The Joint Commission
Quality Check
Quality Report

Summary of Quality Information
University Medical Center, Inc.
Org ID: 7767
530 South Jackson Street
Louisville, KY  40202
(502)562-3000
www.uoflhealthcare.org


Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full Survey Date Last On-Site Survey Date  
Hospital
Accredited 2/6/2008 5/18/2007 1/9/2009  

Advanced Certification
Programs
Certification
Decision
Effective
Date
Last Full
Review Date
Last On-Site
Review Date
Primary Stroke Center
Certification 9/13/2008  9/12/2008  9/12/2008 


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
Hospital
2009 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  2008 -
Jun  2009
Heart Attack 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.
Heart Failure Care See Detail
This organization’s performance is below the target range/value.
This organization’s performance is similar to 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
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 below the target range/value.
This organization’s performance is below the target range/value.
  • Hip Joint Replacement
See Detail
This organization’s performance is below the target range/value.
This organization’s performance is below 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 similar to the target range/value.
This organization’s performance is similar to the target range/value.
  • Open Heart Surgery
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
University of Louisville Hospital  *
530 South Jackson Street
Louisville, KY  40202
Joint Commission Advanced Certification Programs:
  • Primary Stroke Center
Services:
  • Abdominal Aortic Aneurysm (Inpatient)
  • Acquired Brain Injury (Inpatient, 24-hour Acute Care/Crisis Stabilization)
  • Acute Coronary Syndrome (Inpatient, Outpatient)
  • Acute Myocardial Infarction (Inpatient, Outpatient)
  • Alzheimers Disease (Inpatient)
  • Anxiety/panic disorders (Outpatient)
  • Arthritis (Inpatient)
  • Asthma (Inpatient, Outpatient)
  • Asthma, Pediatrics (Inpatient, Outpatient)
  • Atrial Fibrillation (Inpatient)
  • Audiology (Inpatient)
  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult)
  • Bipolar disorder (Inpatient, Outpatient)
  • Bone Marrow Transplant (Inpatient)
  • Breast Cancer (Inpatient, Outpatient)
  • Burn Treatment (Inpatient, Outpatient)
  • Cancer Center/Oncology (Inpatient, Outpatient)
  • Cardiac Catheterization Lab (Inpatient, Outpatient)
  • Cardiac Surgery (Inpatient)
  • Cardiac Unit/Cardiology (Inpatient)
  • Carotid Stenosis (Inpatient)
  • Cellulitis (Inpatient, Outpatient)
  • Cerebral Bleeding (Inpatient, Outpatient)
  • Cervical Spine Treatment (Inpatient)
  • Chronic Kidney Disease (Inpatient, Outpatient)
  • Chronic Obstructive Pulmonary Disease (Inpatient, Outpatient)
  • Coagulopathy Treatment (Inpatient)
  • Colon/Rectal Cancer (Inpatient, Outpatient)
  • Coronary Artery Bypass Graft (Inpatient)
  • Coronary Artery Disease (Inpatient, Outpatient)
  • Crohn's Disease (Inpatient, Outpatient)
  • CT Scanner (Inpatient, Outpatient)
  • Cystic Fibrosis (Inpatient)
  • Dentistry (Inpatient)
  • Depression (Inpatient, Outpatient)
  • Dermatology (Inpatient)
  • Diabetes Mellitus (Inpatient)
  • Dialysis (Inpatient)
  • Eating Disorders (Inpatient)
  • EEG/EKG/EMG Lab (Inpatient, Outpatient)
  • Electroconvulsive Therapy (Inpatient)
  • Emergency Room (Outpatient)
  • Emphysema (Inpatient, Outpatient)
  • End Stage Renal Disease (Inpatient)
  • Endocrinology (Inpatient)
  • Epilepsy (Inpatient, Outpatient)
  • Esophageal Cancer (Inpatient, Outpatient)
  • Family Practice (Inpatient)
  • Gastroenterology (Inpatient, Outpatient)
  • Gastroesophageal Reflux Disease (Inpatient, Outpatient)
  • General Medical Services (Inpatient)
  • General Surgery (Inpatient, Outpatient)
  • GI or Endoscopy Lab (Inpatient, Outpatient)
  • Gynecology (Inpatient)
  • Head Injury (Inpatient, Outpatient)
  • Heart Failure (Inpatient, Outpatient)
  • Hematology/Blood Treatment (Inpatient, Outpatient)
  • Hemophilia (Inpatient, Outpatient)
  • Hepatitis B/C (Inpatient, Outpatient)
  • High Risk Neonatal (Inpatient)
  • High Risk Obstetrics (Inpatient)
  • Hip Joint Replacement (Inpatient)
  • HIV/AIDS (Inpatient, Outpatient)
  • Hyperbilirubinemia (Inpatient, Outpatient)
  • Hypertension (Inpatient, Outpatient)
  • Imaging/Radiology (Inpatient, Outpatient)
  • Infectious Diseases (Inpatient)
  • Infusion Services (Inpatient)
  • Inpatient Diabetes (Inpatient)
  • Intensive Care Unit (Inpatient)
  • Internal Medicine (Inpatient)
  • Interventional Cardiac Catheterization (Inpatient, Outpatient)
  • Interventional Radiology (Inpatient, Outpatient)
  • Intraventricular hemorrhage (Inpatient, Outpatient)
  • Irritable Bowel Syndrome (Inpatient, Outpatient)
  • Ischemic Heart Disease (Inpatient, Outpatient)
  • Joint Replacement - Knee (Inpatient)
  • Labor & Delivery (Inpatient)
  • Leukemia (Inpatient, Outpatient)
  • Lithotripsy/Kidney Stone Treatment (Inpatient)
  • Liver Diseases (Inpatient, Outpatient)
  • Low Back Pain (Inpatient, Outpatient)
  • Lumbar Spine Treatment (Inpatient, Outpatient)
  • Lung Cancer (Inpatient, Outpatient)
  • Magnetic Resonance Imaging (Inpatient, Outpatient)
  • Maternal Child (Inpatient, Outpatient)
  • Medical Detoxification (Inpatient)
  • Mental Health (Inpatient, 24-hour Acute Care/Crisis Stabilization)
  • Migraine Headache (Inpatient, Outpatient)
  • Morbid Obesity (Inpatient)
  • Multiple Sclerosis (Inpatient, Outpatient)
  • Neonatal Intensive Care (Inpatient)
  • Neonatology (Inpatient)
  • Nephrology (Inpatient)
  • Neurology (Inpatient)
  • Neurosurgery (Inpatient)
  • Nuclear Medicine (Inpatient, Outpatient)
  • Nursery (Inpatient)
  • Obstetrics (Inpatient)
  • Occupational Health (Inpatient)
  • Operating Room (Inpatient, Outpatient)
  • Ophthalmology/Eye Surgery (Inpatient)
  • Oral Maxillofacial Surgery (Inpatient)
  • Orthopedic Surgery (Inpatient)
  • Osteoporosis (Inpatient, Outpatient)
  • Otolaryngology/Ear, Nose, and Throat (Inpatient)
  • Outpatient Surgery (Outpatient)
  • Pain Management (Inpatient, Outpatient)
  • Pancreatic Cancer (Inpatient, Outpatient)
  • Pancreatitis (Inpatient, Outpatient)
  • Parkinsons Disease (Inpatient, Outpatient)
  • Pathology (Inpatient, Outpatient)
  • Pelvic Inflammatory Disease (Inpatient, Outpatient)
  • Peripheral Vascular Disease (Inpatient, Outpatient)
  • Plastic Surgery (Inpatient)
  • Pneumonia (Inpatient, Outpatient)
  • Podiatry (Inpatient)
  • Post Anesthesia Care Unit (PACU) (Inpatient, Outpatient)
  • Prostate Cancer (Inpatient, Outpatient)
  • Pulmonary Function Lab (Inpatient, Outpatient)
  • Radiation Oncology (Inpatient, Outpatient)
  • Rehabilitation (Inpatient, Outpatient)
  • Respiratory Care (Ventilator) (Inpatient)
  • Respiratory Failure (Inpatient, Outpatient)
  • Rheumatology (Inpatient)
  • Schizophrenia (Inpatient, Outpatient)
  • Self Injury (Inpatient, Outpatient)
  • Sexually Transmitted Disease (Outpatient)
  • Sickle Cell Disease (Inpatient, Outpatient)
  • Sleep Center (Outpatient)
  • Sleeping Disorder (Outpatient)
  • Spinal Fusion (Inpatient, Outpatient)
  • Spine Care (Inpatient, Outpatient)
  • Stroke (Primary Stroke Center) (Inpatient, Outpatient)
  • Subacute Care (Inpatient)
  • Systemic Lupus Erythematosis (Inpatient, Outpatient)
  • Telemetry (Inpatient)
  • Thoracic Spine (Inpatient)
  • Thoracic Surgery (Inpatient)
  • Tobacco Treatment / Cessation (Inpatient)
  • Trauma (Inpatient, Outpatient)
  • Trauma/Burn Unit (Inpatient)
  • Traumatic Brain Injury (Inpatient)
  • Tuberculosis (Inpatient)
  • Ulcerative Colitis (Inpatient, Outpatient)
  • Ultrasound (Inpatient, Outpatient)
  • Urgent Care/Emergency Medicine (Outpatient)
  • Urology (Inpatient)
  • Vascular Disease (Inpatient, Outpatient)
  • Vascular Surgery (Inpatient)
  • Ventricular Assist Device (Inpatient)
  • Women's Health (Inpatient)
  • Wound Care (Inpatient)
University of Louisville Hospital
401 East Chestnut Street
Louisville, KY  40202
  • Ambulatory Surgery Center (Outpatient)
  • Anesthesia (Outpatient)
  • General Outpatient Services (Outpatient)
University of Louisville Hospital Sleep Center
333 E. Market Street
Louisville, KY  40202
  • General Outpatient Services (Outpatient)

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