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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)526-7923
www.evans.amedd.army.mil

Accreditation
Programs		 Accreditation
Decision		 Effective
Date		 Last Full Survey Date Last On-Site Survey Date  
Hospital
Accredited 7/3/2010 7/2/2010 7/2/2010  


Other Accredited Programs / Services
Laboratory  -  Accredited by College of American Pathologists

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 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
Children's Asthma Care See Detail
This organization’s performance is below 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.
Pregnancy 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 similar to the target range/value.
  • 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
Army Substance Abuse Program
1636 Elwell Street (first floor)
Ft Carson, CO  80913
  • Behavioral Health (Non 24 Hour Care - Adult)
  • Chemical Dependency (Non 24 Hour Care - Adult)
Community Behavioral Health Service
2650 Specker Ave
Ft Carson, CO  80913
  • Behavioral Health (Non 24 Hour Care - Adult)
  • Case Management (Non 24 Hour Care - Adult)
Community Behavioral Health Services
6909 Titus Blvd
Ft Carson, CO  80913
  • Behavioral Health (Non 24 Hour Care - Adult)
Community Behavioral Health Services
1854 Hogan Street
Ft Carson, CO  80913
  • Behavioral Health (Non 24 Hour Care - Adult)
DiRaimondo Family Medicine Clinic
Building 1041
Fort Carson, CO  80913
  • General Outpatient Services (Outpatient)
DiRaimondo Family Medicine Clinic South
Bldg 1150, Barkely Ave
Fort Carson, CO  80913-4604
  • Addiction Care (Outpatient)
  • Alcohol & Drug Rehabilitation (Outpatient)
  • Allergy (Outpatient)
  • Audiology (Outpatient)
  • Behavioral Health (Day Programs - Adult)
    (Non 24 Hour Care - Adult)
  • Care Coordination (Non 24 Hour Care)
  • Case Management (Non 24 Hour Care - Adult)
  • CT Scanner (Inpatient, Outpatient)
  • Dermatology (Outpatient)
  • EEG/EKG/EMG Lab (Outpatient)
  • Emergency Room (Outpatient)
  • Family Practice (Inpatient, Outpatient)
  • Gastroenterology (Inpatient, Outpatient)
  • General Medical Services (Inpatient, Outpatient)
  • General Surgery (Inpatient, Outpatient)
  • GI or Endoscopy Lab (Inpatient, Outpatient)
  • Gynecology (Inpatient, Outpatient)
  • Imaging/Radiology (Inpatient, Outpatient)
  • Intensive Care Unit (Inpatient)
  • Internal Medicine (Inpatient, Outpatient)
  • Labor & Delivery (Inpatient)
  • Lithotripsy/Kidney Stone Treatment (Outpatient)
  • Magnetic Resonance Imaging (Inpatient, Outpatient)
  • Mental Health (Outpatient)
  • Neurology (Inpatient, Outpatient)
  • Nuclear Medicine (Inpatient, Outpatient)
  • Nursery (Inpatient)
  • Obstetrics (Inpatient, Outpatient)
  • Occupational Health (Outpatient)
  • Operating Room (Inpatient)
  • Ophthalmology/Eye Surgery (Inpatient, Outpatient)
  • Oral Maxillofacial Surgery (Inpatient, Outpatient)
  • Orthopedic Surgery (Inpatient, Outpatient)
  • Otolaryngology/Ear, Nose, and Throat (Inpatient, Outpatient)
  • Outpatient Surgery (Outpatient)
  • Pain Management (Inpatient, Outpatient)
  • Pediatric Care (Inpatient, Outpatient)
  • Plastic Surgery (Inpatient, Outpatient)
  • Podiatry (Inpatient, Outpatient)
  • Post Anesthesia Care Unit (PACU) (Inpatient)
  • Pulmonary Function Lab (Inpatient, Outpatient)
  • Respiratory Care (Ventilator) (Inpatient)
  • Services Supporting Rehabilitation and Resilience (Non 24 Hour Care - Adult)
  • Ultrasound (Inpatient, Outpatient)
  • Urgent Care/Emergency Medicine (Outpatient)
  • Urology (Inpatient, Outpatient)
Evans Army Community Hospital (Main Site)  *
1650 Cochrane Circle
Ft Carson, CO  80913
  • Addiction Care (Outpatient)
  • Alcohol & Drug Rehabilitation (Outpatient)
  • Allergy (Outpatient)
  • Audiology (Outpatient)
  • Cardiac Unit/Cardiology (Outpatient)
  • CT Scanner (Inpatient, Outpatient)
  • Dermatology (Outpatient)
  • EEG/EKG/EMG Lab (Outpatient)
  • Emergency Room (Outpatient)
  • Family Practice (Inpatient, Outpatient)
  • Gastroenterology (Inpatient, Outpatient)
  • General Medical Services (Inpatient, Outpatient)
  • General Surgery (Inpatient, Outpatient)
  • GI or Endoscopy Lab (Inpatient, Outpatient)
  • Gynecology (Inpatient, Outpatient)
  • Imaging/Radiology (Inpatient, Outpatient)
  • Intensive Care Unit (Inpatient)
  • Internal Medicine (Inpatient, Outpatient)
  • Labor & Delivery (Inpatient)
  • Lithotripsy/Kidney Stone Treatment (Outpatient)
  • Magnetic Resonance Imaging (Inpatient, Outpatient)
  • Mental Health (Outpatient)
  • Neurology (Inpatient, Outpatient)
  • Nuclear Medicine (Inpatient, Outpatient)
  • Nursery (Inpatient)
  • Obstetrics (Inpatient, Outpatient)
  • Occupational Health (Outpatient)
  • Operating Room (Inpatient)
  • Ophthalmology/Eye Surgery (Inpatient, Outpatient)
  • Oral Maxillofacial Surgery (Inpatient, Outpatient)
  • Orthopedic Surgery (Inpatient, Outpatient)
  • Otolaryngology/Ear, Nose, and Throat (Inpatient, Outpatient)
  • Outpatient Surgery (Outpatient)
  • Pain Management (Inpatient, Outpatient)
  • Pediatric Care (Inpatient, Outpatient)
  • Plastic Surgery (Inpatient)
  • Podiatry (Inpatient, Outpatient)
  • Post Anesthesia Care Unit (PACU) (Inpatient)
  • Pulmonary Function Lab (Inpatient, Outpatient)
  • Recovery/Infirmary (Outpatient)
  • Respiratory Care (Ventilator) (Inpatient)
  • Ultrasound (Inpatient, Outpatient)
  • Urgent Care/Emergency Medicine (Outpatient)
  • Urology (Inpatient, Outpatient)
Post Deployment Health Risk Assessment Building
Bldg 1056 O'Connell Blvd
Fort Carson, CO  80913
  • General Outpatient Services (Outpatient)
Premier Army Health Clinic
3920 North Union Blvd
Colorado Springs, CO  80907
  • General Outpatient Services (Outpatient)
Preventive Medicine Clinic
Building #2059
Fort Carson, CO  80913
  • General Outpatient Services (Outpatient)
Robinson Family Medicine Clinic
Building 7490
Fort Carson, CO  80913
  • General Outpatient Services (Outpatient)
Satellite Pharmacy
1525 Wetzel Street
Ft Carson, CO  80913
  • General Outpatient Services (Outpatient)
Transition BRAC Alteration
1650 Cochrane Circle
Ft Carson, CO  80913
  • Single Specialty Group Practice (Outpatient)
Transition NCD
1650 Cochrane Circle
Ft Carson, CO  80913
  • Single Specialty Group Practice (Outpatient)
United States Army Occupational Health Clinic
Pueblo Chemical Depot
Pueblo, CO  81001
  • General Outpatient Services (Outpatient)
United States Army Occupational Health Clinic
Tooele Army Depot Bldg # 400
Tooele, UT  84074
  • General Outpatient Services (Outpatient)
United States Army Occupational Health Clinic
Dugway Proving Ground Bldg # 5116
Dugway, UT  84022
  • General Outpatient Services (Outpatient)
Warrior Family Medicine Clinic
Building 2353
Fort Carson, CO  80913
  • General Outpatient Services (Outpatient)
Warrior Recovery Center-Rehab
1836 Provide Comfort Drive, Bldg 7488
Fort Carson, CO  80913
  • General Outpatient Services (Outpatient)
Warrior Recovery Primary Care Clinic
1837 Provide Comfort Drive, Bldg 7489
Fort Carson, CO  80913
  • General Outpatient Services (Outpatient)
Warrior Transition Unit Clinic
Building 1058 O'Connell Blvd
Fort Carson, CO  80913
  • General Outpatient Services (Outpatient)
WTU Case Manager Building; Building 1059
1852 Irwin Drive
Fort Carson, CO  80913
  • General Outpatient Services (Outpatient)
WTU Social Work Building 813(moved from 1150)
1626 O'Connell Blvd
Fort Carson, CO  80913
  • General Outpatient Services (Outpatient)

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