The Joint Commission
Quality Check
Quality Report

Summary of Quality Information
Saint Thomas West Hospital
DBA: Saint Thomas West Hospital
Org ID: 7891
4220 Harding Road
Nashville, TN  37205
(615)222-2111
www.sths.com


Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full Survey Date Last On-Site Survey Date
Hospital
Accredited 7/21/2012 7/20/2012   4/18/2014  


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
Primary Stroke Center
Certification 7/20/2013  7/19/2013  7/19/2013 
Ventricular Assist Device
Certification 5/21/2014  5/20/2014  5/20/2014 



Certified
Programs
Certification
Decision
Effective
Date
Last Full
Review Date
Last On-Site
Review Date
Hip Fracture
Certification 4/18/2013  4/17/2013  4/17/2013 
Joint Replacement - Hip
Certification 4/17/2013  4/16/2013  4/16/2013 
Joint Replacement - Knee
Certification 4/17/2013  4/16/2013  4/16/2013 


Certification programs recognized by the Centers for Medicare and Medicaid Services (CMS)
Ventricular Assist Device



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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:
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.
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 above the target range/value.
This organization’s performance is above 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 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
Cardiac Outpatient Diagnostic Center
4230 Harding Road, Suite #325 HI
Nashville, TN  37205
    Services:
    • Outpatient Clinics (Outpatient)
    Saint Thomas Anticoagulation Monitoring Clinic
    4230 Harding Road, Plaza West Suite G-
    Nashville, TN  37205
      Services:
      • Outpatient Clinics (Outpatient)
      Saint Thomas Heart Failure Clinic
      4230 Harding Road, Suite #450 HI,
      Nashville, TN  37205
      Joint Commission Advanced Certification Programs:
      • Ventricular Assist Device
        Services:
        • Outpatient Clinics (Outpatient)
        Saint Thomas Heart Outpatient Cardiac Imaging Center
        100 Physician's Way, Suite #305
        Lebanon, TN  37090
          Services:
          • Outpatient Clinics (Outpatient)
          Saint Thomas West Hospital  *
          4220 Harding Road
          Nashville, TN  37205
          Joint Commission Advanced Certification Programs:
          • Primary Stroke Center
          • Ventricular Assist Device
          Joint Commission Certified Programs:
          • Hip Fracture
          • Joint Replacement - Hip
          • Joint Replacement - Knee
          Other Clinics/Practices located at this site:
          • Saint Thomas Anticoagulation Monitoring Clinic
          Services:
          • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult)
          • 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)
          • Family Support (Non 24 Hour Care)
          • 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)
          • Magnetic Resonance Imaging (Imaging/Diagnostic Services)
          • Medical /Surgical Unit (Inpatient)
          • Medical ICU (Intensive Care Unit)
          • Neuro/Spine ICU (Intensive Care Unit)
          • Neuro/Spine Unit (Inpatient)
          • Neurosurgery (Surgical Services)
          • Nuclear Medicine (Imaging/Diagnostic Services)
          • Ophthalmology (Surgical Services)
          • Orthopedic Surgery (Surgical Services)
          • Orthopedic/Spine Unit (Inpatient)
          • Outpatient Clinics (Outpatient)
          • Peer Support (Non 24 Hour Care)
          • Plastic Surgery (Surgical Services)
          • Post Anesthesia Care Unit (PACU) (Inpatient)
          • Radiation Oncology (Imaging/Diagnostic Services)
          • Surgical ICU (Intensive Care Unit)
          • Surgical Unit (Inpatient)
          • Thoracic Surgery (Surgical Services)
          • Transplant Surgery (Surgical Services)
          • Ultrasound (Imaging/Diagnostic Services)
          • Urology (Surgical Services)
          • Vascular Surgery (Surgical Services)

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