Quality Report


Quality Report

Chippenham and Johnston-Willis Hospital
HCO ID: 124600
7101 Jahnke Road
Richmond, VA, 23225
(804) 483-0000
www.cjwmedical.com
Summary of Quality Information

Accreditation Programs

View Accreditation History
Gold Seal
Behavioral Health Care and Human Services
Accreditation Decision
Effective Date
11/28/2023
Last Full Survey Date
11/27/2023
Last On-Site Survey Date
11/27/2023
Gold Seal
Hospital
Accreditation Decision
Effective Date
12/2/2023
Last Full Survey Date
12/1/2023
Last On-Site Survey Date
1/4/2024
Gold Seal
Laboratory
Accreditation Decision
Effective Date
6/9/2023
Last Full Survey Date
6/8/2023
Last On-Site Survey Date
6/8/2023

Advanced Certification Programs

View Certification History
Gold Seal
Advanced Total Hip and Total Knee Replacement
Certification Decision
Effective Date
5/26/2023
Last Full Survey Date
5/25/2023
Last On-Site Survey Date
5/25/2023

Core Certification Programs

Gold Seal
Brain Tumor
Certification Decision
Effective Date
2/15/2023
Last Full Survey Date
2/14/2023
Last On-Site Survey Date
2/14/2023
Gold Seal
Joint Replacement - Hip
Certification Decision
Effective Date
3/4/2023
Last Full Survey Date
3/3/2023
Last On-Site Survey Date
3/3/2023
Gold Seal
Joint Replacement - Knee
Certification Decision
Effective Date
3/4/2023
Last Full Survey Date
3/3/2023
Last On-Site Survey Date
3/3/2023
Gold Seal
Stroke Rehabilitation
Certification Decision
Effective Date
12/24/2022
Last Full Survey Date
12/23/2022
Last On-Site Survey Date
12/23/2022

Sites

Chippenham Hospital - A Campus of CJW Medical Center
7101 Jahnke Road
Richmond, VA, 23225

Available Services

  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult )
  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Child/Youth )
  • Burn Unit (Inpatient )
  • Cardiac Catheterization Lab (Surgical Services )
  • Cardiac Surgery (Surgical Services )
  • Cardiothoracic Surgery (Surgical Services )
  • Cardiovascular Unit (Inpatient )
  • Chemical Dependency (24-hour Acute Care/Crisis Stabilization - Adult )
  • Chemical Dependency (Detox/Non-detox - Adult )
  • Community Integration (Non 24 Hour Care )
  • Coronary Care Unit (Inpatient )
  • CT Scanner (Imaging/Diagnostic Services )
  • Ear/Nose/Throat Surgery (Surgical Services )
  • EEG/EKG/EMG Lab (Imaging/Diagnostic Services )
  • Family Support (Non 24 Hour Care )
  • Gastroenterology (Surgical Services )
  • General Laboratory Tests
  • GI or Endoscopy Lab (Imaging/Diagnostic Services )
  • Gynecological Surgery (Surgical Services )
  • Gynecology (Inpatient )
  • Hazardous Medication Compounding (Inpatient )
  • Inpatient Unit (Inpatient )
  • Interventional Radiology (Imaging/Diagnostic Services )
  • Labor & Delivery (Inpatient )
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services )
  • Medical /Surgical Unit (Inpatient )
  • Medical ICU (Intensive Care Unit )
  • Neurosurgery (Surgical Services )
  • Non-Sterile Medication Compounding (Inpatient )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Ophthalmology (Surgical Services )
  • Orthopedic Surgery (Surgical Services )
  • Orthopedic/Spine Unit (Inpatient )
  • Outpatient Clinics (Outpatient )
  • Pediatric Unit (Inpatient )
  • Peer Support (Non 24 Hour Care )
  • Plastic Surgery (Surgical Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Sterile Medication Compounding (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Surgical Unit (Inpatient )
  • Teleradiology (Imaging/Diagnostic Services )
  • Thoracic Surgery (Surgical Services )
  • Toxicology
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Advanced Total Hip and Total Knee Replacement

Other Clinics/Practices Located at This Site:

  • Wound Clinic and Hydrotherapy

CHIPPENHAM MEDICAL CENTER RESPIRATORY CARE
7101 JAHNKE ROAD
Richmond, VA, 23225

Available Services

  • General Laboratory Tests
  • Toxicology

CJW MEDICAL CENTER CHIPPENHAM CAMPUS MAIN LABORATORY
7101 JAHNKE ROAD
Richmond, VA, 23225

Available Services

  • General Laboratory Tests
  • Toxicology

CJW MEDICAL CENTER JOHNSTON WILLIS MAIN LABORATORY
1401 JOHNSTON-WILLIS DRIVE
Richmond, VA, 23235

Available Services

  • General Laboratory Tests
  • Toxicology

CJW MEDICAL CENTER- JOHNSTON WILLIS RES PULMONARY LAB
1401 Johnston-Willis Drive
Richmond, VA, 23235

Available Services

  • General Laboratory Tests
  • Toxicology

Comprehensive Outpatient Therapies
1011 Johnston-Willis Drive, Suite 250
Richmond, VA, 23235

Available Services

  • Single Specialty Practitioner (Outpatient )

HCA VA Sports Medicine
1115 Boulders Parkway Suite 110
Richmond, VA, 23225

Available Services

  • Outpatient Clinics (Outpatient )

Johnston Willis Advanced Imaging Center
1011 Johnston Willis Drive
Richmond, VA, 23235

Available Services

  • Administration of High Risk Medications (Outpatient )
  • General Laboratory Tests
  • Single Specialty Practitioner (Outpatient )

Johnston Willis Hospital - A Campus of CJW Medical Center
1401 Johnston-Willis Drive
Richmond, VA, 23235

Available Services

  • Brachytherapy (Imaging/Diagnostic Services )
  • CT Scanner (Imaging/Diagnostic Services )
  • Ear/Nose/Throat Surgery (Surgical Services )
  • EEG/EKG/EMG Lab (Imaging/Diagnostic Services )
  • Gastroenterology (Surgical Services )
  • General Laboratory Tests
  • GI or Endoscopy Lab (Imaging/Diagnostic Services )
  • Gynecological Surgery (Surgical Services )
  • Gynecology (Inpatient )
  • Hazardous Medication Compounding (Inpatient )
  • Hematology/Oncology Unit (Inpatient )
  • Inpatient Unit (Inpatient )
  • Interventional Radiology (Imaging/Diagnostic Services )
  • Labor & Delivery (Inpatient )
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services )
  • Medical /Surgical Unit (Inpatient )
  • Medical ICU (Intensive Care Unit )
  • Neuro/Spine ICU (Intensive Care Unit )
  • Neuro/Spine Unit (Inpatient )
  • Neurosurgery (Surgical Services )
  • Non-Sterile Medication Compounding (Inpatient )
  • Normal Newborn Nursery (Inpatient )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Orthopedic Surgery (Surgical Services )
  • Orthopedic/Spine Unit (Inpatient )
  • Outpatient Clinics (Outpatient )
  • Plastic Surgery (Surgical Services )
  • Positron Emission Tomography (PET) (Imaging/Diagnostic Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Radiation Oncology (Imaging/Diagnostic Services )
  • Rehabilitation Unit (Inpatient )
  • Rehabilitation Unit (24-hour Acute Care/Crisis Stabilization )
  • Sterile Medication Compounding (Inpatient )
  • Surgical Unit (Inpatient )
  • Teleradiology (Imaging/Diagnostic Services )
  • Toxicology
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Brain Tumor
  • Joint Replacement - Hip
  • Joint Replacement - Knee
  • Stroke Rehabilitation

Other Clinics/Practices Located at This Site:

  • Gamma Knife
  • Infusion Center
  • Physical Medicine and Rehabilitation Clinic
  • Radiation Oncology
  • The Perinatal Centers

Johnston-Willis Hospital Perinatal Center
1011 Johnston Willis Dr. Suite 100
Richmond, VA, 23235

Available Services

  • Outpatient Clinics (Outpatient )

Swift Creek Emergency Room
DBA: Chippenham Swift Creek Emergency Room
14720 Hancock Village St
Chesterfield, VA, 23832

Available Services

  • Administration of Blood Product (Outpatient )
  • Administration of High Risk Medications (Outpatient )
  • Anesthesia (Outpatient )
  • General Laboratory Tests
  • Perform Invasive Procedure (Outpatient )

Tucker Wellness&Recovery Center a Dept of CJW Medical Center
500 Hioaks Rd Suite A
Richmond, VA, 23225

Available Services

  • Behavioral Health (Day Programs - Adult )
  • Behavioral Health (Day Programs - Child/Youth )
  • Behavioral Health (Partial Hospitalization - Adult )
  • Behavioral Health (Partial Hospitalization - Child/Youth )
  • Community Integration (Non 24 Hour Care )
  • Family Support (Non 24 Hour Care )
  • Peer Support (Non 24 Hour Care )

Cooperative Agreements

Hospital - Accredited by American College of Surgeons-Commission on Cancer (ACoS-COC)

National Patient Safety Goals and National Quality Improvement Goals

Symbol Key

  • starThis organization achieved the best possible results
  • plusThis organization's performance is better than the target range/value
  • checkThis organization's performance is similar to the target range/value
  • minusThis organization's performance is worse than the target range /value
  • naThis measure is not applicable for this organization
  • ndNot displayed

Measures 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.
  12. The measure rate is within optimal range.

Symbol Key

  • starThis organization achieved the best possible results
  • plusThis organization's performance is better than the target range/value
  • checkThis organization's performance is similar to the target range/value
  • minusThis organization's performance is worse than the target range/value
  • naThis measure is not applicable for this organization
  • ndNot displayed

Measures 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.
  12. The measure rate is within optimal range.

* This information can also be viewed at Hospital Compare.

**      Indicates per 1000 hours of patient care.
***   The measure was not in effect for this quarter.
----   Null value or data not displayed.

Disease-Specific Care Certification 2009 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Hospital 2023 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Behavioral Health Care and Human Services 2023 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Laboratory 2023 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Reporting Period: January 2022 - December 2022
Perinatal Care National Comparison: nd 2 Statewide Comparison: nd 2

New Changes to Quarterly Measure

Download Quarterly Measure Results

* State results are not calculated for the National Patient Safety Goals.