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Quality Report

Summary of Quality Information
Maury Regional Hospital
Org ID: 7820
1224 Trotwood Ave.
Columbia, TN  38401
(931)381-1111
www.mauryregional.com

Accreditation
Programs 		Accreditation
Decision 		Effective
Date 		Last Full Survey Date Last On-Site Survey Date
Laboratory Accreditation Program
Accredited 11/18/2011 11/17/2011   11/17/2011  
Home Care
Accredited 7/17/2010 7/16/2010   7/16/2010  
Hospital
Accredited 7/17/2010 7/16/2010   7/16/2010  


Accreditation programs recognized by the Centers for Medicare and Medicaid Services (CMS)
Pathology and Clinical Laboratory
Hospital


Advanced Certification
Programs 		Certification
Decision 		Effective
Date 		Last Full
Review Date 		Last On-Site
Review Date
Inpatient Diabetes
Certification 2/10/2013  12/5/2011  12/5/2011 



Certified
Programs 		Certification
Decision 		Effective
Date 		Last Full
Review Date 		Last On-Site
Review Date
Joint Replacement - Hip
Certification 1/25/2013  12/5/2011  12/5/2011 
Joint Replacement - Knee
Certification 1/25/2013  12/5/2011  12/5/2011 



Special Quality Awards


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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
Laboratory Accreditation Program
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.
*
Home Care
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.
*
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:
Oct  2011 -
Sep  2012
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 above the target range/value.
This organization’s performance is above the target range/value.
  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
Chapel Hill Physical Therapy
4700 Nashville Highway
Chapel Hill, TN  37034
    Services:
    • Outpatient Clinics (Outpatient)
    Lewis Health Center
    617 West Main Street
    Hohenwald, TN  38462
      Services:
      • General Laboratory Tests
      • Outpatient Clinics (Outpatient)
      • Toxicology
      Maury Outpatient PT
      858 West James Campbell Blvd.
      Columbia, TN  38401
        Services:
        • Outpatient Clinics (Outpatient)
        Maury Outpatient PT
        1300 Trotwood Ave.
        Columbia, TN  38401
          Services:
          • Outpatient Clinics (Outpatient)
          Maury Regional Cancer Center
          808 S. James Campbell Boulevard
          Columbia, TN  38401
            Services:
            • Administration of Blood Product (Outpatient)
            • Administration of High Risk Medications (Outpatient)
            • Outpatient Clinics (Outpatient)
            Maury Regional Home Infusion
            854 West James Campbell Blvd.
            Columbia, TN  38401
              Services:
              • Pharmacy/Dispensary,General Services
              Maury Regional Home Services
              830 Hatcher Lane
              Columbia, TN  38401
                Services:
                • Home Health Aides
                • Home Health, Non-Hospice Services
                • Medical Social Services
                • Occupational Therapy
                • Physical Therapy
                • Skilled Nursing Services
                Maury Regional Hospital  *
                1224 Trotwood Avenue
                Columbia, TN  38401
                Joint Commission Advanced Certification Programs:
                • Inpatient Diabetes
                Joint Commission Certified Programs:
                • Joint Replacement - Hip
                • Joint Replacement - Knee
                  Services:
                  • Brachytherapy (Imaging/Diagnostic Services)
                  • Cardiac Catheterization Lab (Surgical Services)
                  • Cardiac Surgery (Surgical Services)
                  • Cardiothoracic Surgery (Surgical Services)
                  • Cardiovascular 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)
                  • Medical /Surgical Unit (Inpatient)
                  • Medical ICU (Intensive Care Unit)
                  • Neuro/Spine ICU (Intensive Care Unit)
                  • 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)
                  • Positron Emission Tomography (PET) (Imaging/Diagnostic Services)
                  • Post Anesthesia Care Unit (PACU) (Inpatient)
                  • Radiation Oncology (Imaging/Diagnostic Services)
                  • Sleep Laboratory (Sleep Laboratory)
                  • Surgical ICU (Intensive Care Unit)
                  • Surgical Unit (Inpatient)
                  • Teleradiology (Imaging/Diagnostic Services)
                  • Thoracic Surgery (Surgical Services)
                  • Ultrasound (Imaging/Diagnostic Services)
                  • Urology (Surgical Services)
                  • Vascular Surgery (Surgical Services)
                  Maury Regional Out Patient Pavilion
                  1220 Trotwood Avenue
                  Columbia, TN  38401
                    Services:
                    • Administration of Blood Product (Outpatient)
                    • Administration of High Risk Medications (Outpatient)
                    • Ambulatory Surgery Center (Outpatient)
                    • Anesthesia (Outpatient)
                    • Outpatient Clinics (Outpatient)
                    • Perform Invasive Procedure (Outpatient)
                    MRMC Surgery Center
                    725 South James Campbell Boulevard
                    Columbia, TN  38401
                      Services:
                      • Administration of Blood Product (Outpatient)
                      • Ambulatory Surgery Center (Outpatient)
                      • Anesthesia (Outpatient)
                      • Perform Invasive Procedure (Outpatient)
                      Spring Hill Physical Therapy
                      1003 Reserve Boulevard Suite 310
                      Spring Hill, TN  37174
                        Services:
                        • Outpatient Clinics (Outpatient)

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