The Joint Commission
Quality Check
Quality Report

Summary of Accreditation Quality Information
366th Medical Group (ACC)
Org ID: 9325
90 Hope Drive, Building 6000
Mountain Home A F B, ID  83648-1000
(208)828-7436
www.mountainhome.af.mil


Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full Survey Date Last On-Site Survey Date  
Hospital
Accredited 8/7/2009 8/6/2009 8/6/2009  


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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
Surgical Care Improvement Project (SCIP)    
SCIP - Cardiac See Detail
   
SCIP - Infection Prevention
For All Reported Procedures:
See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
  • Blood Vessel Surgery
See Detail
Not displayed.
3
Not displayed.
3
  • Colon/Large Intestine Surgery
See Detail
Not displayed.
3
Not displayed.
3
  • Coronary Artery Bypass Graft
See Detail
Not displayed.
3
Not displayed.
3
  • Hip Joint Replacement
See Detail
Not displayed.
3
Not displayed.
3
  • 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
Not displayed.
3
Not displayed.
3
  • Open Heart Surgery
See Detail
Not displayed.
3
Not displayed.
3
SCIP – Venous Thromboembolism (VTE) See Detail
   
 
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
366th Medical Group (ACC)  *
90 Hope Dr, Bldg 6000
Mountain Home A F B, ID  83648-5300
  • Alcohol & Drug Rehabilitation (Outpatient)
  • Allergy (Outpatient)
  • Audiology (Outpatient)
  • CT Scanner (Inpatient, Outpatient)
  • Dentistry (Outpatient)
  • Family Practice (Inpatient, Outpatient)
  • General Medical Services (Inpatient, Outpatient)
  • General Surgery (Inpatient, Outpatient)
  • GI or Endoscopy Lab (Inpatient, Outpatient)
  • Gynecology (Inpatient, Outpatient)
  • Imaging/Radiology (Inpatient, Outpatient)
  • Internal Medicine (Inpatient, Outpatient)
  • Labor & Delivery (Inpatient)
  • Magnetic Resonance Imaging (Inpatient, Outpatient)
  • Mental Health (Outpatient)
  • Nursery (Inpatient)
  • Obstetrics (Inpatient, Outpatient)
  • Occupational Health (Outpatient)
  • Operating Room (Inpatient, Outpatient)
  • Outpatient Surgery (Outpatient)
  • Pediatric Care (Inpatient, Outpatient)
  • Post Anesthesia Care Unit (PACU) (Inpatient, Outpatient)
  • Rehabilitation and Physical Medicine (Outpatient)
  • Ultrasound (Inpatient, Outpatient)
  • Urgent Care/Emergency Medicine (Outpatient)
  • Women's Health (Outpatient)
  • Wound Care (Inpatient, Outpatient)

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