The Joint Commission
Quality Check
Quality Report

Summary of Accreditation Quality Information
Norwegian American Hospital
Org ID: 7296
1044 North Francisco
Chicago, IL  60622
(773)292-8200
www.nahospital.org

Accreditation Decision: Accredited
Decision Effective Date: December 13, 2008
This organization is in full compliance with all applicable standards.  


Accredited Programs Last Full Survey Date Last On-Site Survey Date  
Hospital 12/12/2008 12/12/2008  


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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
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.
*
National Quality Improvement Goals:    
Reporting Period:
Jan  2009 -
Dec  2009
Heart Attack Care See Detail
This organization’s performance is below the target range/value.
This organization’s performance is below the target range/value.
Heart Failure Care See Detail
This organization’s performance is below the target range/value.
This organization’s performance is below the target range/value.
Pneumonia Care See Detail
This organization’s performance is below the target range/value.
This organization’s performance is below 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 below the target range/value.
This organization’s performance is below the target range/value.
  • Blood Vessel Surgery
See Detail
Not displayed.
3
Not displayed.
3
  • Colon/Large Intestine Surgery
See Detail
Not displayed.
3
Not displayed.
3
  • Hip Joint Replacement
See Detail
Not displayed.
3
Not displayed.
3
  • Hysterectomy
See Detail
This organization’s performance is below the target range/value.
This organization’s performance is below the target range/value.
  • Knee Replacement
See Detail
Not displayed.
3
Not displayed.
3
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)
 
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
CHIME - Center for Health, Integrative Medicine & Education
1044 N. Francisco, Suite 403
Chicago, IL  60622
  • General Outpatient Services (Outpatient)
Medicina Familiar
6035 W. Cermak Road
Chicago, IL  60804
  • General Outpatient Services (Outpatient)
NAH Division Street Clinic
2736 West Division
Chicago, IL  60622
  • General Outpatient Services (Outpatient)
NAH Milwaukee Clinic
2844 N Milwaukee
Chicago, IL  60647
  • General Outpatient Services (Outpatient)
Norwegian American Hospital  *
1044 North Francisco
Chicago, IL  60622
  • Acute Coronary Syndrome (Inpatient)
  • Acute Myocardial Infarction (Inpatient)
  • Atrial Fibrillation (Inpatient)
  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult)
  • Benign prostatic hyperplasia (BPH) (Inpatient)
  • Breast Cancer (Inpatient, Outpatient)
  • Cancer Center/Oncology (Inpatient)
  • Cardiac Catheterization Lab (Inpatient)
  • Chronic Kidney Disease (Inpatient)
  • Chronic Obstructive Pulmonary Disease (Inpatient)
  • Colon/Rectal Cancer (Inpatient, Outpatient)
  • Coronary Artery Disease (Inpatient)
  • CT Scanner (Inpatient)
  • Depression (Inpatient)
  • Diabetes Mellitus (Inpatient, Outpatient)
  • Dialysis (Inpatient)
  • EEG/EKG/EMG Lab (Inpatient)
  • Emergency Room (Outpatient)
  • Emphysema (Inpatient, Outpatient)
  • End Stage Renal Disease (Inpatient)
  • Family Practice (Inpatient)
  • Gastroenterology (Inpatient, Outpatient)
  • General Medical Services (Inpatient)
  • General Surgery (Inpatient)
  • GI or Endoscopy Lab (Inpatient, Outpatient)
  • Gynecology (Inpatient, Outpatient)
  • Heart Failure (Inpatient)
  • Hematology/Blood Treatment (Inpatient, Outpatient)
  • Hypertension (Inpatient)
  • Imaging/Radiology (Inpatient, Outpatient)
  • Infectious Diseases (Inpatient)
  • Infusion Therapy (Inpatient, Outpatient)
  • Inpatient Diabetes (Inpatient)
  • Intensive Care Unit (Inpatient)
  • Internal Medicine (Inpatient, Outpatient)
  • Interventional Cardiac Catheterization (Inpatient)
  • Interventional Radiology (Inpatient, Outpatient)
  • Labor & Delivery (Inpatient)
  • Low Back Pain (Inpatient)
  • Lung Cancer (Inpatient)
  • Magnetic Resonance Imaging (Inpatient, Outpatient)
  • Medical Detoxification (Inpatient)
  • Mental Health (Inpatient, 24-hour Acute Care/Crisis Stabilization)
  • Methadone Detoxification (24-hour Acute Care/Crisis Stabilization - Adult)
  • Neonatal Intensive Care (Inpatient)
  • Neonatology (Inpatient)
  • Nephrology (Inpatient, Outpatient)
  • Neurology (Inpatient, Outpatient)
  • Nuclear Medicine (Inpatient, Outpatient)
  • Nursery (Inpatient)
  • Nutrition Programs (Inpatient)
  • Obstetrics (Inpatient, Outpatient)
  • Occupational Health (Outpatient)
  • Operating Room (Inpatient)
  • Ophthalmology/Eye Surgery (Inpatient, Outpatient)
  • Orthopedic Surgery (Inpatient, Outpatient)
  • Otolaryngology/Ear, Nose, and Throat (Inpatient, Outpatient)
  • Outpatient Surgery (Outpatient)
  • Pain Management (Inpatient, Outpatient)
  • Pancreatic Cancer (Inpatient)
  • Pancreatitis (Inpatient)
  • Pathology (Inpatient, Outpatient)
  • Pediatric Care (Inpatient, Outpatient)
  • Pelvic Inflammatory Disease (Inpatient)
  • Pneumonia (Inpatient)
  • Podiatry (Inpatient, Outpatient)
  • Post Anesthesia Care Unit (PACU) (Inpatient, Outpatient)
  • Prematurity (Inpatient)
  • Pulmonary Function Lab (Inpatient, Outpatient)
  • Recovery/Infirmary (Outpatient)
  • Rehabilitation and Physical Medicine (Inpatient, Outpatient)
  • Respiratory Care (Ventilator) (Inpatient)
  • Rheumatology (Inpatient, Outpatient)
  • Sexually Transmitted Disease (Inpatient)
  • Telemetry (Inpatient)
  • Ultrasound (Inpatient, Outpatient)
  • Urgent Care/Emergency Medicine (Outpatient)
  • Urology (Inpatient, Outpatient)
  • Vascular Surgery (Inpatient, Outpatient)
  • Wound Care (Inpatient, Outpatient)
Pediatric Mobile Van
1044 N. Francisco, Suite 403
Chicago, IL  60622
  • General Outpatient Services (Outpatient)

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