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Quality Report

Summary of Accreditation Quality Information
Evans Army Community Hospital
Org ID: 9365
1650 Cochrane Circle, BLDG 7500
Colorado Springs, CO  80913-4604
(719)526-7500
www.evans.amedd.army.mil

Accreditation
Programs 		Accreditation
Decision 		Effective
Date 		Last Full Survey Date Last On-Site Survey Date
Behavioral Health Care
Accredited 3/19/2013 3/18/2013   3/18/2013  
Hospital
Accredited 3/23/2013 3/22/2013   3/22/2013  




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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.
National Patient Safety Goals and National Quality Improvement Goals
    Compared to other Joint Commission Accredited Organizations
    Nationwide Statewide
Behavioral Health Care
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.
*
Hospital
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 Improvement Goals:    
Reporting Period:
Oct  2011 -
Sep  2012
Children's Asthma 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.
Perinatal Care See Detail
Not displayed.
10
Not displayed.
10
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
Not displayed.
3
Not displayed.
3
  • Colon/Large Intestine Surgery
 See Detail
Not displayed.
3
Not displayed.
3
  • 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 similar to the target range/value.
This organization’s performance is similar to the target range/value.
SCIP – Venous Thromboembolism (VTE) See Detail
   
Venous Thromboembolism (VTE) See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is above the target range/value.
 
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
ASAP - Army Substance Abuse Program
1638 Elwell St, Building 6236
Colorado Springs, CO  80913
    Services:
    • Behavioral Health (Day Programs - Adult)
      (Non 24 Hour Care - Adult/Child/Youth)
      (Partial - Adult)
    • Case Management (Non 24 Hour Care - Adult)
    • Chemical Dependency (Non 24 Hour Care - Adult)
    • Community Integration (Non 24 Hour Care)
    DiRaimondo Family Medicine Clinic
    Building 1041
    Fort Carson, CO  80913
      Services:
      • Outpatient Clinics (Outpatient)
      DiRaimondo Family Medicine Clinic - West
      Building 1058 O'Connell Blvd
      Fort Carson, CO  80913
        Services:
        • Single Specialty Practitioner (Outpatient)
        DiRaimondo Family Medicine Clinic South
        Bldg 1150, Barkely Ave
        Fort Carson, CO  80913-4604
          Services:
          • Outpatient Clinics (Outpatient)
          Embedded Behavioral Health - Team 5
          Bldg 1226
          Colorado Springs, CO  80913
            Services:
            • Behavioral Health (Non 24 Hour Care - Adult)
            • Case Management (Non 24 Hour Care - Adult)
            • Community Integration (Non 24 Hour Care)
            Embedded Behavioral Health - Team 1
            6541 Specker Rd, Bldg 1830
            Ft Carson, CO  80913
              Services:
              • Behavioral Health (Non 24 Hour Care - Adult)
              • Case Management (Non 24 Hour Care - Adult)
              • Community Integration (Non 24 Hour Care)
              Embedded Behavioral Health - Team 3
              Bldg 1657 - corner of Prussman and Barkely
              Ft Carson, CO  80913
                Services:
                • Behavioral Health (Non 24 Hour Care - Adult)
                • Case Management (Non 24 Hour Care - Adult)
                • Community Integration (Non 24 Hour Care)
                Embedded Behavioral Health - Team 4
                Bldg 9481 - Wilderness Road
                Ft Carson, CO  80913
                  Services:
                  • Behavioral Health (Non 24 Hour Care - Adult)
                  • Case Management (Non 24 Hour Care - Adult)
                  • Community Integration (Non 24 Hour Care)
                  Embedded Behavioral Health -Bldg 2361- Team 2
                  Titus and McGrath
                  Fort Carson, CO  80913
                    Services:
                    • Behavioral Health (Non 24 Hour Care - Adult)
                    • Case Management (Non 24 Hour Care - Adult)
                    • Community Integration (Non 24 Hour Care)
                    Evans Army Community Hospital  *
                    1650 Cochrane Circle
                    Ft Carson, CO  80913
                      Services:
                      • CT Scanner (Imaging/Diagnostic Services)
                      • 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)
                      • Interventional Radiology (Imaging/Diagnostic Services)
                      • 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)
                      • Plastic Surgery (Surgical Services)
                      • Post Anesthesia Care Unit (PACU) (Inpatient)
                      • Surgical ICU (Intensive Care Unit)
                      • Teleradiology (Imaging/Diagnostic Services)
                      • Ultrasound (Imaging/Diagnostic Services)
                      • Urology (Surgical Services)
                      Forrest Resiliency Center
                      1891 Prussman Avenue, Bldg 1843, Fort Carson
                      Colorado Springs, CO  80913
                        Services:
                        • Single Specialty Practitioner (Outpatient)
                        Fountain School District #8
                        10665 Jimmy Camp Road
                        Fountain, CO  80817
                          Services:
                          • Behavioral Health (Non 24 Hour Care - Child/Youth)
                          • Community Integration (Non 24 Hour Care)
                          Medical Boards and Evaluations - BLDG 1059
                          1852 Irwin Drive Bldg 1059
                          Ft Carson, CO  80913
                            Services:
                            • Single Specialty Practitioner (Outpatient)
                            Post Deployment Health Risk Assessment Building
                            Bldg 1056 O'Connell Blvd
                            Fort Carson, CO  80913
                              Services:
                              • Single Specialty Practitioner (Outpatient)
                              Premier Army Health Clinic
                              3920 North Union Blvd
                              Colorado Springs, CO  80907
                                Services:
                                • Behavioral Health (Non 24 Hour Care - Adult)
                                • Case Management (Non 24 Hour Care - Adult)
                                • Community Integration (Non 24 Hour Care)
                                • Outpatient Clinics (Outpatient)
                                • Perform Invasive Procedure (Outpatient)
                                Preventive Medicine Clinic
                                6582 Magrath Ave Bldg 2059
                                Fort Carson, CO  80913
                                  Services:
                                  • Single Specialty Practitioner (Outpatient)
                                  Robinson Family Medicine Clinic
                                  Building 7490
                                  Fort Carson, CO  80913
                                    Services:
                                    • Single Specialty Practitioner (Outpatient)
                                    Soldier Family Care Center
                                    1670 Cochrane Circle
                                    Ft Carson, CO  80913
                                      Services:
                                      • Administration of Blood Product (Outpatient)
                                      • Outpatient Clinics (Outpatient)
                                      • Perform Invasive Procedure (Outpatient)
                                      United States Army Occupational Health Clinic
                                      Pueblo Chemical Depot
                                      Pueblo, CO  81001
                                        Services:
                                        • Single Specialty Practitioner (Outpatient)
                                        United States Army Occupational Health Clinic
                                        Tooele Army Depot Bldg # 400
                                        Tooele, UT  84074
                                          Services:
                                          • Single Specialty Practitioner (Outpatient)
                                          United States Army Occupational Health Clinic
                                          Dugway Proving Ground Bldg # 5116
                                          Dugway, UT  84022
                                            Services:
                                            • Single Specialty Practitioner (Outpatient)
                                            United States Army Occupational Health Clinic
                                            DCD Aid Station Bldg 5010
                                            Stockton, UT  84071
                                              Services:
                                              • Single Specialty Practitioner (Outpatient)
                                              Warrior Recovery Center-Rehab
                                              1836 Provide Comfort Drive, Bldg 7488
                                              Fort Carson, CO  80913
                                                Services:
                                                • Outpatient Clinics (Outpatient)
                                                • Perform Invasive Procedure (Outpatient)
                                                Warrior Recovery Primary Care Clinic
                                                1837 Provide Comfort Drive, Bldg 7489
                                                Fort Carson, CO  80913
                                                  Services:
                                                  • Single Specialty Practitioner (Outpatient)
                                                  WTU Social Work Building
                                                  1667 Cochrane Circle Bldg 7494
                                                  Fort Carson, CO  80913
                                                    Services:
                                                    • Single Specialty Practitioner (Outpatient)

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