The Joint Commission
Quality Check
Quality Report

Summary of Accreditation Quality Information
Fairfield Medical Center
Org ID: 7060
401 North Ewing Street
Lancaster, OH  43130-3371
(740)687-8000
www.fmchealth.org


Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full Survey Date Last On-Site Survey Date
Hospital
Accredited 6/11/2011 6/6/2014   6/6/2014  


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





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
Hospital
2012 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  2013 -
Dec  2013
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
   
 
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
DHS - Amanda
123 E. Main Street
Amanda, OH  43102
    Services:
    • Laboratory Draw Station (Outpatient)
    DHS - Colonade
    1550 Sheridan Dr
    Lancaster, OH  43130
      Services:
      • Laboratory Draw Station (Outpatient)
      DHS - Millersport
      DBA:  Lab
      12135 Lancaster Street NE
      Millersport, OH  43046
        Services:
        • Outpatient Clinics (Outpatient)
        DHS- Granville Pike
        1781 Country Side Dr
        Lancaster, OH  43130
          Services:
          • Laboratory Draw Station (Outpatient)
          Diagnostic Health Care Services
          1159 East Main Street
          Lancaster, OH  43130
            Services:
            • Outpatient Clinics (Outpatient)
            Ewing Square
            DBA:  Ambulatory Infusion Center
            1253 East Main Street
            Lancaster, OH  43130
              Services:
              • Administration of Blood Product (Outpatient)
              • Administration of High Risk Medications (Outpatient)
              • Outpatient Clinics (Outpatient)
              Fairfield Diagnostic Imaging
              DBA:  Fairfield Diagnostic Imaging
              1241 River Valley Boulevard
              Lancaster, OH  43130
                Services:
                • Outpatient Clinics (Outpatient)
                Fairfield Medical Center  *
                401 N. Ewing Street
                Lancaster, OH  43130
                  Services:
                  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - 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)
                  • Ear/Nose/Throat Surgery (Surgical Services)
                  • EEG/EKG/EMG Lab (Imaging/Diagnostic Services)
                  • Gastroenterology (Surgical Services)
                  • GI or Endoscopy Lab (Imaging/Diagnostic Services)
                  • Gynecological Surgery (Surgical Services)
                  • Gynecology (Inpatient)
                  • Hematology/Oncology Unit (Inpatient)
                  • Interventional Radiology (Imaging/Diagnostic Services)
                  • Labor & Delivery (Inpatient)
                  • Magnetic Resonance Imaging (Imaging/Diagnostic Services)
                  • Medical /Surgical Unit (Inpatient)
                  • Normal Newborn Nursery (Inpatient)
                  • Nuclear Medicine (Imaging/Diagnostic Services)
                  • Orthopedic Surgery (Surgical Services)
                  • Orthopedic/Spine Unit (Inpatient)
                  • Outpatient Clinics (Outpatient)
                  • Pediatric Unit (Inpatient)
                  • Peer Support (Non 24 Hour Care)
                  • Plastic Surgery (Surgical Services)
                  • Positron Emission Tomography (PET) (Imaging/Diagnostic Services)
                  • Post Anesthesia Care Unit (PACU) (Inpatient)
                  • Radiation Oncology (Imaging/Diagnostic Services)
                  • Sleep Laboratory (Sleep Laboratory)
                  • Teleradiology (Imaging/Diagnostic Services)
                  • Thoracic Surgery (Surgical Services)
                  • Ultrasound (Imaging/Diagnostic Services)
                  • Urology (Surgical Services)
                  • Vascular Surgery (Surgical Services)
                  Fairfield Medical Diagnostic Services at Riverview
                  DBA:  Fairfield Medical Diagnostic Services at Riverview
                  2405 N. Columbus St
                  Lancaster, OH  43130
                    Services:
                    • Outpatient Clinics (Outpatient)
                    Rehabilitation Services
                    1143 East Main Street
                    Lancaster, OH  43130
                      Services:
                      • Outpatient Clinics (Outpatient)
                      River Valley Laboratory
                      1203-B River Valley Boulevard
                      Lancaster, OH  43130
                        Services:
                        • Laboratory Draw Station (Outpatient)
                        Riverview Surgery Center
                        2401 N. Columbus Street
                        Lancaster, OH  43130
                          Services:
                          • Administration of High Risk Medications (Outpatient)
                          • Ambulatory Surgery Center (Outpatient)
                          • Anesthesia (Outpatient)
                          • Perform Invasive Procedure (Outpatient)
                          Surgery and Medical Office Pavilion
                          DBA:  Outpatient surgery
                          135 North Ewing Street
                          Lancaster, OH  43130
                            Services:
                            • Administration of High Risk Medications (Outpatient)
                            • Ambulatory Surgery Center (Outpatient)
                            • Anesthesia (Outpatient)
                            • Perform Invasive Procedure (Outpatient)
                            Wound Care Services
                            135 North Ewing Suite 302
                            Lancaster, OH  43130
                              Services:
                              • Outpatient Clinics (Outpatient)

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