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Quality Report

Summary of Quality Information
Baptist Hospital
Org ID: 7884
2000 Church Street
Nashville, TN  37236
(615)284-5555
www.baptisthospital.com

Accreditation
Programs 		Accreditation
Decision 		Effective
Date 		Last Full Survey Date Last On-Site Survey Date
Hospital
Accredited 4/9/2011 4/8/2011   4/8/2011  


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 6/2/2012  6/1/2012  6/1/2012 
Primary Stroke Center
Certification 6/2/2012  6/1/2012  6/1/2012 



Certified
Programs 		Certification
Decision 		Effective
Date 		Last Full
Review Date 		Last On-Site
Review Date
Joint Replacement - Hip
Certification 6/2/2012  6/1/2012  6/1/2012 
Joint Replacement - Knee
Certification 6/2/2012  6/1/2012  6/1/2012 



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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
Hospital
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.
*
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.
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 above the target range/value.
This organization’s performance is above 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 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
   
  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
Baptist 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
    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)
    • Hematology/Oncology 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)
    • Orthopedic Surgery (Surgical Services)
    • Orthopedic/Spine Unit (Inpatient)
    • 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)
    • 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)
    Baptist Hospital - Diabetes Center
    2010 Church Street
    Nashville, TN  37203
      Services:
      • Outpatient Clinics (Outpatient)
      Baptist Hospital Outpatient Cardiac Imaging
      222 22nd Avenue North
      Nashville, TN  37203
        Services:
        • Outpatient Clinics (Outpatient)
        Baptist Medical Plaza I - Life Therapies, Nashville TN
        2011 Church Street, Ste. 105
        Nashville, TN  37203
          Services:
          • Outpatient Clinics (Outpatient)
          Baptist Sport Medicine/Life Therapies - Cool Springs
          101 International Blvd.
          Franklin, TN  37067
            Services:
            • Outpatient Clinics (Outpatient)
            Baptist Sports Medicine - Antioch/Lavergne
            3534 Murfreesboro Pike, Ste. 101
            Antioch, TN  37013
              Services:
              • Outpatient Clinics (Outpatient)
              Baptist Sports Medicine - Bellevue, Nashville TN
              7640 Highway 70 South, Suite 104
              Nashville, TN  37221
                Services:
                • Outpatient Clinics (Outpatient)
                Baptist Sports Medicine - Gordon Jewish Community Center
                801 Percy Warner Blvd.
                Nashville, TN  37215
                  Services:
                  • Outpatient Clinics (Outpatient)
                  Baptist Sports Medicine - Lipscomb
                  3901 Granny White Pike
                  Nashville, TN  37215
                    Services:
                    • Outpatient Clinics (Outpatient)
                    Baptist Sports Medicine - Plaza II, Nashville TN
                    2021 Church Street
                    Nashville, TN  37204
                      Services:
                      • Outpatient Clinics (Outpatient)
                      Baptist Sports Medicine - Pleasant View
                      254 Ren-Mar Blvd.
                      Pleasant View, TN  37146
                        Services:
                        • Outpatient Clinics (Outpatient)
                        Baptist Sports Medicine - Rivergate, Madison TN
                        1777 Gallatin Pike, North
                        Madison, TN  37115
                          Services:
                          • Outpatient Clinics (Outpatient)
                          Baptist Sports Medicine - Spring Hill, TN
                          2009 Wall Street
                          Spring Hill, TN  37174
                            Services:
                            • Outpatient Clinics (Outpatient)
                            Baptist Sports Medicine - White House
                            491 Sage road
                            White House, TN  37188
                              Services:
                              • Outpatient Clinics (Outpatient)
                              Diagnostic Radiology-Franklin
                              4323 North Carothers Suite 310
                              Franklin, TN  37067
                                Services:
                                • Outpatient Clinics (Outpatient)
                                STHS Heart - Goodlettsville
                                900 Conference Drive, Ste. 8
                                Goodlettsville, TN  37072
                                  Services:
                                  • Outpatient Clinics (Outpatient)
                                  UT Medical Resident's Clinic
                                  1911 State Street
                                  Nashville, TN  37203
                                    Services:
                                    • Outpatient Clinics (Outpatient)

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