The Joint Commission
Quality Check
Quality Report

Summary of Quality Information
FirstHealth Moore Regional Hospital
Org ID: 6534
155 Memorial Drive
Pinehurst, NC  28374
(910)715-1442
www.firsthealth.org


Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full Survey Date Last On-Site Survey Date  
Hospital
Accredited 3/13/2010 3/12/2010 3/12/2010  
Pathology and Clinical Laboratory
Accredited 10/31/2008 7/28/2010 7/28/2010  

Advanced Certification
Programs
Certification
Decision
Effective
Date
Last Full
Review Date
Last On-Site
Review Date
Primary Stroke Center
Certification 4/3/2009  2/9/2009  2/9/2009 


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
Children's Asthma Care See Detail
This organization’s performance is below the target range/value.
This organization’s performance is below the target range/value.
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 above 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
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 above the target range/value.
This organization’s performance is above 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 above the target range/value.
This organization’s performance is above 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
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.
*
 
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
FirstHealth Critical Care Transport
Jordon Drive
Pinehurst, NC  28374
  • General Laboratory Tests
FirstHealth Moore Regional Hospital  *
155 Memorial Drive
Pinehurst, NC  28374
Joint Commission Advanced Certification Programs:
  • Primary Stroke Center
Services:
  • Addiction Care (Inpatient)
  • Alcohol & Drug Rehabilitation (Inpatient)
  • Behavioral Health (Day Programs - Adult)
    (Non 24 Hour Care - Adult/Child/Youth)
    (24-hour Acute Care/Crisis Stabilization - Adult)
  • Cancer Center/Oncology (Inpatient, Outpatient)
  • Cardiac Catheterization Lab (Inpatient, Outpatient)
  • Cardiac Surgery (Inpatient)
  • Cardiac Unit/Cardiology (Inpatient)
  • CT Scanner (Inpatient, Outpatient)
  • Dermatology (Inpatient)
  • Dialysis (Inpatient)
  • EEG/EKG/EMG Lab (Inpatient, Outpatient)
  • Electroconvulsive Therapy (Inpatient, Outpatient)
  • Emergency Room (Outpatient)
  • Family Practice (Inpatient)
  • Gastroenterology (Inpatient, Outpatient)
  • General Laboratory Tests
  • General Medical Services (Inpatient, Outpatient)
  • General Surgery (Inpatient, Outpatient)
  • GI or Endoscopy Lab (Inpatient, Outpatient)
  • Gynecology (Inpatient, Outpatient)
  • Hematology/Blood Treatment (Inpatient, Outpatient)
  • Imaging/Radiology (Inpatient, Outpatient)
  • Infectious Diseases (Inpatient)
  • Inpatient Intake (Inpatient)
  • Intensive Care Unit (Inpatient)
  • Internal Medicine (Inpatient, Outpatient)
  • Labor & Delivery (Inpatient)
  • Lithotripsy/Kidney Stone Treatment (Inpatient, Outpatient)
  • Magnetic Resonance Imaging (Inpatient, Outpatient)
  • Medical Detoxification (Inpatient)
  • Mental Health (Inpatient, Outpatient, 24-hour Acute Care/Crisis Stabilization)
  • Neonatal Intensive Care (Inpatient)
  • Nephrology (Inpatient, Outpatient)
  • Neurology (Inpatient, Outpatient)
  • Neurosurgery (Inpatient)
  • Nuclear Medicine (Inpatient, Outpatient)
  • Nursery (Inpatient)
  • Obstetrics (Inpatient, Outpatient)
  • Occupational Health (Outpatient)
  • Operating Room (Inpatient, Outpatient)
  • Ophthalmology/Eye Surgery (Inpatient, Outpatient)
  • Oral Maxillofacial Surgery (Inpatient, Outpatient)
  • Orthopedic Surgery (Inpatient, Outpatient)
  • Otolaryngology/Ear, Nose, and Throat (Inpatient, Outpatient)
  • Outpatient Surgery (Outpatient)
  • Pain Management (Outpatient)
  • Pediatric Care (Inpatient, Outpatient)
  • Plastic Surgery (Inpatient, Outpatient)
  • Podiatry (Inpatient, Outpatient)
  • Post Anesthesia Care Unit (PACU) (Inpatient, Outpatient)
  • Pulmonary Function Lab (Inpatient, Outpatient)
  • Radiation Oncology (Inpatient, Outpatient)
  • Rehabilitation and Physical Medicine (Inpatient, Outpatient)
  • Respiratory Care (Ventilator) (Inpatient)
  • Sleep Center (Outpatient)
  • Telemetry (Inpatient)
  • Thoracic Surgery (Inpatient)
  • Toxicology
  • Ultrasound (Inpatient, Outpatient)
  • Urgent Care/Emergency Medicine (Outpatient)
  • Urology (Inpatient)
  • Vascular Surgery (Inpatient)
FirstHealth Outpatient Cancer Center
220 Page Road
Pinehurst, NC  28374
  • General Outpatient Services (Outpatient)
FirstHealth Outpatient Specialty Center
35 Memorial Drive
Pinehurst, NC  28374
  • Behavioral Health (Day Programs - Adult)
    (Non 24 Hour Care - Adult/Child/Youth)
  • General Outpatient Services (Outpatient)
  • Single Specialty Group Practice (Outpatient)
FirstHealth Richmond Memorial Hospital
925 Long Drive
Rockingham, NC  28379
Joint Commission Advanced Certification Programs:
  • Primary Stroke Center
Services:
  • Cardiac Catheterization Lab (Outpatient)
  • Cardiac Unit/Cardiology (Inpatient)
  • CT Scanner (Inpatient, Outpatient)
  • EEG/EKG/EMG Lab (Inpatient, Outpatient)
  • Emergency Room (Outpatient)
  • Family Practice (Inpatient, Outpatient)
  • Gastroenterology (Inpatient, Outpatient)
  • General Laboratory Tests
  • General Medical Services (Inpatient, Outpatient)
  • General Surgery (Inpatient, Outpatient)
  • GI or Endoscopy Lab (Inpatient, Outpatient)
  • Gynecology (Inpatient, Outpatient)
  • Imaging/Radiology (Inpatient, Outpatient)
  • Intensive Care Unit (Inpatient)
  • Internal Medicine (Inpatient, Outpatient)
  • Labor & Delivery (Inpatient)
  • Magnetic Resonance Imaging (Inpatient, Outpatient)
  • Neurology (Inpatient, Outpatient)
  • Nuclear Medicine (Inpatient, Outpatient)
  • Nursery (Inpatient)
  • Obstetrics (Inpatient, Outpatient)
  • Operating Room (Inpatient, Outpatient)
  • Ophthalmology/Eye Surgery (Outpatient)
  • Orthopedic Surgery (Inpatient, Outpatient)
  • Outpatient Surgery (Outpatient)
  • Pain Management (Outpatient)
  • Pediatric Care (Inpatient)
  • Podiatry (Inpatient, Outpatient)
  • Post Anesthesia Care Unit (PACU) (Inpatient, Outpatient)
  • Respiratory Care (Ventilator) (Inpatient)
  • Sleep Center (Outpatient)
  • Telemetry (Inpatient)
  • Toxicology
  • Ultrasound (Inpatient, Outpatient)
  • Urgent Care/Emergency Medicine (Outpatient)
  • Urology (Inpatient, Outpatient)
  • Vascular Surgery (Inpatient, Outpatient)
  • Wound Care (Outpatient)

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