Quality Report


Quality Report

Highland Hospital of Rochester
HCO ID: 2872
1000 South Avenue
Rochester, NY, 14620
(585) 341-8399
http://www.urmc.rochester.edu/highland.aspx
Summary of Quality Information

Accreditation Programs

View Accreditation History
Gold Seal
Hospital
Accreditation Decision
Effective Date
12/10/2022
Last Full Survey Date
12/9/2022
Last On-Site Survey Date
12/9/2022

Advanced Certification Programs

View Certification History
Gold Seal
Advanced Palliative Care
Certification Decision
Effective Date
11/3/2023
Last Full Survey Date
11/2/2023
Last On-Site Survey Date
11/2/2023
Gold Seal
Advanced Total Hip and Total Knee Replacement
Certification Decision
Effective Date
2/10/2022
Last Full Survey Date
3/13/2024
Last On-Site Survey Date
3/13/2024
Gold Seal
Perinatal Care Certification
Certification Decision
Effective Date
7/7/2022
Last Full Survey Date
4/27/2022
Last On-Site Survey Date
4/27/2022
Gold Seal
Primary Stroke Center
Certification Decision
Effective Date
8/8/2022
Last Full Survey Date
6/7/2022
Last On-Site Survey Date
6/7/2022

Core Certification Programs

Gold Seal
Hip Fracture
Certification Decision
Effective Date
3/15/2024
Last Full Survey Date
3/14/2024
Last On-Site Survey Date
3/14/2024

Sites

Avon Family Medicine
470 Collins Street
Avon, NY, 14414

Available Services

  • Outpatient Clinics (Outpatient )

Caledonia Family Medicine
3350 Brown Road
Caledonia, NY, 14423

Available Services

  • Outpatient Clinics (Outpatient )

Calkins Creek Family Medicine
200 Red Creek Drive, Suite 100
Rochester, NY, 14623

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

Culver Medical Group
913 Culver Road
Rochester, NY, 14609

Available Services

  • Outpatient Clinics (Outpatient )

Daisy Marquis Jones Radiation Oncology Center
DBA: Wilmot Cancer Institute at Greece
155 Bellwood Drive
Rochester, NY, 14626

Available Services

  • Single Specialty Practitioner (Outpatient )

East Ridge Family Medicine
999 East Ridge Road, Suite 800
Rochester, NY, 14621

Available Services

  • Outpatient Clinics (Outpatient )

Genesee Valley Family Medicine Lakeville
3509 Thomas Drive
Lakeville, NY, 14480

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

Genesee Valley Family Medicine- Geneseo
4400 Lakeville Road
Geneseo, NY, 14454

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

Genessee Valley Family Medicine - Mt. Morris
118 Main Street
Mount Morris, NY, 14510

Available Services

  • Outpatient Clinics (Outpatient )

Greece Medical Group
10 South Pointe Landing, Suite 201
Rochester, NY, 14606

Available Services

  • Outpatient Clinics (Outpatient )

Highland Breast Care Center
500 Red Creek Drive
Rochester, NY, 14623

Available Services

  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Highland Breast Imaging at Penfield
2212 Penfield Road, Suite 500
Penfield, NY, 14526

Available Services

  • Single Specialty Practitioner (Outpatient )

Highland Breast Imaging at the Anthony Jordan Health Center
82 Holland Street
Rochester, NY, 14605

Available Services

  • Single Specialty Practitioner (Outpatient )

Highland Cardiology at Red Creek
600 Red Creek Drive, Suite 100
Rochester, NY, 14623

Available Services

  • Single Specialty Practitioner (Outpatient )

Highland Diabetes HealthSource and NutritionEdge
2400 S. Clinton Avenue, Building H, Suite 135
Rochester, NY, 14618

Available Services

  • Single Specialty Practitioner (Outpatient )

Highland Family Medicine
777 - 757 South Clinton Avenue
Rochester, NY, 14620

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

Highland Hospital
1000 South Avenue
Rochester, NY, 14620

Available Services

  • Brachytherapy (Imaging/Diagnostic Services )
  • CT Scanner (Imaging/Diagnostic Services )
  • Dialysis Unit (Inpatient )
  • 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 )
  • 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 Unit (Inpatient )
  • Neurosurgery (Surgical Services )
  • Non-Sterile Medication Compounding (Inpatient )
  • Normal Newborn Nursery (Inpatient )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Ophthalmology (Surgical Services )
  • Orthopedic Surgery (Surgical Services )
  • Orthopedic/Spine Unit (Inpatient )
  • Outpatient Clinics (Outpatient )
  • Plastic Surgery (Surgical Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Radiation Oncology (Imaging/Diagnostic Services )
  • Sterile Medication Compounding (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Surgical Unit (Inpatient )
  • Teleradiology (Imaging/Diagnostic Services )
  • Thoracic Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Advanced Palliative Care
  • Advanced Total Hip and Total Knee Replacement
  • Hip Fracture
  • Perinatal Care Certification
  • Primary Stroke Center

Other Clinics/Practices Located at This Site:

  • Audiology Clinic
  • Cardiology/Vascular Clinic
  • GI Clinic
  • Highland Procedure Center
  • Pulmonary Clinic
  • Radiation Oncology
  • Surgery Clinic

Highland Medical Imaging - Penfield
2212 Penfield Road, Suite 300, Penfield, NY 14526
Penfield, NY, 14526

Available Services

  • Single Specialty Practitioner (Outpatient )

Highland Medical Imaging at Jordan
82 Holland Street
Rochester, NY, 14605

Available Services

  • Single Specialty Practitioner (Outpatient )

Highland Women's Health
990 South Avenue, Suite 103
Rochester, NY, 14620

Available Services

  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Highland Women's Health - Culver
909 Culver Road
Rochester, NY, 14606

Available Services

  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Other Clinics/Practices Located at This Site:

  • RAMP - Rochester Adolescent Maternity Program

Highland Women's Health - Perinton
800 Ayrault Road
Fairport, NY, 14450

Available Services

  • Perform Invasive Procedure (Outpatient )
  • Single Specialty Practitioner (Outpatient )

Penfield Family Medicine
2212 Penfield Road
Penfield, NY, 14526

Available Services

  • Outpatient Clinics (Outpatient )

Sands Cancer Center
DBA: Wilmot Cancer Institute at Canandaigua
395 West Street, Suite 101
Canandaigua, NY, 14424

Available Services

  • Single Specialty Practitioner (Outpatient )

Southwedge Int Med/ Geriatrics & Medicine Associates
990 South Avenue
Rochester, NY, 14620

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

URMC Audiology at Highland Hospital
990 South Avenue, Suite 207
Rochester, NY, 14620

Available Services

  • Single Specialty Practitioner (Outpatient )

Webster Family Medicine
1900 Empire Boulevard
Webster, NY, 14580

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

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.

Hospital 2022 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.