Quality Report


Quality Report

Grady Memorial Hospital Corporation
HCO ID: 3506
80 Jesse Hill, Jr., Drive, S.E.
Atlanta, GA, 30303
(404) 616-4252
www.gradyhealth.org
Summary of Quality Information

Accreditation Programs

View Accreditation History
Gold Seal
Behavioral Health Care and Human Services
Accreditation Decision
Effective Date
5/11/2022
Last Full Survey Date
5/10/2022
Last On-Site Survey Date
5/10/2022
Gold Seal
Hospital
Accreditation Decision
Effective Date
12/20/2023
Last Full Survey Date
5/13/2022
Last On-Site Survey Date
12/19/2023

Advanced Certification Programs

View Certification History
Gold Seal
Advanced Comprehensive Stroke Center
Certification Decision
Effective Date
3/24/2022
Last Full Survey Date
3/23/2022
Last On-Site Survey Date
3/23/2022

Sites

Adult Outpatient Behavioral Health
10 Park Place South, SE
Atlanta, GA, 30303

Available Services

  • Assertive Community Treatment/Community Support Services (Non 24 Hour Care - Adult )
  • Behavioral Health (Day Programs - Adult )
  • Behavioral Health (Non 24 Hour Care - Adult )
  • Behavioral Health (Partial Hospitalization - Adult )
  • Chemical Dependency (Non 24 Hour Care - Adult )
  • Chemical Dependency (Non-detox - Adult )
  • Community Integration (Non 24 Hour Care )
  • Peer Support (Non 24 Hour Care )

Asa G. Yancey Health Center
1247 Donald Lee Hollowell Pkwy. NW
Atlanta, GA, 30318

Available Services

  • Outpatient Clinics (Outpatient )

Brookhaven Health Center
2695 Buford Highway, N.E., Suite 200
Atlanta, GA, 30324

Available Services

  • Outpatient Clinics (Outpatient )

Children's Healthcare of Atlanta Hughes Spalding Hospital
35 Jesse Hill Dr.
Atlanta, GA, 30303

Available Services

  • Allergen Extract (Inpatient )
  • CT Scanner (Imaging/Diagnostic Services )
  • Inpatient Unit (Inpatient )
  • Non-Sterile Medication Compounding (Inpatient )
  • Outpatient Clinics (Outpatient )
  • Pediatric Unit (Inpatient )
  • Sterile Medication Compounding (Inpatient )
  • Ultrasound (Imaging/Diagnostic Services )

Correll Pavilion
80 Gilmer ST S.E.
Atlanta, GA, 30303

Available Services

  • Administration of Blood Product (Outpatient )
  • Administration of High Risk Medications (Outpatient )
  • Ambulatory Surgery Center (Outpatient )
  • Anesthesia (Outpatient )
  • Hazardous Medication Compounding (Outpatient )
  • High Risk Sterile Medication Compounding (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Other Clinics/Practices Located at This Site:

  • Cancer Center
  • ENT
  • GEN SURGERY
  • GI
  • Imaging
  • INFUSION CENTER
  • Infusion Pharmacy
  • OP LAB
  • OPTHALMOLOGY
  • OR satellite
  • oral surgery
  • ORTHOPEDIC
  • Outpatient Surgery
  • PACU
  • PAT
  • Pre-Op/ Post-Op / PACU
  • Rehab

East Point Health Center
1595 West Cleveland Avenue
East Point, GA, 30344

Available Services

  • Outpatient Clinics (Outpatient )

Edward C. Loughlin Radiation - Oncology Center
145 Edgewood Avenue, S.E.
Atlanta, GA, 30303

Available Services

  • Outpatient Clinics (Outpatient )

Grady Memorial Hospital
80 Jesse Hill Jr. Drive S.E.
Atlanta, GA, 30303

Available Services

  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult )
  • Brachytherapy (Imaging/Diagnostic Services )
  • Burn Unit (Inpatient )
  • Cardiac Catheterization Lab (Surgical Services )
  • Cardiac Surgery (Surgical Services )
  • Cardiothoracic Surgery (Surgical Services )
  • Cardiovascular 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 )
  • 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 )
  • Ophthalmology (Surgical 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 )
  • Sleep Laboratory (Sleep Laboratory )
  • Sterile Medication Compounding (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Surgical Unit (Inpatient )
  • Thoracic Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Advanced Comprehensive Stroke Center

Verification Programs

  • Maternal Levels of Care - Level 4

Grady Walk-In Center
56 Jesse Hill Jr. Drive
Atlanta, GA, 30303

Available Services

  • Outpatient Clinics (Outpatient )

Kirkwood Family Medicine
1863 Memorial Dr. SE
Atlanta, GA, 30317

Available Services

  • Outpatient Clinics (Outpatient )

North Fulton Health Center
7741 Roswell Road
Sandy Springs, GA, 30350

Available Services

  • Outpatient Clinics (Outpatient )

Ponce de Leon Center
341 Ponce de Leon Avenue
Atlanta, GA, 30308

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Outpatient Clinics (Outpatient )

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.

Behavioral Health Care and Human Services 2022 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Hospital 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.