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Quality Report

Summary of Quality Information
Erlanger Health System
Org ID: 7809
975 East Third Street
Chattanooga, TN  37403
(423)778-7792
www.erlanger.org

Accreditation
Programs		 Accreditation
Decision		 Effective
Date		 Last Full Survey Date Last On-Site Survey Date  
Critical Access Hospital
Accredited 10/25/2008 10/24/2008 10/24/2008  
Hospital
Accredited 10/25/2008 10/24/2008 2/25/2010  

Advanced Certification
Programs		 Certification
Decision		 Effective
Date		 Last Full
Review Date		 Last On-Site
Review Date
Primary Stroke Center
Certification 3/31/2010  3/30/2010  3/30/2010 



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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
Critical Access Hospital
2008 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
2010 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:
Jan  2009 -
Dec  2009
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 similar to the target range/value.
This organization’s performance is similar to 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 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 similar to the target range/value.
This organization’s performance is similar to the target range/value.
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
Academc Internal Medicine
979 E. Third Street, Suite B-601
Chattanooga, TN  37403
  • Single Specialty Practitioner (Outpatient)
Academic Gastroenterology
979 East Third Street, Suite A-825
Chattanooga, TN  37403
  • Single Specialty Practitioner (Outpatient)
Academic Urology
979 East Third Street, Suite A-450
Chattanooga, TN  37403
  • Single Specialty Practitioner (Outpatient)
Alexian
579 Alexian Way, Suite 401
Signal Mountain, TN  37377
  • General Outpatient Services (Outpatient)
Alton Park (Southside) Community Health Center
100 East 37th Street
Chattanooga, TN  37410
  • General Outpatient Services (Outpatient)
Bledsoe Family Practice
128 Wheelertown Road
Pikeville, TN  37367
  • General Outpatient Services (Outpatient)
Children's Oncology Services
910 Blackford Street
Chattanooga, TN  37403
  • Anesthesia (Outpatient)
  • Single Specialty Practitioner (Outpatient)
Dodson Avenue Community Health Center
1200 Dodson Avenue
Chattanooga, TN  37406
  • General Outpatient Services (Outpatient)
East Family Practice
1755 Gunbarrel Road, Suite 200
Chattanooga, TN  37421
  • General Outpatient Services (Outpatient)
Erlanger Bledsoe Hospital
128 Wheelertown Road
Pikeville, TN  37367
  • Acute Care
  • Emergency Room (Outpatient)
  • Family Practice (Inpatient)
  • General Medical Services (Inpatient)
  • Imaging/Radiology (Inpatient)
  • Internal Medicine (Inpatient, Outpatient)
  • Skilled Nursing Facility (Inpatient)
  • Ultrasound (Outpatient)
  • Urgent Care/Emergency Medicine (Outpatient)
Erlanger East Comprehensive Care
1755 Gunbarrel Road, Suite 106
Chattanooga, TN  37421
  • General Outpatient Services (Outpatient)
Erlanger Health System - East Campus
1751 Gunbarrel Road
Chattanooga, TN  37421
  • CT Scanner (Outpatient)
  • EEG/EKG/EMG Lab (Outpatient)
  • General Medical Services (Inpatient)
  • General Surgery (Inpatient, Outpatient)
  • GI or Endoscopy Lab (Inpatient)
  • Gynecology (Outpatient)
  • Imaging/Radiology (Inpatient, Outpatient)
  • Internal Medicine (Inpatient)
  • Labor & Delivery (Inpatient)
  • Magnetic Resonance Imaging (Outpatient)
  • Neonatal Intensive Care (Inpatient)
  • Nuclear Medicine (Outpatient)
  • Nursery (Inpatient)
  • Obstetrics (Inpatient)
  • Operating Room (Inpatient, Outpatient)
  • Oral Maxillofacial Surgery (Outpatient)
  • Orthopedic Surgery (Inpatient, Outpatient)
  • Outpatient Surgery (Outpatient)
  • Pain Management (Outpatient)
  • Pediatric Care (Outpatient)
  • Plastic Surgery (Inpatient, Outpatient)
  • Post Anesthesia Care Unit (PACU) (Inpatient, Outpatient)
  • Rehabilitation and Physical Medicine (Inpatient)
  • Ultrasound (Inpatient, Outpatient)
  • Urgent Care/Emergency Medicine (Outpatient)
Erlanger Health System - Main Site  *
975 East Third Street
Chattanooga, TN  37403
Joint Commission Advanced Certification Programs:
  • Primary Stroke Center
Services:
  • Cancer Center/Oncology (Inpatient, Outpatient)
  • Cardiac Catheterization Lab (Inpatient, Outpatient)
  • Cardiac Surgery (Inpatient)
  • Cardiac Unit/Cardiology (Inpatient)
  • CT Scanner (Inpatient, Outpatient)
  • Dermatology (Inpatient)
  • Dialysis (Inpatient, Outpatient)
  • EEG/EKG/EMG Lab (Inpatient, Outpatient)
  • Emergency Room (Outpatient)
  • Endocrinology (Inpatient)
  • Family Practice (Inpatient)
  • Gastroenterology (Inpatient, Outpatient)
  • General Medical Services (Inpatient, Outpatient)
  • General Surgery (Inpatient, Outpatient)
  • GI or Endoscopy Lab (Inpatient, Outpatient)
  • Gynecology (Inpatient)
  • Hematology/Blood Treatment (Inpatient)
  • Imaging/Radiology (Inpatient, Outpatient)
  • Infectious Diseases (Inpatient)
  • Infusion Therapy (Inpatient, Outpatient)
  • Intensive Care Unit (Inpatient)
  • Internal Medicine (Inpatient)
  • Labor & Delivery (Inpatient)
  • Lithotripsy/Kidney Stone Treatment (Outpatient)
  • Magnetic Resonance Imaging (Inpatient, Outpatient)
  • Medical Detoxification (Inpatient)
  • Nephrology (Inpatient)
  • Neurology (Inpatient)
  • Neurosurgery (Inpatient)
  • Nuclear Medicine (Inpatient, Outpatient)
  • Nursery (Inpatient)
  • Obstetrics (Inpatient)
  • Operating Room (Inpatient, Outpatient)
  • Ophthalmology/Eye Surgery (Inpatient)
  • Oral Maxillofacial Surgery (Inpatient, Outpatient)
  • Orthopedic Surgery (Inpatient)
  • Otolaryngology/Ear, Nose, and Throat (Inpatient)
  • Outpatient Surgery (Outpatient)
  • Pain Management (Inpatient, Outpatient)
  • Pediatric Care (Inpatient, Outpatient)
  • Plastic Surgery (Inpatient, Outpatient)
  • Podiatry (Inpatient)
  • Post Anesthesia Care Unit (PACU) (Inpatient, Outpatient)
  • Pulmonary Function Lab (Inpatient, Outpatient)
  • Radiation Oncology (Inpatient, Outpatient)
  • Rehabilitation and Physical Medicine (Inpatient)
  • Respiratory Care (Ventilator) (Inpatient)
  • Rheumatology (Inpatient)
  • Subacute Care (Inpatient)
  • Telemetry (Inpatient)
  • Thoracic Surgery (Inpatient)
  • Trauma/Burn Unit (Inpatient)
  • Ultrasound (Inpatient, Outpatient)
  • Urgent Care/Emergency Medicine (Outpatient)
  • Urology (Inpatient)
  • Vascular Surgery (Inpatient)
  • Wound Care (Inpatient, Outpatient)
Erlanger Health System - North Campus
632 Morrison Springs Road
Chattanooga, TN  37415
  • CT Scanner (Inpatient, Outpatient)
  • EEG/EKG/EMG Lab (Inpatient, Outpatient)
  • Electroconvulsive Therapy (Inpatient, Outpatient)
  • Emergency Room (Outpatient)
  • Family Practice (Outpatient)
  • Gastroenterology (Inpatient, Outpatient)
  • General Surgery (Inpatient)
  • GI or Endoscopy Lab (Inpatient, Outpatient)
  • Imaging/Radiology (Inpatient, Outpatient)
  • Mental Health (Inpatient, 24-hour Acute Care/Crisis Stabilization)
  • Operating Room (Inpatient, Outpatient)
  • Orthopedic Surgery (Inpatient, Outpatient)
  • Outpatient Surgery (Outpatient)
  • Pain Management (Outpatient)
  • Post Anesthesia Care Unit (PACU) (Outpatient)
  • Pulmonary Function Lab (Inpatient, Outpatient)
  • Rehabilitation and Physical Medicine (Outpatient)
  • Sleep Center (Outpatient)
  • Telemetry (Inpatient)
  • Ultrasound (Inpatient, Outpatient)
  • Urgent Care/Emergency Medicine (Outpatient)
Erlanger Health System-North Family Practice
632 Morrison Springs Road
Chattanooga, TN  37415
  • General Outpatient Services (Outpatient)
Erlanger Ooltewah Family Practice
9309 Apison Pike
Ooltewah, TN  37363
  • General Outpatient Services (Outpatient)
Erlanger South Family Practice
5195 Battlefield Parkway
Ringgold, GA  30736
  • General Outpatient Services (Outpatient)
Hypertension Management Center
960 East Third Street, Suite 408
Chattanooga, TN  37403
  • Single Specialty Group Practice (Outpatient)
Kidney Transplant OutPatient Clinic
975 East Third Street, Suite 1105
Chattanooga, TN  37403
  • Single Specialty Group Practice (Outpatient)
Kidney Transplant Outpatient Clinic
975 East Third Street, Suite 1002
Chattanooga, TN  37403
  • Single Specialty Group Practice (Outpatient)
Life Style Center
325 Market Street
Chattanooga, TN  37401
  • General Outpatient Services (Outpatient)
Neuro Behavior & Memory Services -W. Rafauls, MD
632 Morrison Springs Road
Chattanooga, TN  37415
  • Single Specialty Practitioner (Outpatient)
Southeast Regional Stroke Center
979 East Third Street, Suite C830
Chattanooga, TN  37403
  • General Outpatient Services (Outpatient)
Southern Orthopaedic Trauma Surgeons
979 East Third Street Suite A-450
Chattanooga, TN  37403
  • Single Specialty Group Practice (Outpatient)
T.C. Thompson Children's Hospital
910 Blackford Street
Chattanooga, TN  37403
  • Allergy (Outpatient)
  • Audiology (Inpatient, Outpatient)
  • Cancer Center/Oncology (Inpatient, Outpatient)
  • Cardiac Unit/Cardiology (Inpatient, Outpatient)
  • Dentistry (Outpatient)
  • Dermatology (Outpatient)
  • Developmental Disabilities - Hospital (Inpatient, Outpatient)
  • EEG/EKG/EMG Lab (Inpatient, Outpatient)
  • Emergency Room (Outpatient)
  • Endocrinology (Inpatient, Outpatient)
  • Gastroenterology (Inpatient, Outpatient)
  • General Medical Services (Inpatient)
  • General Surgery (Inpatient)
  • GI or Endoscopy Lab (Inpatient, Outpatient)
  • Hematology/Blood Treatment (Inpatient, Outpatient)
  • Imaging/Radiology (Inpatient, Outpatient)
  • Infectious Diseases (Inpatient, Outpatient)
  • Intensive Care Unit (Inpatient)
  • Neonatal Intensive Care (Inpatient)
  • Nephrology (Inpatient, Outpatient)
  • Neurology (Inpatient, Outpatient)
  • Neurosurgery (Inpatient)
  • Operating Room (Inpatient)
  • Oral Maxillofacial Surgery (Inpatient)
  • Orthopedic Surgery (Inpatient, Outpatient)
  • Otolaryngology/Ear, Nose, and Throat (Inpatient)
  • Outpatient Surgery (Outpatient)
  • Pediatric Care (Inpatient, Outpatient)
  • Plastic Surgery (Inpatient, Outpatient)
  • Post Anesthesia Care Unit (PACU) (Inpatient, Outpatient)
  • Pulmonary Function Lab (Outpatient)
  • Respiratory Care (Ventilator) (Inpatient)
  • Telemetry (Inpatient)
  • Ultrasound (Inpatient, Outpatient)
  • Urgent Care/Emergency Medicine (Outpatient)
  • Urology (Inpatient, Outpatient)
TCT Children's Subspecialty Center
1504 North Thornton Avenue
Dalton, GA  30720
  • General Outpatient Services (Outpatient)
TCT Children's Subspecialty Center
2700 West Side Drive
Cleveland, TN  37312
  • General Outpatient Services (Outpatient)
University Health Services
501 Houston Street
Chattanooga, TN  37403
  • General Outpatient Services (Outpatient)
University Medical Assoc
960 East Third Street
Chattanooga, TN  37403
  • General Outpatient Services (Outpatient)
University Pediatrics
910 Blackford Street
Chattanooga, TN  37403
  • Multi Specialty Group Practice (Outpatient)
University Rheumatology Associates
979 East Third Street, Suite B-805
Chattanooga, TN  37403
  • Single Specialty Practitioner (Outpatient)
UT Family Practice
1100 East Third Street
Chattanooga, TN  37403
  • Anesthesia (Outpatient)
  • General Outpatient Services (Outpatient)
Workforce at Riverside
1501 Riverside Drive
Chattanooga, TN  37406
  • General Outpatient Services (Outpatient)

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