The Joint Commission
Quality Check
Quality Report

Summary of Quality Information
Rush University Medical Center
Org ID: 7297
1653 West Congress Parkway
Chicago, IL  60612
(312)942-5000
www.rush.edu


Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full Survey Date Last On-Site Survey Date
Behavioral Health Care
Accredited 9/18/2012 9/17/2012   9/17/2012  
Hospital
Accredited 9/22/2012 9/21/2012   9/21/2012  
Laboratory Accreditation Program
Accredited 8/4/2012 8/3/2012   8/3/2012  


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


Advanced Certification
Programs
Certification
Decision
Effective
Date
Last Full
Review Date
Last On-Site
Review Date
Advanced Comprehensive Stroke Center
Certification 11/19/2013  9/20/2013  9/20/2013 
Ventricular Assist Device
Certification 7/19/2013  7/18/2013  7/18/2013 





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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.
National Patient Safety Goals and National Quality Improvement Goals
    Compared to other Joint Commission Accredited Organizations
    Nationwide Statewide
Behavioral Health Care
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.
*
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:
Jul  2012 -
Jun  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.
Perinatal Care See Detail
Not displayed.
8
Not displayed.
8
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 above the target range/value.
This organization’s performance is above 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 above the target range/value.
This organization’s performance is above 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
   
Laboratory Accreditation Program
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 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
Clinical Psychology
1645 West Jackson Boulevard, Suite 400
Chicago, IL  60612
    Services:
    • Outpatient Clinics (Outpatient)
    RUMC - 1611 West Harrison Street
    1611 West Harrison Street
    Chicago, IL  60612
    Other Clinics/Practices located at this site:
    • Rush Otolaryngology, Head and Neck Surgery
    • University Rheumatologists
    Services:
    • Administration of High Risk Medications (Outpatient)
    • Outpatient Clinics (Outpatient)
    • Perform Invasive Procedure (Outpatient)
    RUMC - 1725 West Harrison Street
    1725 West Harrison Street
    Chicago, IL  60612
    Other Clinics/Practices located at this site:
    • Consultants in Allergy and Immunology
    • Consultants in Endocrinology
    • Dermatology Clinic
    • Neurology Epilepsy Clinic
    • Rush Cancer Center
    • Rush University Senior Care
    • Rush University Surgeons
    • Rush University Urology
    • University Cardiologists
    • University Gastroenterologists
    • University Neurologists
    • University Neurologists, Movement Disorders
    • University Neurologists, Multiple Sclerosis Center
    • University Thoracic Surgeons
    Services:
    • Administration of Blood Product (Outpatient)
    • Administration of High Risk Medications (Outpatient)
    • Anesthesia (Outpatient)
    • Outpatient Clinics (Outpatient)
    • Perform Invasive Procedure (Outpatient)
    RUMC - 610 South Maple Avenue
    610 South Maple Avenue
    Oak Park, IL  60304
    Other Clinics/Practices located at this site:
    • Rush Cancer Center - Oak Park
    • Rush Otolaryngology - Head and Neck Surgery
    • Rush University Urology
    Services:
    • Administration of Blood Product (Outpatient)
    • Administration of High Risk Medications (Outpatient)
    • Outpatient Clinics (Outpatient)
    • Perform Invasive Procedure (Outpatient)
    Rush University Medical Center at Lisle
    430 Warrenville Road, Suite 200
    Lisle, IL  60532
      Services:
      • Administration of High Risk Medications (Outpatient)
      • Outpatient Clinics (Outpatient)
      • Perform Invasive Procedure (Outpatient)
      Rush Center for Advanced Reproductive Care/Andrology Lab
      1725 West Harrison Street, Suite 119
      Chicago, IL  60612
        Services:
        • General Laboratory Tests
        • Laboratory Draw Station (Outpatient)
        Rush Center for Advanced Reproductive Care/Embryology Lab
        1725 West Harrison Street, Suite 217
        Chicago, IL  60612
          Services:
          • General Laboratory Tests
          • Laboratory Draw Station (Outpatient)
          Rush Center for Congenital Heart Disease
          1650 West Harrison Street, 708 Kellogg
          Chicago, IL  60612
            Services:
            • Outpatient Clinics (Outpatient)
            Rush Day Hospital
            2150 West Harrison Street
            Chicago, IL  60612
              Services:
              • Behavioral Health (Day Programs - Adult)
                (Partial - Adult)
              • Peer Support (Non 24 Hour Care)
              Rush Day School
              2150 West Harrison Street
              Chicago, IL  60612
                Services:
                • Other
                Rush University Medical Center  *
                1653 West Congress Parkway
                Chicago, IL  60612
                Joint Commission Advanced Certification Programs:
                • Advanced Comprehensive Stroke Center
                • Ventricular Assist Device
                  Services:
                  • Behavioral Health (Non 24 Hour Care - Adult/Child/Youth)
                    (24-hour Acute Care/Crisis Stabilization - Adult/Child/Youth)
                  • Brachytherapy (Imaging/Diagnostic Services)
                  • Cardiac Catheterization Lab (Surgical Services)
                  • Cardiac Surgery (Surgical Services)
                  • Cardiothoracic Surgery (Surgical Services)
                  • Cardiovascular Unit (Inpatient)
                  • Coronary Care Unit (Inpatient)
                  • CT Scanner (Imaging/Diagnostic Services)
                  • Ear/Nose/Throat Surgery (Surgical Services)
                  • Eating Disorders (Outpatient)
                  • 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 (Inpatient, Outpatient, Imaging/Diagnostic Services)
                  • Labor & Delivery (Inpatient)
                  • Magnetic Resonance Imaging (Imaging/Diagnostic Services)
                  • Medical /Surgical Unit (Inpatient)
                  • Medical ICU (Intensive Care Unit)
                  • Neuro/Spine ICU (Intensive Care Unit)
                  • Neuro/Spine Unit (Inpatient)
                  • Neurosurgery (Surgical Services)
                  • Normal Newborn Nursery (Inpatient)
                  • Nuclear Medicine (Imaging/Diagnostic Services)
                  • Ophthalmology (Surgical Services)
                  • Orthopedic Surgery (Surgical Services)
                  • Orthopedic/Spine Unit (Inpatient)
                  • Outpatient Clinics (Outpatient)
                  • Pediatric Cardiac Catheterization (Inpatient - Child/Youth)
                    (Outpatient - Child/Youth)
                  • Pediatric Cardiology (Inpatient - Child/Youth)
                    (Outpatient - Child/Youth)
                  • Pediatric Cardiothoracic Surgery (Inpatient - Child/Youth)
                    (Outpatient - Child/Youth)
                  • Pediatric Dentistry (Inpatient - Child/Youth)
                    (Outpatient - Child/Youth)
                  • Pediatric Dermatology (Inpatient - Child/Youth)
                    (Outpatient - Child/Youth)
                  • Pediatric Emergency Medicine (Outpatient - Child/Youth)
                  • Pediatric Endocrinology (Inpatient - Child/Youth)
                    (Outpatient - Child/Youth)
                  • Pediatric Gastroenterology (Inpatient - Child/Youth)
                    (Outpatient - Child/Youth)
                  • Pediatric General Surgery (Inpatient - Child/Youth)
                    (Outpatient - Child/Youth)
                  • Pediatric Nephrology (Inpatient - Child/Youth)
                    (Outpatient - Child/Youth)
                  • Pediatric Neurology (Inpatient - Child/Youth)
                    (Outpatient - Child/Youth)
                  • Pediatric Neurosurgery (Inpatient - Child/Youth)
                    (Outpatient - Child/Youth)
                  • Pediatric Ophthalmology (Inpatient - Child/Youth)
                    (Outpatient - Child/Youth)
                  • Pediatric Oral/Maxofacial Surgery (Inpatient - Child/Youth)
                    (Outpatient - Child/Youth)
                  • Pediatric Otolaryngology (Inpatient - Child/Youth)
                    (Outpatient - Child/Youth)
                  • Pediatric Plastic Surgery (Inpatient - Child/Youth)
                    (Outpatient - Child/Youth)
                  • 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)
                  • Rehabilitation Unit (Inpatient, 24-hour Acute Care/Crisis Stabilization)
                  • Sleep Laboratory (Sleep Laboratory)
                  • Surgical ICU (Intensive Care Unit)
                  • Surgical Unit (Inpatient)
                  • Thoracic Surgery (Surgical Services)
                  • Transplant Surgery (Surgical Services)
                  • Ultrasound (Imaging/Diagnostic Services)
                  • Urology (Surgical Services)
                  • Vascular Surgery (Surgical Services)
                  Rush University Urology
                  900 North Westmoreland, Suite 226
                  Lake Forest, IL  60045
                    Services:
                    • Outpatient Clinics (Outpatient)
                    • Perform Invasive Procedure (Outpatient)
                    Sleep Center
                    710 South Paulina, Suite 600
                    Chicago, IL  60612
                      Services:
                      • Outpatient Clinics (Outpatient)

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