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Quality Report

Summary of Quality Information
University of Chicago Medical Center
Org ID: 7315
5841 South Maryland Avenue
Chicago, IL  60637
(773)702-9785
www.uchospitals.edu

Accreditation
Programs 		Accreditation
Decision 		Effective
Date 		Last Full Survey Date Last On-Site Survey Date
Hospital
Accredited 4/10/2010 3/22/2013   3/22/2013  


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


Advanced Certification
Programs 		Certification
Decision 		Effective
Date 		Last Full
Review Date 		Last On-Site
Review Date
Primary Stroke Center
Certification 4/22/2011  4/21/2011  4/21/2011 
Ventricular Assist Device
Certification 8/18/2011  8/17/2011  8/17/2011 



Certification programs recognized by the Centers for Medicare and Medicaid Services (CMS)
Ventricular Assist Device



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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
Hospital
2011 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:
Oct  2011 -
Sep  2012
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 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 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 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
   
  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
Comer Children's Hospital
5721 South Maryland Avenue
Chicago, IL  60637
    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)
    • EEG/EKG/EMG Lab (Imaging/Diagnostic Services)
    • Gastroenterology (Surgical Services)
    • Gynecological Surgery (Surgical Services)
    • Interventional Radiology (Imaging/Diagnostic Services)
    • Magnetic Resonance Imaging (Imaging/Diagnostic Services)
    • Medical ICU (Intensive Care Unit)
    • Neurosurgery (Surgical Services)
    • Orthopedic Surgery (Surgical Services)
    • Pediatric Unit (Inpatient)
    • Plastic Surgery (Surgical Services)
    • Positron Emission Tomography (PET) (Imaging/Diagnostic Services)
    • Post Anesthesia Care Unit (PACU) (Inpatient)
    • 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)
    Joliet Cancer Center - Physician Office
    1850 Silver Cross Blvd.
    New Lenox, IL  60451
      Services:
      • Administration of High Risk Medications (Outpatient)
      • Outpatient Clinics (Outpatient)
      Outpatient Senior Health Center at South Shore
      7101 S. Exchange Avenue
      Chicago, IL  60637
        Services:
        • General Laboratory Tests
        • Single Specialty Practitioner (Outpatient)
        University of Chicago Center for Care and Discovery
        5700 South Maryland Avenue
        Chicago, IL  60637
          Services:
          • Brachytherapy (Imaging/Diagnostic Services)
          • Cardiac Surgery (Surgical Services)
          • Cardiothoracic Surgery (Surgical Services)
          • Cardiovascular Unit (Inpatient)
          • Coronary Care Unit (Inpatient)
          • CT Scanner (Imaging/Diagnostic Services)
          • Dialysis Unit (Inpatient)
          • 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)
          • Hematology/Oncology Unit (Inpatient)
          • Interventional Radiology (Imaging/Diagnostic Services)
          • 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)
          • Orthopedic Surgery (Surgical Services)
          • Orthopedic/Spine Unit (Inpatient)
          • Plastic Surgery (Surgical Services)
          • Positron Emission Tomography (PET) (Imaging/Diagnostic Services)
          • Post Anesthesia Care Unit (PACU) (Inpatient)
          • Radiation Oncology (Imaging/Diagnostic Services)
          • 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)
          University of Chicago Hospitals and Health Systems  *
          5841 South Maryland Avenue
          Chicago, IL  60637
          Joint Commission Advanced Certification Programs:
          • Primary Stroke Center
          • Ventricular Assist Device
            Services:
            • Behavioral Health (Non 24 Hour Care - Adult/Child/Youth)
            • Brachytherapy (Imaging/Diagnostic Services)
            • Burn Unit (Inpatient)
            • Cardiac Catheterization Lab (Surgical Services)
            • Cardiac Surgery (Surgical Services)
            • Cardiothoracic Surgery (Surgical Services)
            • Chemical Dependency (Non 24 Hour Care - Adult)
            • Coronary Care Unit (Inpatient)
            • CT Scanner (Imaging/Diagnostic Services)
            • Dialysis Unit (Inpatient)
            • Ear/Nose/Throat Surgery (Surgical Services)
            • Eating Disorders (Outpatient - Adult)
              (Non 24 Hour Care - Adult)
            • EEG/EKG/EMG Lab (Imaging/Diagnostic Services)
            • Family Support (Non 24 Hour Care)
            • 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)
            • Medical ICU (Intensive Care Unit)
            • Neuro/Spine ICU (Intensive Care Unit)
            • Neurosurgery (Surgical Services)
            • Normal Newborn Nursery (Inpatient)
            • Nuclear Medicine (Imaging/Diagnostic Services)
            • Orthopedic Surgery (Surgical Services)
            • Pediatric Unit (Inpatient)
            • 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)
            • 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)

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