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Quality Report

Summary of Accreditation Quality Information
Cape Fear Valley Health System
Org ID: 6495
1638 Owen Drive
Fayetteville, NC  28304
(910)615-6700
www.capefearvalley.com

Accreditation
Programs		 Accreditation
Decision		 Effective
Date		 Last Full Survey Date Last On-Site Survey Date  
Hospital
Accredited 6/27/2009 6/26/2009 6/26/2009  
Pathology and Clinical Laboratory
Accredited 6/19/2009 6/18/2009 6/18/2009  


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
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.
*
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 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.
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 above the target range/value.
This organization’s performance is above 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 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)
Pathology and Clinical Laboratory
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.
*
 
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
Behavioral Healthcare of Cape Fear Valley Health System
3425 Melrose Road
Fayetteville, NC  28304
  • Behavioral Health (Non 24 Hour Care - Adult/Child/Youth)
    (24-hour Acute Care/Crisis Stabilization - Adult/Child/Youth)
  • General Laboratory Tests
  • Mental Health (Inpatient, 24-hour Acute Care/Crisis Stabilization)
Cape Fear Valley Internal Medicine
101 Robeson Street, Suite 300
Fayetteville, NC  28301
  • General Laboratory Tests
  • General Outpatient Services (Outpatient)
Cape Fear Valley Medical Center  *
1638 Owen Drive
Fayetteville, NC  28302
  • Abdominal Aortic Aneurysm (Inpatient)
  • Acute Coronary Syndrome (Inpatient)
  • Acute Myocardial Infarction (Inpatient)
  • Adolescent medicine (Inpatient)
  • Alzheimers Disease (Inpatient)
  • Anxiety/panic disorders (Inpatient, Outpatient)
  • Arthritis (Inpatient, Outpatient)
  • Asthma (Inpatient)
  • Asthma, Pediatrics (Inpatient)
  • Atrial Fibrillation (Inpatient)
  • Attention Deficit Disorder (Outpatient)
  • Bariatric Surgery (Inpatient)
  • Benign prostatic hyperplasia (BPH) (Inpatient, Outpatient)
  • Bipolar disorder (Inpatient, Outpatient)
  • Breast Cancer (Inpatient, Outpatient)
  • Cancer Center/Oncology (Inpatient, Outpatient)
  • Cardiac Catheterization Lab (Inpatient, Outpatient)
  • Cardiac Surgery (Inpatient, Outpatient)
  • Cardiac Unit/Cardiology (Inpatient, Outpatient)
  • Cellulitis (Inpatient, Outpatient)
  • Cerebral Bleeding (Inpatient)
  • Chronic Kidney Disease (Inpatient)
  • Chronic Obstructive Pulmonary Disease (Inpatient)
  • Coagulopathy Treatment (Inpatient, Outpatient)
  • Colon/Rectal Cancer (Inpatient, Outpatient)
  • Congenital Anomalies (Inpatient)
  • Coronary Artery Disease (Inpatient)
  • Crohn's Disease (Inpatient, Outpatient)
  • CT Scanner (Inpatient, Outpatient)
  • Depression (Inpatient, Outpatient)
  • Developmental Pediatrics (Outpatient)
  • Diabetes Mellitus (Inpatient)
  • Dialysis (Inpatient)
  • EEG/EKG/EMG Lab (Inpatient, Outpatient)
  • Electroconvulsive Therapy (Inpatient)
  • Emergency Room (Outpatient)
  • Emphysema (Inpatient)
  • End Stage Renal Disease (Inpatient)
  • Epilepsy (Inpatient)
  • Esophageal Cancer (Inpatient, Outpatient)
  • Gastroesophageal Reflux Disease (Outpatient)
  • General Laboratory Tests
  • General Medical Services (Inpatient)
  • General Surgery (Inpatient, Outpatient)
  • GI or Endoscopy Lab (Inpatient, Outpatient)
  • Gynecology (Inpatient, Outpatient)
  • Head Injury (Inpatient)
  • Health Social Work (Inpatient)
  • Heart Failure (Inpatient)
  • Hematology/Blood Treatment (Inpatient)
  • Hepatitis B/C (Inpatient, Outpatient)
  • Hip Joint Replacement (Inpatient)
  • HIV/AIDS (Inpatient, Outpatient)
  • Hodgkin's disease (Inpatient, Outpatient)
  • Hyperbilirubinemia (Inpatient)
  • Hyperlipidemia (Inpatient)
  • Hypertension (Inpatient, Outpatient)
  • Hyperthyroidism/Hypothyroidism (Inpatient)
  • Imaging/Radiology (Inpatient, Outpatient)
  • Infectious Diseases (Inpatient, Outpatient)
  • Infusion Therapy (Inpatient, Outpatient)
  • Inpatient Diabetes (Inpatient)
  • Inpatient Intake (Inpatient)
  • Intensive Care Unit (Inpatient)
  • Internal Medicine (Inpatient, Outpatient)
  • Interventional Cardiac Catheterization (Inpatient, Outpatient)
  • Interventional Radiology (Inpatient, Outpatient)
  • Intraventricular hemorrhage (Inpatient)
  • Irritable Bowel Syndrome (Inpatient, Outpatient)
  • Ischemic Heart Disease (Inpatient)
  • Joint Replacement - Knee (Inpatient, Outpatient)
  • Labor & Delivery (Inpatient)
  • Laminectomy (Inpatient, Outpatient)
  • Leukemia (Inpatient, Outpatient)
  • Lithotripsy/Kidney Stone Treatment (Inpatient, Outpatient)
  • Liver Diseases (Inpatient, Outpatient)
  • Low Back Pain (Outpatient)
  • Lung Cancer (Inpatient, Outpatient)
  • Magnetic Resonance Imaging (Inpatient, Outpatient)
  • Mental Health (Inpatient, 24-hour Acute Care/Crisis Stabilization)
  • Microdiscectomy (Outpatient)
  • Migraine Headache (Outpatient)
  • 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, Outpatient)
  • Nursery (Inpatient)
  • Nutrition Programs (Inpatient, Outpatient)
  • Obstetrics (Inpatient)
  • Occupational Health (Outpatient)
  • Operating Room (Inpatient, Outpatient)
  • Ophthalmology/Eye Surgery (Outpatient)
  • Oral Maxillofacial Surgery (Inpatient, Outpatient)
  • Orthopedic Surgery (Inpatient, Outpatient)
  • Osteoporosis (Inpatient)
  • Otolaryngology/Ear, Nose, and Throat (Inpatient, Outpatient)
  • Outpatient Surgery (Outpatient)
  • Pain Management (Inpatient, Outpatient)
  • Pancreatic Cancer (Inpatient, Outpatient)
  • Pancreatitis (Inpatient)
  • Parkinsons Disease (Inpatient)
  • Pathology (Inpatient)
  • Pediatric Cardiology (Inpatient - Child/Youth)
  • Pediatric Care (Inpatient, Outpatient)
  • Pediatric Dentistry (Outpatient - Child/Youth)
  • Pediatric Dermatology (Inpatient - Child/Youth)
  • Pediatric Emergency Department (Outpatient - Child/Youth)
  • Pediatric Emergency Medicine (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric General Surgery (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Intensivists (Inpatient - Child/Youth)
  • Pediatric Neurology (Inpatient - Child/Youth)
  • Pediatric Neurosurgery (Inpatient - Child/Youth)
  • Pediatric Oral/Maxofacial Surgery (Outpatient - Child/Youth)
  • Pediatric Orthopedics (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Otolaryngology (Outpatient - Child/Youth)
  • Pediatric Pathology (Inpatient - Child/Youth)
  • Pediatric Physical Medicine and Rehab (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 (Outpatient)
  • Peripheral Vascular Disease (Inpatient)
  • Plastic Surgery (Inpatient, Outpatient)
  • Pneumonia (Inpatient, Outpatient)
  • Podiatry (Inpatient, Outpatient)
  • Post Anesthesia Care Unit (PACU) (Inpatient, Outpatient)
  • Prematurity (Inpatient)
  • Prostate Cancer (Inpatient, Outpatient)
  • Pulmonary Function Lab (Inpatient, Outpatient)
  • Radiation Oncology (Inpatient, Outpatient)
  • Recovery/Infirmary (Outpatient)
  • Respiratory Care (Ventilator) (Inpatient)
  • Respiratory Failure (Inpatient)
  • Schizophrenia (Inpatient, Outpatient)
  • Self Injury (Inpatient, Outpatient)
  • Sexually Transmitted Disease (Inpatient, Outpatient)
  • Sickle Cell Disease (Inpatient)
  • Sleep Center (Outpatient)
  • Sleeping Disorder (Outpatient)
  • Spine Care (Inpatient)
  • Stroke Rehabilitation (Inpatient, Outpatient)
  • Stroke (Primary Stroke Center) (Inpatient)
  • Subacute Care (Inpatient)
  • Systemic Lupus Erythematosis (Inpatient)
  • Telemetry (Inpatient)
  • Thoracic Surgery (Inpatient)
  • Trauma (Inpatient)
  • Tuberculosis (Inpatient)
  • Ulcerative Colitis (Inpatient, Outpatient)
  • Ultrasound (Inpatient, Outpatient)
  • Urgent Care/Emergency Medicine (Outpatient)
  • Urology (Inpatient)
  • Vascular Surgery (Inpatient)
  • Women's Health (Inpatient, Outpatient)
  • Wound Care (Inpatient, Outpatient)
Cape Fear Valley Neurosurgery
3308 Melrose Road
Fayetteville, NC  28301
  • General Outpatient Services (Outpatient)
Cape Fear Valley OB/GYN
1341 Walter Reed Road
Fayetteville, NC  28304
  • General Laboratory Tests
  • General Outpatient Services (Outpatient)
Cape Fear Valley Outpatient Anticoagulation Clinic
3403 Melrose Road
Fayetteville, NC  28301
  • General Laboratory Tests
Cape Fear Valley Pediatric Care
101 Robeson Street, Ste. 401
Fayetteville, NC  28304
  • General Laboratory Tests
  • General Outpatient Services (Outpatient)
Cape Fear Valley Perinatology
2109 Valleygate Dr., Ste 103
Fayetteville, NC  28304
  • General Outpatient Services (Outpatient)
Cape Fear Valley Wound Care Center
101 Robeson Street Suite 210
Fayetteville, NC  28301
    Employee Health Services of CFVHS
    524 Beaumont Road
    Fayetteville, NC  28304
    • General Laboratory Tests
    • General Outpatient Services (Outpatient)
    Health Pavilion North Family Care
    6837 Ramsey Street
    Fayetteville, NC  28311-9426
    • General Laboratory Tests
    • General Outpatient Services (Outpatient)
    Health Plex of CFVHS
    1930 Skibo Road
    Fayetteville, NC  28314
    • General Laboratory Tests
    • General Outpatient Services (Outpatient)
    Highsmith Rainey Hospital of Cape Fear Valley Health System
    150 Robeson Street
    Fayetteville, NC  28301
    • CT Scanner (Inpatient, Outpatient)
    • Dialysis (Inpatient)
    • EEG/EKG/EMG Lab (Inpatient, Outpatient)
    • General Laboratory Tests
    • General Medical Services (Inpatient)
    • General Surgery (Outpatient)
    • GI or Endoscopy Lab (Outpatient)
    • Imaging/Radiology (Inpatient, Outpatient)
    • Infectious Diseases (Inpatient)
    • Infusion Therapy (Outpatient)
    • Intensive Care Unit (Inpatient)
    • Magnetic Resonance Imaging (Inpatient, Outpatient)
    • Nephrology (Inpatient)
    • Operating Room (Inpatient, Outpatient)
    • Outpatient Surgery (Outpatient)
    • Post Anesthesia Care Unit (PACU) (Inpatient, Outpatient)
    • Pulmonary Function Lab (Inpatient, Outpatient)
    • Rehabilitation and Physical Medicine (Inpatient, Outpatient)
    • Respiratory Care (Ventilator) (Inpatient)
    • Ultrasound (Inpatient, Outpatient)
    • Urgent Care/Emergency Medicine (Outpatient)
    • Wound Care (Inpatient)
    Hoke Family Medical Center
    405 South Main Street
    Raeford, NC  28376
    • General Laboratory Tests
    • General Outpatient Services (Outpatient)
    Hope Mills Family Care
    4092 Professional Drive
    Hope Mills, NC  28348
    • General Laboratory Tests
    • General Outpatient Services (Outpatient)
    Murchison Medical Care
    2409 Murchison Rd., Suite 101
    Fayetteville, NC  28301
    • General Laboratory Tests
    • General Outpatient Services (Outpatient)
    Senior Health Services
    101 Robeson Street, Suite 202
    Fayetteville, NC  28301
    • General Laboratory Tests
    • General Outpatient Services (Outpatient)
    Sleep Center - Medical Arts Building
    101 Robeson St.
    Fayetteville, NC  28301
    • General Outpatient Services (Outpatient)
    Sleep Center - Walter Reed Rd.
    1213 Walter Reed Road
    Fayetteville, NC  28304
    • General Outpatient Services (Outpatient)
    Southeastern Regional Rehabilitation Center
    1638 Owen Drive
    Fayetteville, NC  28302
    • Audiology (Inpatient, Outpatient)
    • Rehabilitation and Physical Medicine (Inpatient, Outpatient)
    • Sleep Center (Outpatient)
    • Wound Care (Inpatient, Outpatient)
    Stedman Medical Care
    114 Forte Road
    Stedman, NC  28391
    • General Laboratory Tests
    • General Outpatient Services (Outpatient)
    The Transition of Care Clinic
    1638 Owen Drive
    Fayetteville, NC  28304
      V. Infectious Disease Care/Reg. Diabetes and Endocrine Care
      101 Robeson Street, Suite 405
      Fayetteville, NC  28301
      • General Laboratory Tests
      • General Outpatient Services (Outpatient)
      Westside Medical Care
      1463 Pamalee Drive
      Fayetteville, NC  28303
      • General Laboratory Tests
      • General Outpatient Services (Outpatient)

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