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Quality Report

Summary of Quality Information
Vanderbilt University Hospital and The Vanderbilt Clinic
Org ID: 7892
1211 22nd Avenue South
Nashville, TN  37232-2101
(615)343-9566
www.mc.vanderbilt.edu

Accreditation
Programs		 Accreditation
Decision		 Effective
Date		 Last Full Survey Date Last On-Site Survey Date  
Hospital
Accredited 8/8/2009 8/7/2009 8/7/2009  

Advanced Certification
Programs		 Certification
Decision		 Effective
Date		 Last Full
Review Date		 Last On-Site
Review Date
Primary Stroke Center
Certification 3/27/2010  3/26/2010  3/26/2010 



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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 of patients 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.
National Patient Safety Goals and National Quality Improvement Goals
    Compared to other Joint Commission Accredited Organizations
    Nationwide Statewide
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:
Jan  2009 -
Dec  2009
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 similar to the target range/value.
This organization’s performance is below 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 similar to the target range/value.
This organization’s performance is similar to the target range/value.
  • Hysterectomy
 See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to 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 similar to the target range/value.
This organization’s performance is similar to the target range/value.
SCIP – Venous Thromboembolism (VTE) See Detail
   
  30 Day Risk Adjusted Mortality Rates (see details)
  30 Day Hospital Readmission Rates (see details)
  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
Adolescent Medicine at One Hundred Oaks
719 Thompson Lane Suite 36300
Nashville, TN  37204
  • General Outpatient Services (Outpatient)
Center for Women's Health, Obstetrics - Coolsprings
2009 Mallory Lane, Suite 230
Franklin, TN  37067
  • General Outpatient Services (Outpatient)
Comprehensive Spine Center at 100 Oaks
719 Thompson Lane; Suite 23108
Nashville, TN  37204
  • General Outpatient Services (Outpatient)
Coolsprings GYN Clinic
2009 Mallory Lane, Ste 230
Franklin, TN  37067
  • General Outpatient Services (Outpatient)
Coolsprings Pediatric Specialties Clinic
2105 Edward Curd Lane, Ste 230
Franklin, TN  37067
  • General Outpatient Services (Outpatient)
Coolsprings Urology Clinic
2009 Mallory Lane, Ste 210
Franklin, TN  37067
  • General Outpatient Services (Outpatient)
Cytogenetics Lab at 100 Oaks
719 Thompson Lane; Suite 23119
Nashville, TN  37204
  • General Outpatient Services (Outpatient)
Franklin Acute Care
919 Murfreesboro Rd.
Franklin, TN  37064
  • General Outpatient Services (Outpatient)
Franklin Dermatology Clinic
919 Murfreesboro Rd.
Franklin, TN  37064
  • General Outpatient Services (Outpatient)
Franklin Family Medicine Practice
2105 Edward Curd Lane
Franklin, TN  37067
  • General Outpatient Services (Outpatient)
Franklin Gastroenterology Clinic
2105 Edward Curd Lane
Franklin, TN  37067
  • General Outpatient Services (Outpatient)
Franklin General Internal Medicine Practice
2105 Edward Curd Lane
Franklin, TN  37067
  • General Outpatient Services (Outpatient)
Franklin General Surgery Clinic
2105 Edward Curd Lane
Franklin, TN  37067
  • General Outpatient Services (Outpatient)
Hemodialysis Clinic East
20 Rachel Drive
Nashville, TN  37214
  • General Outpatient Services (Outpatient)
Ilarde Clinic
841 Union Streeet, Suite 200
Shelbyville, TN  37160
  • General Outpatient Services (Outpatient)
Maternal / Fetal Medicine Clinic - Clarksville
647 Dunlap Lane Suite 206
Clarksville, TN  37040
  • General Outpatient Services (Outpatient)
Multiple Sclerosis Clinic at 100 Oaks
719 Thompson Lane, Suite 24000
Nashville, TN  37204
  • General Outpatient Services (Outpatient)
Neurosurgery Clinic - Cool Springs
2009 Mallory Lane, suite 230
Franklin, TN  37067
  • General Outpatient Services (Outpatient)
Patterson Medical Clinic
1020 South Main Street. Ste B
Franklin, KY  42134
  • General Outpatient Services (Outpatient)
Pediatric Allergy at One Hundred Oaks
719 Thompson Lane Suite 36300
Nashville, TN  37204
  • General Outpatient Services (Outpatient)
Pediatric Cardiology clinic - Clarksville
647 Dunlap Lane Suite 206
Clarksville, TN  37040
  • General Outpatient Services (Outpatient)
Radiology - 100 Oaks
719 Thompson Lane
Nashville, TN  37204
  • General Outpatient Services (Outpatient)
Rapid Response Lab at 100 Oaks
719 Thompson Lane, Suite 23200
Nashville, TN  37204
  • General Outpatient Services (Outpatient)
Shelbyville Dermatology Clinic
841 Union Street, Suite 201
Shelbyville, TN  37160
  • General Outpatient Services (Outpatient)
Sleep Lab
Marriott @ Vanderbilt, 2555 West End Ave
Nashville, TN  37203
  • General Outpatient Services (Outpatient)
Sterile Processing at 100 Oaks
719 thompson Lane
Nashville, TN  37204
  • General Outpatient Services (Outpatient)
TN Lions Eye Center Pediatric Ophthalmology Clinic
2105 Edward Curd Lane - 3rd Floor
Franklin, TN  37067
  • General Outpatient Services (Outpatient)
University Pediatrics - 100 Oaks
719 Thompson Lane, Suite 24500
Nashville, TN  37204
  • General Outpatient Services (Outpatient)
Vanderbilt Infusion Clinic at 100 Oaks
719 Thompson Lane Suite 24131
Nashville, TN  37204
  • General Outpatient Services (Outpatient)
Vanderbilt Bone & Joint Surgery Center
225 Bedford Way
Franklin, TN  37064
  • Ambulatory Surgery Center (Outpatient)
  • Anesthesia (Outpatient)
Vanderbilt Bone & Joint Clinic
206 Bedford Way
Franklin, TN  37064
  • General Outpatient Services (Outpatient)
Vanderbilt Breast Center - 100 Oaks
719 Thompson Lane, Suite 25000
Nashville, TN  37204
  • General Outpatient Services (Outpatient)
Vanderbilt Brentwood Primary Care Clinic
343 Franklin Road Suite 101
Brentwood, TN  37027
  • General Outpatient Services (Outpatient)
Vanderbilt Center for Women's Health - 100 Oaks
719 Thompson Lane, Suite 27100
Nashville, TN  37204
  • General Outpatient Services (Outpatient)
Vanderbilt Center for Women's Imaging
3319 West End Avenue - Suite 650
Nashville, TN  37203
  • General Outpatient Services (Outpatient)
Vanderbilt Center for Women's Imaging - 100 Oaks
719 Thompson Lane; Suite 23500
Nashville, TN  37204
  • General Outpatient Services (Outpatient)
Vanderbilt Children's Hospital Rehabilitation Services
One Hundred Oaks, 719 Thompson Lane
Nashville, TN  37204
  • General Outpatient Services (Outpatient)
Vanderbilt Dermatology Clinic at 100 Oaks
719 Thompson Lane, Suite 26300
Nashville, TN  37204
  • General Outpatient Services (Outpatient)
Vanderbilt Eye Institute - Murfreesboro
1821 Heritage Park Plaza
Murfreesboro, TN  37129
  • General Outpatient Services (Outpatient)
Vanderbilt Eye Institute at Bellevue
7640 Highway 70 South, Suite 100
Nashville, TN  37221
  • General Outpatient Services (Outpatient)
Vanderbilt Eye Institute at Campbell Station
3098 Campbell Station Parkway
Spring Hill, TN  37174
  • General Outpatient Services (Outpatient)
Vanderbilt Eye Institute at Franklin
100 Covey Drive, Suite 107
Franklin, TN  37067
  • General Outpatient Services (Outpatient)
Vanderbilt Eye Institute Williamson County
919 Murfreesboro Road
Franklin, TN  37064
  • General Outpatient Services (Outpatient)
Vanderbilt Health Pharmacy - 100 Oaks
719 Thompson Lane, suite 24130
Nashville, TN  37204
  • General Outpatient Services (Outpatient)
Vanderbilt Heart and Vascular Clinic at 100 Oaks
719 Thompson Lane Suite 22100
Nashville, TN  37204
  • General Outpatient Services (Outpatient)
Vanderbilt Heart at Franklin
2105 Edward Curd Lane
Franklin, TN  37067
  • General Outpatient Services (Outpatient)
Vanderbilt Heart at Lebanon
1420 Baddour Parkway, Suite 240
Lebanon, TN  37087
  • General Outpatient Services (Outpatient)
Vanderbilt Heart at Murfreesboro
507 N. University Street
Murfreesboro, TN  37130
  • General Outpatient Services (Outpatient)
Vanderbilt Heart at Shelbyville
841 Union Street, Bldg. 2 Suite 202
Shelbyville, TN  37160
  • General Outpatient Services (Outpatient)
Vanderbilt Heart at Winchester
1397 South College Street, Suite 1
Winchester, TN  37398
  • General Outpatient Services (Outpatient)
Vanderbilt Internal Medicine at One Hundred Oaks
719 Thomspson Lane Suite 38500
Nashville, TN  37204
  • General Outpatient Services (Outpatient)
Vanderbilt Interventional Pain Center at 100 Oaks
719 Thompson Lance, Suite 22209
Nashville, TN  37204
  • Anesthesia (Outpatient)
  • General Outpatient Services (Outpatient)
Vanderbilt Medical Group - Westhaven
1025 Westhaven Boulevard
Franklin, TN  37064
  • General Outpatient Services (Outpatient)
Vanderbilt Medical Group at Green Hills
2002 Richards Jones Road Suite B-300
Nashville, TN  37215
  • General Outpatient Services (Outpatient)
Vanderbilt Medical Group at Spring Hill
3098 Campbell Station Parkway
Spring Hill, TN  37174
  • General Outpatient Services (Outpatient)
Vanderbilt Medical Group Oncology Practice at Cool Springs
324 Cool Springs Blvd.
Franklin, TN  37064
  • General Outpatient Services (Outpatient)
Vanderbilt Medical Group-Brentwood
782 Old Hickory Blvd. - Ste. 201
Brentwood, TN  37027
  • General Outpatient Services (Outpatient)
Vanderbilt Neurodiagnostics EEG Lab at 100 Oaks
719 Thompson Lance Suite 23108
Nashville, TN  37204
  • General Outpatient Services (Outpatient)
Vanderbilt Occupational Health Clinic - 100 Oaks
719 Thompson Lane Suite 21100
Nashville, TN  37204
  • General Outpatient Services (Outpatient)
Vanderbilt Orthopaedics - Podiatry - Franklin
324 Coolsprings Boulevard
Franklin, TN  37067
  • General Outpatient Services (Outpatient)
Vanderbilt Pathology Laboratory Services
2105 Edward Curd Lane
Franklin, TN  37064
  • General Outpatient Services (Outpatient)
Vanderbilt Physical Therapy at Franklin
2105 Edward Curd Lane
Franklin, TN  37064
  • General Outpatient Services (Outpatient)
Vanderbilt Preoperative Evaluation Clinic (VPEC) at 100 Oaks
719 Thompson Lane, Suite 21100
Nashville, TN  37204
  • General Outpatient Services (Outpatient)
Vanderbilt Psychiatry at 100 Oaks
719 Thompson Lane; Suite 27100
Nashville, TN  37204
  • General Outpatient Services (Outpatient)
Vanderbilt Psychiatry in Williamson County
2105 Edward Curd Lane
Franklin, TN  37067
  • General Outpatient Services (Outpatient)
Vanderbilt Rheumatology Clinic
2001 Mallory Lane, Suite 100
Franklin, TN  37067
  • General Outpatient Services (Outpatient)
Vanderbilt Sleep Disorders Center - Franklin
650 Bakers Bridge Avenue
Franklin, TN  37067
  • General Outpatient Services (Outpatient)
Vanderbilt Surgical Weight Loss Clinic at 100 Oaks
719 Thompson Lane, Suite 22200
Nashville, TN  37204
  • General Outpatient Services (Outpatient)
Vanderbilt University Hospital and The Vanderbilt Clinic  *
1211 22nd Avenue South
Nashville, TN  37232-2101
Joint Commission Advanced Certification Programs:
  • Primary Stroke Center
Services:
  • Addiction Care (Outpatient)
  • Alcohol & Drug Rehabilitation (Outpatient)
  • Allergy (Outpatient)
  • Audiology (Outpatient)
  • Behavioral Health (Day Programs - Adult/Child/Youth)
    (Non 24 Hour Care - Adult/Child/Youth)
    (24-hour Acute Care/Crisis Stabilization - Adult/Child/Youth)
  • Bone Marrow Transplant (Inpatient)
  • Cancer Center/Oncology (Inpatient, Outpatient)
  • Cardiac Catheterization Lab (Inpatient, Outpatient)
  • Cardiac Surgery (Inpatient, Outpatient)
  • Cardiac Unit/Cardiology (Inpatient, Outpatient)
  • Chemical Dependency (Non 24 Hour Care - Adult)
  • CT Scanner (Inpatient, Outpatient)
  • Dentistry (Outpatient)
  • Dermatology (Inpatient, Outpatient)
  • Developmental Disabilities - Hospital (Outpatient)
  • Dialysis (Inpatient, Outpatient)
  • EEG/EKG/EMG Lab (Inpatient, Outpatient)
  • Electroconvulsive Therapy (Inpatient)
  • Emergency Room (Outpatient)
  • Endocrinology (Inpatient, Outpatient)
  • Gastroenterology (Inpatient, Outpatient)
  • General Medical Services (Inpatient, Outpatient)
  • General Surgery (Inpatient, Outpatient)
  • GI or Endoscopy Lab (Inpatient, Outpatient)
  • Gynecology (Inpatient, Outpatient)
  • Hematology/Blood Treatment (Inpatient, Outpatient)
  • Imaging/Radiology (Inpatient, Outpatient)
  • Infectious Diseases (Inpatient, Outpatient)
  • Infusion Therapy (Inpatient, Outpatient)
  • Inpatient Intake (Inpatient)
  • Intensive Care Unit (Inpatient)
  • Internal Medicine (Inpatient, Outpatient)
  • Labor & Delivery (Inpatient)
  • Lithotripsy/Kidney Stone Treatment (Inpatient, Outpatient)
  • Magnetic Resonance Imaging (Inpatient, Outpatient)
  • Medical Detoxification (Inpatient)
  • Mental Health (Inpatient, Outpatient, 24-hour Acute Care/Crisis Stabilization)
  • Neonatal Intensive Care (Inpatient)
  • Nephrology (Inpatient, Outpatient)
  • Neurology (Inpatient, Outpatient)
  • Neurosurgery (Inpatient)
  • Nuclear Medicine (Inpatient, Outpatient)
  • Nursery (Inpatient)
  • Obstetrics (Inpatient, Outpatient)
  • Occupational Health (Outpatient)
  • Operating Room (Inpatient, Outpatient)
  • Ophthalmology/Eye Surgery (Inpatient, Outpatient)
  • Oral Maxillofacial Surgery (Inpatient, Outpatient)
  • Orthopedic Surgery (Inpatient, Outpatient)
  • Otolaryngology/Ear, Nose, and Throat (Inpatient, Outpatient)
  • Outpatient Surgery (Outpatient)
  • Pain Management (Inpatient, Outpatient)
  • Pediatric Care (Inpatient, Outpatient)
  • Plastic Surgery (Inpatient, Outpatient)
  • Podiatry (Outpatient)
  • Post Anesthesia Care Unit (PACU) (Inpatient, Outpatient)
  • Pulmonary Function Lab (Inpatient, Outpatient)
  • Radiation Oncology (Inpatient, Outpatient)
  • Rehabilitation and Physical Medicine (Inpatient, Outpatient)
  • Respiratory Care (Ventilator) (Inpatient)
  • Rheumatology (Inpatient, Outpatient)
  • Telemetry (Inpatient)
  • Thoracic Surgery (Inpatient, Outpatient)
  • Trauma/Burn Unit (Inpatient)
  • Ultrasound (Inpatient, Outpatient)
  • Urgent Care/Emergency Medicine (Outpatient)
  • Urology (Inpatient, Outpatient)
  • Vascular Surgery (Inpatient, Outpatient)
  • Wound Care (Inpatient, Outpatient)
VMG Williamson County ENT Clinic
100 Covey Drive, Suite 303
Franklin, TN  37067
  • General Outpatient Services (Outpatient)
VMG Williamson ENT Clinic
919 Murfreesboro Road
Franklin, TN  37067
  • General Outpatient Services (Outpatient)
VMG Williamson Plastic Surgery Clinic
919 Murfreesboro
Franklin, TN  37067
  • General Outpatient Services (Outpatient)
West End Women's Health Center
2611 West End Ave., Ste. 380
Nashville, TN  37203
  • General Outpatient Services (Outpatient)
Williamson County Sleep Clinic
2105 Edward Curd Lane
Franklin, TN  37067
  • General Outpatient Services (Outpatient)

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