The Joint Commission
Quality Check
Quality Report

Summary of Quality Information
Chattanooga Hamilton County Hospital Authority
DBA: Erlanger Health System
Org ID: 7809
975 East Third Street
Chattanooga, TN  37403
(423)778-5674
www.erlanger.org


Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full Survey Date Last On-Site Survey Date
Critical Access Hospital
Accredited 4/2/2014 4/1/2014   5/19/2014  
Hospital
Accredited 4/5/2014 4/4/2014   1/8/2015  


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


Advanced Certification
Programs
Certification
Decision
Effective
Date
Last Full
Review Date
Last On-Site
Review Date
Advanced Comprehensive Stroke Center
Certification 3/12/2014  12/18/2013  12/18/2013 



Certified
Programs
Certification
Decision
Effective
Date
Last Full
Review Date
Last On-Site
Review Date
Acute Myocardial Infarction
Certification 2/18/2014  12/10/2013  12/10/2013 



Other Accredited Programs / Services
Hospital  -  Accredited by UHMS Clinical Hyperbaric Facility - Level 2


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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.
11. There were no eligible patients that met the denominator criteria.
National Patient Safety Goals and National Quality Improvement Goals
    Compared to other Joint Commission Accredited Organizations
    Nationwide Statewide
Critical Access Hospital
2014 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
2014 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:
Apr  2013 -
Mar  2014
Children's Asthma 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 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 above the target range/value.
This organization’s performance is above the target range/value.
Perinatal Care See Detail
Not displayed.
2
Not displayed.
2
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 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 above 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
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
   
 
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
Alton Park (Southside) Community Health Center
100 East 37th Street
Chattanooga, TN  37410
    Services:
    • Outpatient Clinics (Outpatient)
    Chattanooga Hamilton County Hospital Authority  *
    DBA:  Erlanger Health System
    975 East Third Street
    Chattanooga, TN  37403
    Joint Commission Advanced Certification Programs:
    • Advanced Comprehensive Stroke Center
    Joint Commission Certified Programs:
    • Acute Myocardial Infarction
    Other Clinics/Practices located at this site:
    • Kidney Transplant OutPatient Clinic, Suite 1005
    • UT Erlanger Cardiology, Suite C-520
    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)
    • 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)
    • Gynecology (Inpatient)
    • Hematology/Oncology Unit (Inpatient)
    • Inpatient Unit (Inpatient)
    • Interventional Radiology (Imaging/Diagnostic Services)
    • Labor & Delivery (Inpatient)
    • Magnetic Resonance Imaging (Imaging/Diagnostic Services)
    • Mammography (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 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)
    • Trauma Center (Trauma Center)
    • Ultrasound (Imaging/Diagnostic Services)
    • Urology (Surgical Services)
    • Vascular Surgery (Surgical Services)
    Chattanooga Hamilton County Hospital Authority
    DBA:  UT Family Practice
    1100 East Third Street
    Chattanooga, TN  37403
      Services:
      • Outpatient Clinics (Outpatient)
      Chattanooga Hamilton County Hospital Authority
      DBA:  Erlanger Health System - East Campus
      1751 Gunbarrel Road
      Chattanooga, TN  37421
        Services:
        • CT Scanner (Imaging/Diagnostic Services)
        • Ear/Nose/Throat Surgery (Surgical Services)
        • EEG/EKG/EMG Lab (Imaging/Diagnostic Services)
        • Gynecological Surgery (Surgical Services)
        • Gynecology (Inpatient)
        • Inpatient Unit (Inpatient)
        • Labor & Delivery (Inpatient)
        • Magnetic Resonance Imaging (Imaging/Diagnostic Services)
        • Mammography (Imaging/Diagnostic Services)
        • Medical /Surgical Unit (Inpatient)
        • Nuclear Medicine (Imaging/Diagnostic Services)
        • Orthopedic Surgery (Surgical Services)
        • Plastic Surgery (Surgical Services)
        • Ultrasound (Imaging/Diagnostic Services)
        • Urology (Surgical Services)
        Chattanooga Hamilton County Hospital Authority
        DBA:  Erlanger Health System - North Campus
        632 Morrison Springs Road
        Chattanooga, TN  37415
          Services:
          • CT Scanner (Imaging/Diagnostic Services)
          • EEG/EKG/EMG Lab (Imaging/Diagnostic Services)
          • Inpatient Unit (Inpatient)
          • Mammography (Imaging/Diagnostic Services)
          • Medical /Surgical Unit (Inpatient)
          • Nuclear Medicine (Imaging/Diagnostic Services)
          • Outpatient Clinics (Outpatient)
          • Sleep Laboratory (Sleep Laboratory)
          • Ultrasound (Imaging/Diagnostic Services)
          Chattanooga Hamilton County Hospital Authority
          DBA:  Life Style Center - Cardiac Rehab
          325 Market Street
          Chattanooga, TN  37401
            Services:
            • Outpatient Clinics (Outpatient)
            Chattanooga Hamilton County Hospital Authority
            DBA:  Workforce at UT Family Practice
            1100 East 3rd Street
            Chattanooga, TN  37403
              Services:
              • Outpatient Clinics (Outpatient)
              Chattanooga Hamilton County Hospital Authority
              DBA:  University Medical Assoc
              960 East Third Street, Whitehall Building, Suite 208
              Chattanooga, TN  37403
                Services:
                • Outpatient Clinics (Outpatient)
                Chattanooga Hamilton County Hospital Authority
                DBA:  Erlanger NeuroBehavior & Memory Svs
                632 Morrison Springs Road, Suite 103
                Chattanooga, TN  37415
                  Services:
                  • Single Specialty Practitioner (Outpatient)
                  Chattanooga Hamilton County Hospital Authority
                  DBA:  Erlanger South Family Practice
                  5195 Battlefield Parkway
                  Ringgold, GA  30736
                    Services:
                    • Outpatient Clinics (Outpatient)
                    Chattanooga Hamilton County Hospital Authority
                    DBA:  University Pediatrics
                    910 Blackford Street - Gr floor Massoud
                    Chattanooga, TN  37403
                      Services:
                      • Outpatient Clinics (Outpatient)
                      Chattanooga Hamilton County Hospital Authority
                      DBA:  Erlanger East Family Practice
                      1751 Gunbarrel Road, Suite 201
                      Chattanooga, TN  37421
                        Services:
                        • Single Specialty Practitioner (Outpatient)
                        Chattanooga Hamilton County Hospital Authority
                        DBA:  Erlanger Bledsoe Internal & Pediatric Medicine
                        136 Wheelertown Avenue
                        Pikeville, TN  37367
                          Services:
                          • Outpatient Clinics (Outpatient)
                          Chattanooga Hamilton County Hospital Authority
                          DBA:  Dalton Pediatrics
                          1504 North Thornton Avenue, Suite 104
                          Dalton, GA  30720
                            Services:
                            • Outpatient Clinics (Outpatient)
                            Chattanooga Hamilton County Hospital Authority
                            DBA:  Academic Endocrinology
                            979 East Third Street, Suite B-601
                            Chattanooga, TN  37403
                            Other Clinics/Practices located at this site:
                            • Academic Gastroenterology, Suite C-825
                            • Academic Internal Medicine, Suite B-601
                            • Academic Urologist at Erlanger, Suite C-535
                            • Erlanger Hypertension Management Center, Suite B-601
                            • Erlanger Neurology Group, Suite 1202
                            • Erlanger Surgical Weight Loss, Suite C-620
                            • Kidney Transplant Outpatient Clinic, Suite 1002
                            • Southeast Regional Stroke Center, Suite 1202
                            • Southern Orthopaedic Trauma Surgeons, Suite C-450
                            • U Erlanger Sprots Medicine & Orthopedics, Suite 202
                            • University Orthopedics, Suite C-220
                            • University Respiratory and Critical Care, Suite C-735
                            • University Rheumatology, Suite B-805
                            • UT Erlanger Dermatology, Suite 425 A
                            • UT Erlanger Ortho South, Suite C-430
                            • Womens Health Specialist, Suite C-725
                            Services:
                            • Outpatient Clinics (Outpatient)
                            • Perform Invasive Procedure (Outpatient)
                            Chattanooga Hamilton County Hospital Authority
                            DBA:  Childrens Hematology/Oncology
                            910 Blackford Street - 5th fl Massoud Bl
                            Chattanooga, TN  37403
                              Services:
                              • Administration of Blood Product (Outpatient)
                              • Administration of High Risk Medications (Outpatient)
                              • Anesthesia (Outpatient)
                              • Outpatient Clinics (Outpatient)
                              • Perform Invasive Procedure (Outpatient)
                              Chattanooga Hamilton County Hospital Authority
                              DBA:  Childrens Cardiology
                              910 Blackford Street - 3rd Fl Massoud
                              Chattanooga, TN  37403
                                Services:
                                • Outpatient Clinics (Outpatient)
                                Chattanooga Hamilton County Hospital Authority
                                DBA:  Childrens Endocrine
                                910 Blackford, 1st fl Massoud
                                Chattanooga, TN  37403
                                  Services:
                                  • Outpatient Clinics (Outpatient)
                                  Chattanooga Hamilton County Hospital Authority
                                  DBA:  Childrens Nephrology
                                  910 Blackford St, Ground Level, TCTCH
                                  Chattanooga, TN  37403
                                    Services:
                                    • Outpatient Clinics (Outpatient)
                                    Chattanooga Hamilton County Hospital Authority
                                    DBA:  UT Erlanger Lookout Mtn Primary Care
                                    100 McFarland Road
                                    Lookout Mountain, GA  30750
                                      Services:
                                      • Outpatient Clinics (Outpatient)
                                      Chattanooga Hamilton County Hospital Authority
                                      DBA:  UT Erlanger Cardiology East
                                      1614 Gunbarrel Road, Ste 101
                                      Chattanooga, TN  37421
                                        Services:
                                        • Outpatient Clinics (Outpatient)
                                        Chattanooga Hamilton County Hospital Authority
                                        DBA:  Urology East
                                        1755 Gunbarrel Road, Suite 209
                                        Chattanooga, TN  37421
                                          Services:
                                          • Single Specialty Practitioner (Outpatient)
                                          Chattanooga Hamilton County Hospital Authority
                                          DBA:  Erlanger at Volkswagen Drive
                                          7380 Volkswagon Drive, Suite 100
                                          Chattanooga, TN  37416
                                            Services:
                                            • Single Specialty Practitioner (Outpatient)
                                            Chattanooga Hamilton County Hospital Authority
                                            DBA:  Erlanger North Sleep Medicine and Neurology
                                            632 Morrison Springs Road, Suite 300
                                            Chattanooga, TN  37415
                                              Services:
                                              • Single Specialty Practitioner (Outpatient)
                                              Chattanooga Hamilton County Hospital Authority
                                              DBA:  UT Erlanger Health & Wellness@Signal Mtn
                                              2600 Taft Highway
                                              Signal Mountain, TN  37377
                                                Services:
                                                • Outpatient Clinics (Outpatient)
                                                Chattanooga Hamilton County Hospital Authority
                                                DBA:  Erlanger East Imaging
                                                1751 Gunbarrel Road
                                                Chattanooga, TN  37421
                                                  Services:
                                                  • Outpatient Clinics (Outpatient)
                                                  Chattanooga Hamilton County Hospital Authority
                                                  DBA:  Erlanger Sequatchie Valley Emergency Department
                                                  16931 Rankin Avenue
                                                  Dunlap, TN  37327-7029
                                                    Services:
                                                    • Administration of Blood Product (Outpatient)
                                                    • Administration of High Risk Medications (Outpatient)
                                                    • Emergency Care (Outpatient)
                                                    Chattanooga Hamilton County Hospital Authority
                                                    DBA:  UT Erlanger Hixson Primary Care
                                                    1025 Executie Drive Suite 100
                                                    Hixson, TN  37343
                                                      Services:
                                                      • Single Specialty Practitioner (Outpatient)
                                                      Chattanooga Hamilton County Hospital Authority
                                                      DBA:  UT Erlanger E Brainerd Internal Medicine
                                                      1720 Gunbarrel Rd Suite 110
                                                      Chattanooga, TN  37421
                                                        Services:
                                                        • Single Specialty Practitioner (Outpatient)
                                                        Chattanooga Hamilton County Hospital Authority
                                                        DBA:  UT Erlanger Institute for Sports & Health
                                                        632 Morrison Springs Road Suite 200
                                                        Chattanooga, TN  37415
                                                          Services:
                                                          • Single Specialty Practitioner (Outpatient)
                                                          Chattanooga Hamilton County Hospital Authority
                                                          DBA:  Childrens Genetics
                                                          910 Blackford Street, 3rd flr Massoud Bld
                                                          Chattanooga, TN  37403
                                                            Services:
                                                            • Single Specialty Practitioner (Outpatient)
                                                            Chattanooga Hamilton County Hospital Authority
                                                            DBA:  Childrens Gastroenterology
                                                            910 Blackford Street, 3rd Flr Massoud Bld
                                                            Chattanooga, TN  37403
                                                              Services:
                                                              • Single Specialty Practitioner (Outpatient)
                                                              Chattanooga Hamilton County Hospital Authority
                                                              DBA:  Urology at Spring Creek
                                                              961 Spring Creek Road, Suite 202
                                                              Chattanooga, TN  37411
                                                                Services:
                                                                • Anesthesia (Outpatient)
                                                                • Perform Invasive Procedure (Outpatient)
                                                                • Single Specialty Practitioner (Outpatient)
                                                                Chattanooga Hamilton County Hospital Authority
                                                                DBA:  Childrens Neurology
                                                                910 BlackFord Street, Ground Flr
                                                                Chattanooga, TN  37403
                                                                  Services:
                                                                  • Outpatient Clinics (Outpatient)
                                                                  Chattanooga Hamilton County Hospital Authority
                                                                  DBA:  Childrens Orthopedics
                                                                  910 Blackford Street, Ground Flr
                                                                  Chattanooga, TN  37403
                                                                    Services:
                                                                    • Outpatient Clinics (Outpatient)
                                                                    Chattanooga Hamilton County Hospital Authority
                                                                    DBA:  Childrens Pulmonology
                                                                    910 Blackford Street, Ground Flr
                                                                    Chattanooga, TN  37403
                                                                      Services:
                                                                      • Outpatient Clinics (Outpatient)
                                                                      Chattanooga Hamilton County Hospital Authority
                                                                      DBA:  Childrens Infectious Disease
                                                                      910 BlackFord Street, 5th Flr Massoud Bld
                                                                      Chattanooga, TN  37403
                                                                        Services:
                                                                        • Outpatient Clinics (Outpatient)
                                                                        Chattanooga Hamilton County Hospital Authority
                                                                        DBA:  Childrens Urgent Care Center
                                                                        910 Blackford Street
                                                                        Chattanooga, TN  37403
                                                                          Services:
                                                                          • Urgent Care (Outpatient)
                                                                          Dodson Avenue Community Health Center
                                                                          1200 Dodson Avenue
                                                                          Chattanooga, TN  37406
                                                                            Services:
                                                                            • Outpatient Clinics (Outpatient)
                                                                            Erlanger Bledsoe Hospital
                                                                            128 Wheelertown Road
                                                                            Pikeville, TN  37367
                                                                            Other Clinics/Practices located at this site:
                                                                            • Erlanger Bledsoe Internal and Pediatric Medicine
                                                                            Services:
                                                                            • Acute Care
                                                                            • CT Scanner (Imaging/Diagnostic Services)
                                                                            • EEG/EKG/EMG Lab (Imaging/Diagnostic Services)
                                                                            • Medical /Surgical Unit (Inpatient)
                                                                            • Outpatient Clinics (Outpatient)
                                                                            • Swing Beds
                                                                            • Ultrasound (Imaging/Diagnostic Services)
                                                                            UT Erlanger Primary Care
                                                                            DBA:  UT Erlanger Primary Care
                                                                            1200 Pineville Road
                                                                            Chattanooga, TN  37405
                                                                              Services:
                                                                              • Outpatient Clinics (Outpatient)

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