The Joint Commission
Quality Check
Quality Report

Summary of Accreditation Quality Information
Evans Army Community Hospital
Org ID: 9365
1650 Cochrane Circle, BLDG 7500
Fort Carson, 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:
Jan  2013 -
Dec  2013
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.
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 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
This organization’s performance is below the target range/value.
This organization’s performance is below 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 above the target range/value.
This organization’s performance is above 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.
 
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
Fort Carson, CO  80913
    Services:
    • Case Management (Non 24 Hour Care - Adult)
    • Chemical Dependency (Non 24 Hour Care - Adult)
    • Community Integration (Non 24 Hour Care)
    Audiology Clinic / Hearing Readiness
    1853 O'Connell Blvd, Bldg 1040
    Fort Carson, CO  80913
      Services:
      • Ambulatory Surgery Center (Outpatient)
      DiRaimondo Family Medicine Clinic - West
      Building 1058 O'Connell Blvd
      Fort Carson, CO  80913
        Services:
        • Single Specialty Practitioner (Outpatient)
        DiRaimondo Family Medicine Clinic North
        Building 1041, Barkeley Ave
        Fort Carson, CO  80913
          Services:
          • Outpatient Clinics (Outpatient)
          DiRaimondo Family Medicine Clinic South
          Bldg 1150, Barkeley Ave
          Fort Carson, CO  80913-4604
            Services:
            • Outpatient Clinics (Outpatient)
            Embedded Behavioral Health - Team 5
            Bldg 1226, Felkins and Specker
            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)
              Embedded Behavioral Health - Team 2
              Bldg 2361, 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)
                Embedded Behavioral Health - Team 3
                Bldg 1657 - corner of Prussman and Barkely
                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)
                  Embedded Behavioral Health - Team 4
                  Bldg 9481 - Wilderness Road
                  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)
                    • Eating Disorders (Non 24 Hour Care - Adult)
                    Embedded Behavioral Health Team 1
                    6541 Specker Ave, Bldg 2649
                    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
                      Fort Carson, CO  80913
                        Services:
                        • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult)
                        • 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)
                        • Ophthalmology (Surgical Services)
                        • Orthopedic Surgery (Surgical Services)
                        • Outpatient Clinics (Outpatient)
                        • Plastic Surgery (Surgical Services)
                        • Post Anesthesia Care Unit (PACU) (Inpatient)
                        • Sleep Laboratory (Sleep Laboratory)
                        • 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
                        Fort Carson, 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 813
                            1626 O'Connell Blvd Bldg 813
                            Fort Carson, CO  80913
                              Services:
                              • Single Specialty Practitioner (Outpatient)
                              Mountain Post Behavioral Health Clinic
                              6541 Specker Rd, Bldg 1830
                              Fort Carson, CO  80913
                                Services:
                                • Behavioral Health (Day Programs - Adult)
                                  (Non 24 Hour Care - Adult)
                                  (Partial - Adult)
                                • Case Management (Non 24 Hour Care - Adult)
                                • Community Integration (Non 24 Hour Care)
                                • Technology-Based Behavioral Health Srvs (Non 24 Hour Care - Adult)
                                Mountain Post Medical Home
                                565 Space Center Blvd
                                Colorado Springs, CO  80915
                                  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:
                                      • Single Specialty Practitioner (Outpatient)
                                      Preventive Medicine Clinic
                                      6582 Magrath Ave Bldg 2059
                                      Fort Carson, CO  80913
                                        Services:
                                        • Single Specialty Practitioner (Outpatient)
                                        Robinson Family Medicine Clinic
                                        Building 7490, Sutherland Cir
                                        Fort Carson, CO  80913
                                          Services:
                                          • Single Specialty Practitioner (Outpatient)
                                          Soldier Family Care Center
                                          1670 Cochrane Circle, Building 7503
                                          Fort Carson, CO  80913
                                            Services:
                                            • Outpatient Clinics (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)
                                                  Warrior Recovery Center-Rehab
                                                  1836 Provide Comfort Drive, Bldg 7488
                                                  Fort Carson, CO  80913
                                                    Services:
                                                    • Outpatient Clinics (Outpatient)
                                                    Warrior Recovery Primary Care Clinic
                                                    1837 Provide Comfort Drive, Bldg 7489
                                                    Fort Carson, CO  80913
                                                      Services:
                                                      • Single Specialty Practitioner (Outpatient)
                                                      Warrior Transition Battalion
                                                      Building 7495, 1667 Cochrane Circle
                                                      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)
                                                        WTU Social Work Building
                                                        1667 Cochrane Circle Bldg 7494
                                                        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)
                                                          • Outpatient Clinics (Outpatient)

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