The Joint Commission
Quality Check
Quality Report

Summary of Quality Information
Baptist Medical Center South
DBA: BMSC HCA Baptist Health, An Affiliate of UAB Health System
Org ID: 7998
2105 East South Boulevard
Montgomery, AL  36116
(334)286-2366
www.baptistfirst.org


Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full Survey Date Last On-Site Survey Date
Home Care
Accredited 9/13/2012 9/12/2012   9/12/2012  
Hospital
Accredited 9/15/2012 9/14/2012   10/26/2012  


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 8/11/2012  8/10/2012  8/10/2012 





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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.
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
2012 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
2012 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 similar to the target range/value.
This organization’s performance is similar to the target range/value.
Stroke Care See Detail
Not displayed.
8
Not displayed.
8
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 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 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 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
Baptist Breast Health Center
6880 Winton Blount Boulevard
Montgomery, AL  36117
    Services:
    • Outpatient Clinics (Outpatient)
    • Perform Invasive Procedure (Outpatient)
    Baptist Medical Center Hospice
    301 Interstate Park
    Montgomery, AL  36109
      Services:
      • Hospice Care
      Baptist Medical Center South  *
      2105 East South Boulevard
      Montgomery, AL  36111
      Joint Commission Advanced Certification Programs:
      • Primary Stroke Center
        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)
        • 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)
        • 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 Unit (Inpatient)
        • Plastic Surgery (Surgical Services)
        • Post Anesthesia Care Unit (PACU) (Inpatient)
        • 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)
        Carmichael Imaging Center
        4145 Carmichael Road
        Montgomery, AL  36106
          Services:
          • Outpatient Clinics (Outpatient)
          • Perform Invasive Procedure (Outpatient)
          Crossbridge Behavioral Health
          2029 Normandie Drive
          Montgomery, AL  36111
            Services:
            • Behavioral Health (Day Programs - Adult)
              (Partial - Adult)
            • Community Integration (Non 24 Hour Care)
            • Family Support (Non 24 Hour Care)
            • Outpatient Clinics (Outpatient)
            • Peer Support (Non 24 Hour Care)
            Crossbridge Behavioral Health
            4385 Narrow Lane Road
            Montgomery, AL  36116
              Services:
              • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult)
              • Community Integration (Non 24 Hour Care)
              • Family Support (Non 24 Hour Care)
              • Peer Support (Non 24 Hour Care)
              Montgomery Cancer Center
              4145 Carmichael Road
              Montgomery, AL  36106
                Services:
                • Administration of High Risk Medications (Outpatient)
                • Outpatient Clinics (Outpatient)
                Montgomery Cancer Center
                645 McQueen Road North Suite 207
                Prattville, AL  36066
                  Services:
                  • Administration of High Risk Medications (Outpatient)
                  • Outpatient Clinics (Outpatient)
                  Montgomery Imaging Center
                  2055 Normandie Drive, Suite 108
                  Montgomery, AL  36111
                    Services:
                    • Outpatient Clinics (Outpatient)
                    Neuroscience Imaging Center
                    2065 E. South Boulevard
                    Montgomery, AL  36116
                      Services:
                      • Outpatient Clinics (Outpatient)
                      The Institute of Advanced Wound Care
                      2167 Normandie Drive
                      Montgomery, AL  36111
                        Services:
                        • Outpatient Clinics (Outpatient)
                        • Perform Invasive Procedure (Outpatient)

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