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   3/25/2015  
Hospital
Accredited 4/5/2014 4/4/2014   3/26/2015  


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 
Primary Stroke Center
Certification 1/10/2015  3/9/2012  1/9/2015 



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
2015 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  2013 -
Sep  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 similar to the target range/value.
This organization’s performance is similar to 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 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
   
 
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 South Family Practice
    5195 Battlefield Parkway
    Ringgold, GA  30736
      Services:
      • Outpatient Clinics (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 Cardiology
          910 Blackford Street - 3rd Fl Massoud
          Chattanooga, TN  37403
          Other Clinics/Practices located at this site:
          • Children's Endocrine, 1st floor Massoud Bldg
          • Children's Gastroenterology, 3rd Floor Massoud Bldg
          • Children's Genetics, 3rd Floor Massoud Bldg
          • Children's Hematology/Oncology, 5th Floor Massoud Bldg
          • Children's Infectious Disease, 5th Floor Massoud Bldg
          • Children's Nephrology, Ground Level
          • Children's Neurology, Ground Level
          • Children's Orthopedic, Ground Level
          • Children's Pulmonology, Ground Level
          • Children's Urgent Care Center, Ground Level
          • University Pediatrics, Ground Level
          Services:
          • Administration of Blood Product (Outpatient)
          • Administration of High Risk Medications (Outpatient)
          • Perform Invasive Procedure (Outpatient)
          • Urgent Care (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
          Other Clinics/Practices located at this site:
          • Workforce UT Family Practice
          Services:
          • Outpatient Clinics (Outpatient)
          Chattanooga Hamilton County Hospital Authority
          DBA:  Erlanger Health System - East Campus
          1751 Gunbarrel Road
          Chattanooga, TN  37421
          Other Clinics/Practices located at this site:
          • Erlanger East Family Practice, Suite 201
          • Erlanger East Imaging
          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)
          • Outpatient Clinics (Outpatient)
          • 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:  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
                Other Clinics/Practices located at this site:
                • Erlanger North Sleep Medicine & Neurology, Suite 300
                • UT Institute for Sports & Health, Sutie 200
                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:  UT Erlanger Health & Wellness@Signal Mtn
                        2600 Taft Highway
                        Signal Mountain, TN  37377
                          Services:
                          • Outpatient Clinics (Outpatient)
                          Chattanooga Hamilton County Hospital Authority
                          DBA:  Erlanger Sequatchie Valley Emergency Department
                          16931 Rankin Avenue
                          Dunlap, TN  37327-7029
                          Other Clinics/Practices located at this site:
                          • Sequatchie Valley Clinic, Suite B100
                          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:  Urology at Spring Creek
                              961 Spring Creek Road, Suite 202
                              Chattanooga, TN  37411
                                Services:
                                • Anesthesia (Outpatient)
                                • Perform Invasive Procedure (Outpatient)
                                • Single Specialty Practitioner (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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