Quality Report


Quality Report

Phoenix VA Health Care System
HCO ID: 2508
650 East Indian School Road
Phoenix, AZ, 85012-1892
(602) 277-5551
www.phoenix.med.va.gov
Summary of Quality Information

Accreditation Programs

Gold Seal
Behavioral Health Care and Human Services
Accreditation Decision
Effective Date
4/17/2021
Last Full Survey Date
4/16/2021
Last On-Site Survey Date
4/16/2021
Gold Seal
Home Care
Accreditation Decision
Effective Date
4/17/2021
Last Full Survey Date
4/16/2021
Last On-Site Survey Date
4/16/2021
Gold Seal
Hospital
Accreditation Decision
Effective Date
4/17/2021
Last Full Survey Date
4/16/2021
Last On-Site Survey Date
4/16/2021

Sites

Carl T. Hayden VA Medical Center
650 East Indian School Road
Phoenix, AZ, 85012-1892

Available Services

  • Behavioral Health (Day Programs - Adult )
  • Behavioral Health (Non 24 Hour Care - Adult )
  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult )
  • Behavioral Health (Partial Hospitalization - Adult )
  • Cardiac Catheterization Lab (Surgical Services )
  • Chemical Dependency (Non 24 Hour Care - Adult )
  • Chemical Dependency (24-hour Acute Care/Crisis Stabilization - Adult )
  • Chemical Dependency (Residential Care - Adult )
  • Chemical Dependency (Non-detox - Adult )
  • Community Integration (Non 24 Hour Care )
  • Coronary Care Unit (Inpatient )
  • CT Scanner (Imaging/Diagnostic Services )
  • Dialysis Unit (Inpatient )
  • Ear/Nose/Throat Surgery (Surgical Services )
  • Eating Disorders
  • Eating Disorders
  • Eating Disorders (Outpatient )
  • Eating Disorders (Outpatient - Adult )
  • Eating Disorders (Non 24 Hour Care - Adult )
  • EEG/EKG/EMG Lab (Imaging/Diagnostic Services )
  • Employment Services (Non 24 Hour Care )
  • Family Support (Non 24 Hour Care )
  • Gastroenterology (Surgical Services )
  • GI or Endoscopy Lab (Imaging/Diagnostic Services )
  • Gynecological Surgery (Surgical Services )
  • Hazardous Medication Compounding (Inpatient )
  • Hematology/Oncology Unit (Inpatient )
  • Home Health, Non-Hospice Services
  • In-Home Behavioral Health Services (Non 24 Hour Care - Adult )
  • Inpatient Unit (Inpatient )
  • Interventional Radiology (Inpatient )
  • Interventional Radiology (Outpatient )
  • Interventional Radiology (Imaging/Diagnostic Services )
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services )
  • Medical /Surgical Unit (Inpatient )
  • Medical ICU (Intensive Care Unit )
  • Medical Social Services
  • Non-Sterile Medication Compounding (Inpatient )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Occupational Therapy
  • Orthopedic Surgery (Surgical Services )
  • Orthopedic/Spine Unit (Inpatient )
  • Outpatient Clinics (Outpatient )
  • Peer Support (Non 24 Hour Care )
  • Pharmacy/Dispensary,General Services
  • Physical Therapy
  • Plastic Surgery (Surgical Services )
  • Positron Emission Tomography (PET) (Imaging/Diagnostic Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Respite Care
  • Respite Care (Residential / Group Homes )
  • Skilled Nursing Services
  • Sleep Laboratory
  • Sleep Laboratory (Sleep Laboratory )
  • Sterile Medication Compounding (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Surgical Unit (Inpatient )
  • Technology-Based Behavioral Health Srvs (Non 24 Hour Care - Adult )
  • Telehealth
  • Thoracic Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )
  • Vocational Rehabilitation (Non 24 Hour Care - Adult )
  • Wound Care

Community Resource & Referral Center
1500 East Thomas Road, Suite 106
Phoenix, AZ, 85014

Available Services

  • Behavioral Health (Non 24 Hour Care - Adult )
  • Community Integration (Non 24 Hour Care )
  • Employment Services (Non 24 Hour Care )
  • Family Support (Non 24 Hour Care )
  • Outpatient Clinics (Outpatient )
  • Peer Support (Non 24 Hour Care )

Other Clinics/Practices Located at This Site:

  • Lab draw section

Globe VA Health Care Clinic
5860 South Hospital Drive, Suite 111
Globe, AZ, 85501-9449

Available Services

  • Behavioral Health (Non 24 Hour Care - Adult )
  • Outpatient Clinics (Outpatient )
  • Peer Support (Non 24 Hour Care )
  • Technology-Based Behavioral Health Srvs (Non 24 Hour Care - Adult )

Other Clinics/Practices Located at This Site:

  • Lab draw section

Midtown VA Clinic
5040 North 15th Avenue
Phoenix, AZ, 85015

Available Services

  • Behavioral Health (Non 24 Hour Care - Adult )
  • Outpatient Clinics (Outpatient )
  • Technology-Based Behavioral Health Srvs (Non 24 Hour Care - Adult )

Other Clinics/Practices Located at This Site:

  • Lab draw section

Northeast VA Health Care Clinic
11390 E. Via Linda Rd.
Scottsdale, AZ, 85259

Available Services

  • Behavioral Health (Non 24 Hour Care - Adult )
  • Outpatient Clinics (Outpatient )
  • Technology-Based Behavioral Health Srvs (Non 24 Hour Care - Adult )

Other Clinics/Practices Located at This Site:

  • Lab draw section

Northwest VA Health Care Clinic
13985 W. Grand Ave., Suite 101
Surprise, AZ, 85374

Available Services

  • Behavioral Health (Non 24 Hour Care - Adult )
  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )
  • Technology-Based Behavioral Health Srvs (Non 24 Hour Care - Adult )

Other Clinics/Practices Located at This Site:

  • Lab draw section

Payson VA Health Care Clinic
903 East Highway 260
Payson, AZ, 85541

Available Services

  • Behavioral Health (Non 24 Hour Care - Adult )
  • Technology-Based Behavioral Health Srvs (Non 24 Hour Care - Adult )

Other Clinics/Practices Located at This Site:

  • Lab draw section

Show Low VA Health Care Clinic
5171 Cub Lake Road, Suite C380
Show Low, AZ, 85901

Available Services

  • Behavioral Health (Non 24 Hour Care - Adult )
  • Home Health, Non-Hospice Services
  • Medical Social Services
  • Outpatient Clinics (Outpatient )
  • Physical Therapy
  • Skilled Nursing Services
  • Technology-Based Behavioral Health Srvs (Non 24 Hour Care - Adult )

Other Clinics/Practices Located at This Site:

  • Lab draw section

Southeast VA Health Care Clinic
3285 S. Val Vista Drive
Gilbert, AZ, 85295

Available Services

  • Behavioral Health (Non 24 Hour Care - Adult )
  • Chemical Dependency (Non 24 Hour Care - Adult )
  • Chemical Dependency (Non-detox - Adult )
  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )
  • Technology-Based Behavioral Health Srvs (Non 24 Hour Care - Adult )

Other Clinics/Practices Located at This Site:

  • Lab draw section

Southwest Community-Based Outpatient Clinic
9250 West Thomas Road
Phoenix, AZ, 85037

Available Services

  • Behavioral Health (Non 24 Hour Care - Adult )
  • Outpatient Clinics (Outpatient )
  • Technology-Based Behavioral Health Srvs (Non 24 Hour Care - Adult )

Other Clinics/Practices Located at This Site:

  • Lab draw section

Thunderbird VA Health Care Clinic
9424 N. 25th Avenue
Phoenix, AZ, 85021

Available Services

  • Behavioral Health (Non 24 Hour Care - Adult )
  • Outpatient Clinics (Outpatient )
  • Technology-Based Behavioral Health Srvs (Non 24 Hour Care - Adult )

Other Clinics/Practices Located at This Site:

  • Lab draw section

National Patient Safety Goals and National Quality Improvement Goals

Symbol Key

  • starThis organization achieved the best possible results
  • plusThis organization's performance is above the target range/value
  • checkThis organization's performance is similar to the target range/value
  • minusThis organization's performance is below 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.

Symbol Key

  • starThis organization achieved the best possible results
  • plusThis organization's performance is above the target range/value
  • checkThis organization's performance is similar to the target range/value
  • minusThis organization's performance is below 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.

The Joint Commission only reports measures endorsed by the National Quality Forum.
* 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.

Hospital 2021 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Behavioral Health Care and Human Services 2021 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Home Care 2021 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Reporting Period: January 2019 - December 2019
Emergency Department National Comparison: nd 2 Statewide Comparison: nd 2
Immunization National Comparison: nd 2 Statewide Comparison: nd 2

New Changes to Quarterly Measure

Download Quarterly Measure Results

The Joint Commission only reports measures endorsed by the National Quality Forum.
* State results are not calculated for the National Patient Safety Goals.