The Joint Commission
Quality Check
Quality Report

Summary of Quality Information
Saint Thomas Midtown Hospital
DBA: Saint Thomas Midtown Hospital
Org ID: 7884
2000 Church Street
Nashville, TN  37236
(615)284-5555
www.sths.com


Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full Survey Date Last On-Site Survey Date
Hospital
Accredited 3/29/2014 3/28/2014   3/28/2014  


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


Advanced Certification
Programs
Certification
Decision
Effective
Date
Last Full
Review Date
Last On-Site
Review Date
Inpatient Diabetes
Certification 7/11/2014  7/10/2014  7/10/2014 
Primary Stroke Center
Certification 7/24/2014  7/23/2014  7/23/2014 



Certified
Programs
Certification
Decision
Effective
Date
Last Full
Review Date
Last On-Site
Review Date
Joint Replacement - Hip
Certification 7/25/2014  7/24/2014  7/24/2014 
Joint Replacement - Knee
Certification 7/25/2014  7/24/2014  7/24/2014 




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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
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.
*
National Quality Improvement Goals:    
Reporting Period:
Apr  2013 -
Mar  2014
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
Craig Center for Advanced Wound Healing at Midtown Hospital
2000 Murphy Avenue
Nashville, TN  37203
Other Clinics/Practices located at this site:
  • Midtown Hospital Diabetes Center
Services:
  • Outpatient Clinics (Outpatient)
Saint Thomas Midtown Hospital  *
2000 Church Street
Nashville, TN  37236
Joint Commission Advanced Certification Programs:
  • Inpatient Diabetes
  • Primary Stroke Center
Joint Commission Certified Programs:
  • Joint Replacement - Hip
  • Joint Replacement - Knee
Other Clinics/Practices located at this site:
  • Craig Center for Wound Healing
  • Saint Thomas Heart Midtown OP Cardiac Imaging
  • Saint Thomas Outpatient Rehab
  • Tennessee Breast Specialists
  • UT Clinic
Services:
  • Brachytherapy (Imaging/Diagnostic 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 (Inpatient, Outpatient, Imaging/Diagnostic Services)
  • Labor & Delivery (Inpatient)
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services)
  • Medical /Surgical Unit (Inpatient)
  • Medical 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 Emergency Medicine (Outpatient - Child/Youth)
  • Pediatric General Surgery (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Otolaryngology (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Plastic Surgery (Surgical Services)
  • Post Anesthesia Care Unit (PACU) (Inpatient)
  • Radiation Oncology (Imaging/Diagnostic Services)
  • Rehabilitation Unit (Inpatient, 24-hour Acute Care/Crisis Stabilization)
  • Sleep Laboratory (Sleep Laboratory)
  • Surgical ICU (Intensive Care Unit)
  • Surgical Unit (Inpatient)
  • Thoracic Surgery (Surgical Services)
  • Ultrasound (Imaging/Diagnostic Services)
  • Urology (Surgical Services)
  • Vascular Surgery (Surgical Services)
Saint Thomas Midtown Hospital OP Cardiac Imaging
900 Conference Drive, Ste. 8
Goodlettsville, TN  37072
    Services:
    • Outpatient Clinics (Outpatient)
    Saint Thomas Midtown Hospital OP Cardiac Imaging - Franklin
    4323 North Carothers Pkwy, Suite 310
    Franklin, TN  37067
      Services:
      • Outpatient Clinics (Outpatient)
      Saint Thomas Midtown Hospital OP Cardiac Imaging Ctr
      222 22nd Ave N., STE 501
      Nashville, TN  37203
        Services:
        • Outpatient Clinics (Outpatient)
        Saint Thomas Outpatient Rehab
        491 Sage Road
        White House, TN  37188
          Services:
          • Outpatient Clinics (Outpatient)
          Saint Thomas Outpatient Rehab- Antioch/Lavergne
          3534 Murfreesboro Pike, Ste. 101
          Antioch, TN  37013
            Services:
            • Outpatient Clinics (Outpatient)
            Saint Thomas Outpatient Rehab- Bellevue, Nashville TN
            7640 Highway 70 South, Suite 104
            Nashville, TN  37221
              Services:
              • Outpatient Clinics (Outpatient)
              Saint Thomas Outpatient Rehab- Cool Springs
              101 International Blvd.
              Franklin, TN  37067
                Services:
                • Outpatient Clinics (Outpatient)
                Saint Thomas Outpatient Rehab- Rivergate
                1777 Gallatin Pike, North
                Madison, TN  37115
                  Services:
                  • Outpatient Clinics (Outpatient)
                  Saint Thomas Outpatient Rehab- South
                  6005 Nolensville Road
                  Nashville, TN  37211
                    Services:
                    • Outpatient Clinics (Outpatient)
                    Saint Thomas Outpatient Rehab-Dickson
                    7101 Ramsy Way,
                    Dickson, TN  37055
                      Services:
                      • Outpatient Clinics (Outpatient)
                      Saint Thomas Outpatient Rehab-Downtown YMCA
                      1000 Church Street
                      Nashville, TN  37203
                        Services:
                        • Outpatient Clinics (Outpatient)
                        Saint Thomas Outpatient Rehab-Green Hills
                        3810 BedfordAve. Suite 120
                        Nashville, TN  37215
                          Services:
                          • Outpatient Clinics (Outpatient)
                          Saint Thomas Outpatient Rehab-Maryland Farms
                          5101 Maryland Way
                          Brentwood, TN  37027
                            Services:
                            • Outpatient Clinics (Outpatient)
                            Saint Thomas Outpatient Rehab-Murfreesboro
                            1203B Memorial Blvd.
                            Murfreesboro, TN  37129
                              Services:
                              • Outpatient Clinics (Outpatient)
                              Tennessee Breast Specialists
                              300 20th Ave. North, Suite 601
                              Nashville, TN  37203
                                Services:
                                • Outpatient Clinics (Outpatient)
                                • Perform Invasive Procedure (Outpatient)
                                UT Resident Clinic
                                316 22nd Avenue North
                                Nashville, TN  37203
                                  Services:
                                  • Outpatient Clinics (Outpatient)

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