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Quality Report

Summary of Quality Information
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 9/28/2011 9/27/2011   9/27/2011  
Hospital
Accredited 4/13/2012 9/30/2011   4/12/2012  


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
Primary Stroke Center
Certification 4/18/2013  3/9/2012  3/9/2012 




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.
National Patient Safety Goals and National Quality Improvement Goals
    Compared to other Joint Commission Accredited Organizations
    Nationwide Statewide
Critical Access 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.
*
  Survey of Patients' Hospital Experiences (see details)
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 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 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 similar to the target range/value.
This organization’s performance is similar to 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 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 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
Academc Internal Medicine and Endocrinology
979 E. Third Street, Suite B-601
Chattanooga, TN  37403
    Services:
    • Outpatient Clinics (Outpatient)
    Academic Gastroenterology
    979 East Third Street, Suite C-825
    Chattanooga, TN  37403
      Services:
      • Single Specialty Practitioner (Outpatient)
      Academic Urologist at Erlanger
      979 East Third Street, Suite C - 535
      Chattanooga, TN  37403
        Services:
        • Perform Invasive Procedure (Outpatient)
        • Single Specialty Practitioner (Outpatient)
        Alton Park (Southside) Community Health Center
        100 East 37th Street
        Chattanooga, TN  37410
          Services:
          • Outpatient Clinics (Outpatient)
          Dodson Avenue Community Health Center
          1200 Dodson Avenue
          Chattanooga, TN  37406
            Services:
            • Outpatient Clinics (Outpatient)
            Erlanger Academic Urologists
            1755 Gunbarrel Road, Suite 209
            Chattanooga, TN  37421
              Services:
              • Single Specialty Practitioner (Outpatient)
              Erlanger at Alexian
              579 Alexian Way, Suite 401
              Signal Mountain, TN  37377
                Services:
                • Outpatient Clinics (Outpatient)
                Erlanger at Volkswagon Drive Wellness Center
                7380 Volkswagon Drive, Suite 110
                Chattanooga, TN  37416
                  Services:
                  • Single Specialty Practitioner (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)
                  • Swing Beds
                  • Ultrasound (Imaging/Diagnostic Services)
                  Erlanger Bledsoe Internal & Pediatric Medicine
                  136 Wheelertown Avenue
                  Pikeville, TN  37367
                    Services:
                    • Outpatient Clinics (Outpatient)
                    Erlanger East Family Practice
                    1755 Gunbarrel Road, Suite 201
                    Chattanooga, TN  37421
                      Services:
                      • Single Specialty Practitioner (Outpatient)
                      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)
                        • Labor & Delivery (Inpatient)
                        • Magnetic Resonance Imaging (Imaging/Diagnostic Services)
                        • Mammography (Imaging/Diagnostic Services)
                        • Nuclear Medicine (Imaging/Diagnostic Services)
                        • Orthopedic Surgery (Surgical Services)
                        • Plastic Surgery (Surgical Services)
                        • Surgical Unit (Inpatient)
                        • Ultrasound (Imaging/Diagnostic Services)
                        Erlanger Health System - Main Site  *
                        975 East Third Street
                        Chattanooga, TN  37403
                        Joint Commission Advanced Certification Programs:
                        • Primary Stroke Center
                          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)
                          • 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)
                          • Orthopedic Surgery (Surgical Services)
                          • Orthopedic/Spine Unit (Inpatient)
                          • Pediatric Unit (Inpatient)
                          • Plastic Surgery (Surgical 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)
                          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)
                            • Mammography (Imaging/Diagnostic Services)
                            • Medical /Surgical Unit (Inpatient)
                            • Nuclear Medicine (Imaging/Diagnostic Services)
                            • Sleep Laboratory (Sleep Laboratory)
                            • Ultrasound (Imaging/Diagnostic Services)
                            Erlanger Hypertension Management Center
                            979 East Third Street, Suite B601
                            Chattanooga, TN  37403
                              Services:
                              • Single Specialty Practitioner (Outpatient)
                              Erlanger Neurology/Southeast Regional Stroke Center
                              979 East Third Street, Suite C830
                              Chattanooga, TN  37403
                                Services:
                                • Outpatient Clinics (Outpatient)
                                Erlanger North Family & Multi-Speciality Practice
                                632 Morrison Springs Road
                                Chattanooga, TN  37415
                                  Services:
                                  • Outpatient Clinics (Outpatient)
                                  Erlanger North Sleep Medicine and Neurology
                                  632 Morrison Springs Road, Suite 300
                                  Chattanooga, TN  37415
                                    Services:
                                    • Single Specialty Practitioner (Outpatient)
                                    Erlanger South Family Practice
                                    60 Erlanger Drive, Suite A
                                    Ringgold, GA  30736
                                      Services:
                                      • Outpatient Clinics (Outpatient)
                                      Erlanger Specialty Care for OB and Peds
                                      1504 North Thornton Avenue, Suite 104
                                      Dalton, GA  30720
                                        Services:
                                        • Outpatient Clinics (Outpatient)
                                        Kidney Transplant OutPatient Clinic
                                        975 East Third Street, Suite 1005
                                        Chattanooga, TN  37403
                                          Services:
                                          • Outpatient Clinics (Outpatient)
                                          Kidney Transplant Outpatient Clinic
                                          979 East Third Street, Suite 1002
                                          Chattanooga, TN  37403
                                            Services:
                                            • Outpatient Clinics (Outpatient)
                                            Life Style Center - Cardiac Rehab
                                            325 Market Street
                                            Chattanooga, TN  37401
                                              Services:
                                              • Outpatient Clinics (Outpatient)
                                              Lifestyle Hypertension Center and Surgical Weight Loss
                                              325 Market Street, Suite 200
                                              Chattanooga, TN  37401
                                                Services:
                                                • Outpatient Clinics (Outpatient)
                                                Southern Orthopaedic Trauma Surgeons
                                                979 East Third Street Suite C-225
                                                Chattanooga, TN  37403
                                                  Services:
                                                  • Single Specialty Practitioner (Outpatient)
                                                  TCT Cardiology/GI/Genetics
                                                  910 Blackford Street - 3rd Fl Massoud
                                                  Chattanooga, TN  37403
                                                    Services:
                                                    • Outpatient Clinics (Outpatient)
                                                    TCT Children's Subspecialty Center
                                                    2700 West Side Drive
                                                    Cleveland, TN  37312
                                                      Services:
                                                      • Outpatient Clinics (Outpatient)
                                                      TCT Dermatology
                                                      979 East Third Street, - 4th fl Med Mall
                                                      Chattanooga, TN  37403
                                                        Services:
                                                        • Outpatient Clinics (Outpatient)
                                                        TCT Endocrine
                                                        910 Blackford, 1st fl Massoud
                                                        Chattanooga, TN  37403
                                                          Services:
                                                          • Outpatient Clinics (Outpatient)
                                                          TCT 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)
                                                            TCT Nephrology
                                                            910 Blackford St, Ground Level, TCTCH
                                                            Chattanooga, TN  37403
                                                              Services:
                                                              • Outpatient Clinics (Outpatient)
                                                              University Health Obstetrics & Gynecology
                                                              979 East Third Street, Suite C-725
                                                              Chattanooga, TN  37403
                                                                Services:
                                                                • Outpatient Clinics (Outpatient)
                                                                University Health Services
                                                                1100 East Third Street, Suite 102
                                                                Chattanooga, TN  37403
                                                                  Services:
                                                                  • Outpatient Clinics (Outpatient)
                                                                  University Medical Assoc
                                                                  960 East Third Street, Whitehall Building, Suite 200
                                                                  Chattanooga, TN  37403
                                                                    Services:
                                                                    • Outpatient Clinics (Outpatient)
                                                                    University Pediatrics
                                                                    910 Blackford Street - Gr floor Massoud
                                                                    Chattanooga, TN  37403
                                                                      Services:
                                                                      • Outpatient Clinics (Outpatient)
                                                                      University Pulmonary and Critical Care
                                                                      979 East Third Street, Suite C 735
                                                                      Chattanooga, TN  37403
                                                                        Services:
                                                                        • Outpatient Clinics (Outpatient)
                                                                        University Rheumatology Associates
                                                                        979 East Third Street, Suite B-805
                                                                        Chattanooga, TN  37403
                                                                          Services:
                                                                          • Single Specialty Practitioner (Outpatient)
                                                                          UT Erlanger Cardiology
                                                                          975 East Third Street, Suite C-520
                                                                          Chattanooga, TN  37403
                                                                            Services:
                                                                            • Outpatient Clinics (Outpatient)
                                                                            UT Erlanger Cardiology East
                                                                            1614 Gunbarrel Road, Ste 101
                                                                            Chattanooga, TN  37421
                                                                              Services:
                                                                              • Outpatient Clinics (Outpatient)
                                                                              UT Erlanger Lookout Mtn Primary Care
                                                                              100 McFarland Road
                                                                              Lookout Mountain, GA  30750
                                                                                Services:
                                                                                • Outpatient Clinics (Outpatient)
                                                                                UT Erlanger Primary and Athletic Health
                                                                                1200 Pineville Road
                                                                                Chattanooga, TN  37405
                                                                                  Services:
                                                                                  • Outpatient Clinics (Outpatient)
                                                                                  UT Family Practice
                                                                                  1100 East Third Street
                                                                                  Chattanooga, TN  37403
                                                                                    Services:
                                                                                    • Outpatient Clinics (Outpatient)
                                                                                    Workforce at UT Family Practice
                                                                                    1100 East 3rd Street
                                                                                    Chattanooga, TN  37403
                                                                                      Services:
                                                                                      • Outpatient Clinics (Outpatient)

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