The Joint Commission
Quality Check
Quality Report

Summary of Quality Information
Maury Regional Hospital
DBA: Maury Regional Medical Center
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
Home Care
Accredited 6/28/2013 6/27/2013   6/27/2013  
Hospital
Accredited 7/3/2013 7/2/2013   7/2/2013  
Laboratory Accreditation Program
Accredited 11/28/2013 11/27/2013   11/27/2013  


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 12/7/2013  12/6/2013  12/6/2013 



Certified
Programs
Certification
Decision
Effective
Date
Last Full
Review Date
Last On-Site
Review Date
Joint Replacement - Hip
Certification 11/9/2013  11/8/2013  11/8/2013 
Joint Replacement - Knee
Certification 11/9/2013  11/8/2013  11/8/2013 




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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
Home Care
2013 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
2013 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  2013 -
Dec  2013
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.
Laboratory Accreditation Program
2013 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 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 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  *
              DBA:  Maury Regional Medical Center
              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)
                • 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)
                • 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)
                  Maury Regional Physical Therapy Pulaski
                  425 West College Street
                  Pulaski, TN  38478
                    Services:
                    • Outpatient Clinics (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
                      Other Clinics/Practices located at this site:
                      • Spring Hill Specialty Clinic Imaging, Suite 320
                      Services:
                      • Outpatient Clinics (Outpatient)

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