The Joint Commission
Quality Check
Quality Report

Summary of Accreditation Quality Information
Woman's Hospital
Org ID: 8701
100 Woman's Way
Baton Rouge, LA  70817
(225)927-1300
www.womans.org


Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full Survey Date Last On-Site Survey Date
Home Care
Accredited 9/29/2012 9/28/2012   9/28/2012  
Hospital
Accredited 9/28/2012 9/27/2012   9/27/2012  
Laboratory Accreditation Program
Accredited 5/16/2013 5/15/2013   5/15/2013  


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





Other Accredited Programs / Services
Hospital  -  Accredited by American College of Surgeons-Commission on Cancer (ACoS-COC)

Special Quality Awards


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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
Perinatal Care See Detail
Not displayed.
2
Not displayed.
2
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.
  • Colon/Large Intestine Surgery
See Detail
Not displayed.
3
Not displayed.
3
  • Hysterectomy
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
   
Laboratory Accreditation Program
2013 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 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
Woman's Center for Wellness
9637 Jefferson Hwy.
Baton Rouge, LA  70895
    Services:
    • Outpatient Clinics (Outpatient)
    Woman's Hospital  *
    100 Woman's Way
    Baton Rouge, LA  70817
      Services:
      • CT Scanner (Imaging/Diagnostic Services)
      • Ear/Nose/Throat Surgery (Surgical Services)
      • General Laboratory Tests
      • Gynecological Surgery (Surgical Services)
      • Gynecology (Inpatient)
      • Hematology/Oncology Unit (Inpatient)
      • Inpatient Unit (Inpatient)
      • Labor & Delivery (Inpatient)
      • Magnetic Resonance Imaging (Imaging/Diagnostic Services)
      • Medical /Surgical Unit (Inpatient)
      • Medical ICU (Intensive Care Unit)
      • Normal Newborn Nursery (Inpatient)
      • Nuclear Medicine (Imaging/Diagnostic Services)
      • Orthopedic Surgery (Surgical Services)
      • Outpatient Clinics (Outpatient)
      • Plastic Surgery (Surgical Services)
      • Post Anesthesia Care Unit (PACU) (Inpatient)
      • Sleep Laboratory (Sleep Laboratory)
      • Surgical Unit (Inpatient)
      • Ultrasound (Imaging/Diagnostic Services)
      • Urology (Surgical Services)
      Woman's Hospital Physician's Office Building
      500 Rue de la Vie
      Baton Rouge, LA  70817
      Other Clinics/Practices located at this site:
      • Health Center for Obstetrics and Gynecology (Suite 414)
      • Health Center for Obstetrics and Gynecology (Suite 414)
      • Woman's Gynecologic Oncology (Suite 311)
      • Woman's Hospital Outpatient Lab (Suite 105)
      • Woman's Hospital Pre-Surgery Center (Suite 409)
      • Woman's Outpatient Clinics (Suite 513/515)
      • Woman's Surgical Specialty Group (Suite 407)
      Services:
      • Administration of High Risk Medications (Outpatient)
      • General Laboratory Tests
      • Outpatient Clinics (Outpatient)
      • Perform Invasive Procedure (Outpatient)
      Woman's OB/GYN in Gonzales
      2306 S. Burnside, Ste. B
      Gonzales, LA  70737
        Services:
        • General Laboratory Tests
        • Outpatient Clinics (Outpatient)

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