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Quality Report

Summary of Accreditation Quality Information
Decatur County Memorial Hospital
Org ID: 7166
720 North Lincoln Street
Greensburg, IN  47240
(812)663-4331
www.dcmh.net

Accreditation
Programs		 Accreditation
Decision		 Effective
Date		 Last Full Survey Date Last On-Site Survey Date  
Critical Access Hospital
Accredited 11/4/2009 11/3/2009 11/3/2009  
Home Care
Accredited 11/4/2009 11/3/2009 11/3/2009  


Other Accredited Programs / Services
Laboratory  -  Accredited by College of American Pathologists


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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
Critical Access 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
Not displayed.
3
Not displayed.
3
Heart Failure Care See Detail
Not displayed.
3
Not displayed.
3
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 above the target range/value.
This organization’s performance is similar to the target range/value.
  • Colon/Large Intestine Surgery
 See Detail
Not displayed.
3
Not displayed.
3
  • 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.
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)
Home Care
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.
*
 
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
Decatur County Memorial Hospital  *
720 North Lincoln Street
Greensburg, IN  47240
  • Abdominal Aortic Aneurysm (Outpatient)
  • Acute Care
  • Acute Coronary Syndrome (Inpatient, Outpatient)
  • Acute Myocardial Infarction (Inpatient, Outpatient)
  • Arthritis (Inpatient, Outpatient)
  • Asthma (Inpatient)
  • Asthma, Pediatrics (Inpatient)
  • Atrial Fibrillation (Inpatient, Outpatient)
  • Audiology (Outpatient)
  • Benign prostatic hyperplasia (BPH) (Inpatient, Outpatient)
  • Breast Cancer (Outpatient)
  • Burn Treatment (Outpatient)
  • Cancer Center/Oncology (Outpatient)
  • Cardiac Rehabilitation (Inpatient, Outpatient)
  • Carotid Stenosis (Outpatient)
  • Cellulitis (Inpatient, Outpatient)
  • Chronic Obstructive Pulmonary Disease (Inpatient)
  • Coagulopathy Treatment (Outpatient)
  • Colon/Rectal Cancer (Inpatient, Outpatient)
  • Coronary Artery Disease (Inpatient, Outpatient)
  • Crohn's Disease (Outpatient)
  • CT Scanner (Inpatient, Outpatient)
  • Dentistry (Outpatient)
  • Diabetes Mellitus (Inpatient, Outpatient)
  • EEG/EKG/EMG Lab (Inpatient, Outpatient)
  • Emergency Room (Outpatient)
  • Emphysema (Inpatient, Outpatient)
  • Epilepsy (Outpatient)
  • Esophageal Cancer (Outpatient)
  • Family Practice (Inpatient, Outpatient)
  • Gastroenterology (Outpatient)
  • Gastroesophageal Reflux Disease (Inpatient, Outpatient)
  • General Laboratory Tests
  • General Medical Services (Inpatient, Outpatient)
  • General Surgery (Inpatient, Outpatient)
  • Gynecology (Inpatient, Outpatient)
  • Head Injury (Outpatient)
  • Health and Wellness (Outpatient)
  • Health Social Work (Inpatient, Outpatient)
  • Heart Failure (Inpatient, Outpatient)
  • Hematology/Blood Treatment (Outpatient)
  • Hip Joint Replacement (Inpatient)
  • Hyperbilirubinemia (Inpatient)
  • Hypertension (Inpatient)
  • Imaging/Radiology (Inpatient, Outpatient)
  • Infusion Therapy (Inpatient, Outpatient)
  • Inpatient Diabetes (Inpatient)
  • Internal Medicine (Inpatient, Outpatient)
  • Irritable Bowel Syndrome (Outpatient)
  • Ischemic Heart Disease (Inpatient, Outpatient)
  • Joint Replacement - Knee (Inpatient)
  • Labor & Delivery (Inpatient)
  • Liver Diseases (Outpatient)
  • Low Back Pain (Outpatient)
  • Magnetic Resonance Imaging (Inpatient, Outpatient)
  • Migraine Headache (Outpatient)
  • Nephrology (Outpatient)
  • Neurology (Outpatient)
  • 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 (Outpatient)
  • Otolaryngology/Ear, Nose, and Throat (Inpatient, Outpatient)
  • Outpatient Surgery (Outpatient)
  • Pain Management (Inpatient, Outpatient)
  • Pancreatitis (Inpatient)
  • Parkinsons Disease (Inpatient, Outpatient)
  • Pathology (Inpatient, Outpatient)
  • Pediatric Cardiology (Outpatient - Child/Youth)
  • Pediatric Care (Inpatient, Outpatient)
  • Pediatric Neurology (Outpatient - Child/Youth)
  • Pelvic Inflammatory Disease (Inpatient, Outpatient)
  • Peripheral Vascular Disease (Outpatient)
  • Plastic Surgery (Inpatient, Outpatient)
  • Pneumonia (Inpatient, Outpatient)
  • Podiatry (Inpatient, Outpatient)
  • Post Anesthesia Care Unit (PACU) (Inpatient, Outpatient)
  • Prostate Cancer (Inpatient, Outpatient)
  • Pulmonary Function Lab (Outpatient)
  • Rehabilitation and Physical Medicine (Inpatient, Outpatient)
  • Respiratory Care (Ventilator) (Inpatient)
  • Respiratory Failure (Inpatient, Outpatient)
  • Respite Care
  • Self Injury (Outpatient)
  • Sleep Center (Outpatient)
  • Sleeping Disorder (Outpatient)
  • Sports Medicine (Outpatient)
  • Stroke Rehabilitation (Outpatient)
  • Telemetry (Inpatient)
  • Tobacco Treatment / Cessation (Outpatient)
  • Trauma (Outpatient)
  • Ulcerative Colitis (Outpatient)
  • Ultrasound (Inpatient, Outpatient)
  • Urgent Care/Emergency Medicine (Outpatient)
  • Vascular Surgery (Outpatient)
  • Weight Loss (Outpatient)
  • Women's Health (Inpatient, Outpatient)
  • Wound Care (Inpatient, Outpatient)
Decatur County Memorial Hospital Diagnostic Center
955 North Michigan Street
Greensburg, IN  47240
  • General Laboratory Tests
  • General Outpatient Services (Outpatient)
Decatur County Memorial Hospital Home Health Care
425 Montgomery Road
Greensburg, IN  47240
  • Diagnostic Care
  • Home Health, Non-Hospice Services
  • Nutrition
  • Occupational Therapy
  • Personal Care/Support Non-Hospice
  • Physical Therapy
  • Social Work
  • Speech Therapy
  • Wound Care
Decatur County Primary Care
718 North Lincoln Street
Greensburg, IN  47240
  • Single Specialty Group Practice (Outpatient)
Tree City Medical Partners
955 North Michigan Street
Greensburg, IN  47240
  • Single Specialty Group Practice (Outpatient)
  • Single Specialty Practitioner (Outpatient)
Westport Clinic
308 East Mulberry Street
Westport, IN  47283
  • Arthritis (Outpatient)
  • Diabetes Mellitus (Outpatient)
  • Single Specialty Practitioner (Outpatient)
WorkWell
955 North Michigan Street
Greensburg, IN  47240
  • General Outpatient Services (Outpatient)

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