    • Surgical Unit (Inpatient)
    • Thoracic Surgery (Surgical Services)
    • Ultrasound (Imaging/Diagnostic Services)
    • Urology (Surgical Services)
    • Vascular Surgery (Surgical Services)
    WVU Cheat Lake Physicians operated by WVU Hospitals, Inc.
    608 Cheat Road
    Morgantown, WV  26508
    Other Clinics/Practices located at this site:
    • Cheat Lake Lab
    • Cheat Lake OB/GYN Clinic
    • Cheat Lake Radiology
    • Family Medicine Clinic
    • Pediatric Clinic
    • WVU Wound Management Center
    Services:
    • General Laboratory Tests
    • Outpatient Clinics (Outpatient)
    • Perform Invasive Procedure (Outpatient)
    WVU Heart Institute operated by WVU Hospitals, Inc.
    600 Suncrest Towne Centre
    Morgantown, WV  26505
    Other Clinics/Practices located at this site:
    • Heart Institute Clinic
    • Heart Institute Pulmonary and Rehabilitation Services
    Services:
    • Administration of High Risk Medications (Outpatient)
    • General Laboratory Tests
    • Outpatient Clinics (Outpatient)
    • Perform Invasive Procedure (Outpatient)
    WVU Pain Management Center operated by WVU Hospitals, Inc.
    Suite 150 1075 VanVoorhis Road
    Morgantown, WV  26505
      Services:
      • Administration of High Risk Medications (Outpatient)
      • Outpatient Clinics (Outpatient)
      • Perform Invasive Procedure (Outpatient)
      WVU Sleep Evaluation Center operated by WVU Hospitals, Inc.
      205 Bakers Ridge Road
      Morgantown, WV  26508
        Services:
        • General Laboratory Tests
        • Outpatient Clinics (Outpatient)
        WVU Spine Medicine Center operated by WVU Hospitals, Inc.
        943 Maple Drive, Lower Level
        Morgantown, WV  26505
          Services:
          • Administration of Blood Product (Outpatient)
          • Outpatient Clinics (Outpatient)

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