Quality Report


Quality Report

Decatur Memorial Hospital
HCO ID: 4632
2300 North Edward Street
Decatur, IL, 62526
(217) 876-2106
www.memorial.health
Summary of Quality Information

Accreditation Programs

View Accreditation History
Gold Seal
Hospital
Accreditation Decision
Effective Date
3/12/2022
Last Full Survey Date
3/11/2022
Last On-Site Survey Date
5/9/2022

Advanced Certification Programs

View Certification History
Gold Seal
Primary Stroke Center
Certification Decision
Effective Date
7/27/2022
Last Full Survey Date
7/26/2022
Last On-Site Survey Date
7/26/2022

Sites

Decatur Memorial Hospital
DBA: Forsyth Imaging Center
389 W Weaver Rd
Forsyth, IL, 62535

Available Services

  • Outpatient Clinics (Outpatient )

Decatur Memorial Hospital
DBA: West Hay Medical Center
302 W Hay St
Decatur, IL, 62526

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Other Clinics/Practices Located at This Site:

  • DMH Breast Center - Suite 117A
  • Memorial Specialty Care Pulmonology

Decatur Memorial Hospital
441 W Hay St
Decatur, IL, 62526

Available Services

  • Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

  • Memorial Care on West Hay

Decatur Memorial Hospital
DBA: Memorial Care in Sullivan
1220 W Jackson St
Sullivan, IL, 61951

Available Services

  • Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

  • Physical Therapy at Sullivan

Decatur Memorial Hospital
DBA: Physician Plaza East
1 Memorial Dr
Decatur, IL, 62526

Available Services

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

Other Clinics/Practices Located at This Site:

  • Bailey and Gilman's Office - Suite 300
  • Memorial Specialty Care General Surgery
  • Memorial Specialty Care Plastic Surgery

Decatur Memorial Hospital
DBA: Memorial Specialty Care Nephrology
301 West Hay
Decatur, IL, 62526

Available Services

  • Single Specialty Practitioner (Outpatient )

Decatur Memorial Hospital
DBA: West Hay Medical Center
304 W Hay St
Decatur, IL, 62526

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Anesthesia (Outpatient )
  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Other Clinics/Practices Located at This Site:

  • Dectur Memorial Hospital (DMH Surgery Center) - Suite 114
  • Memorial Pain Center
  • Memorial Specialty Care Infectious Disease
  • Memorial Specialty Care Orthopedics

Decatur Memorial Hospital
DBA: Memorial Imaging Center in Mt. Zion
1724 N. State Route 121
Mt Zion, IL, 62549

Available Services

  • Single Specialty Practitioner (Outpatient )

Decatur Memorial Hospital
DBA: DMH Physical Therapy
1830 S 44th St
Decatur, IL, 62521

Available Services

  • Outpatient Clinics (Outpatient )

Decatur Memorial Hospital
DBA: Physician Plaza West
2 Memorial Dr
Decatur, IL, 62526

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Anesthesia (Outpatient )
  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Other Clinics/Practices Located at This Site:

  • Decatur Neurosurgery Associates - Suite 207
  • Dectur Memorial Hospital (Endoscopy Center) - Suite 102
  • Memorial Specialty Care Gastroenterology

Decatur Memorial Hospital
DBA: Cancer Care Center of Decatur
210 W McKinley Ave
Decatur, IL, 62526

Available Services

  • Outpatient Clinics (Outpatient )

Decatur Memorial Hospital
DBA: Memorial Specialty Care ENT & Allergy
101 W McKinley Ave
Decatur, IL, 62526

Available Services

  • Single Specialty Practitioner (Outpatient )

Decatur Memorial Hospital
2300 N Edward St
Decatur, IL, 62526

Available Services

  • Brachytherapy (Imaging/Diagnostic Services )
  • Cardiac Catheterization Lab (Surgical Services )
  • Cardiovascular Unit (Inpatient )
  • 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 )
  • 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 )
  • Normal Newborn Nursery (Inpatient )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Nuclear Pharmacy (Inpatient )
  • Ophthalmology (Surgical Services )
  • Orthopedic Surgery (Surgical Services )
  • Orthopedic/Spine Unit (Inpatient )
  • Outpatient Clinics (Outpatient )
  • Pediatric Unit (Inpatient )
  • 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 Unit (Inpatient )
  • Teleradiology (Imaging/Diagnostic Services )
  • Thoracic Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Primary Stroke Center

Other Clinics/Practices Located at This Site:

  • Illinois Heart Specialists - Suite 2400

Decatur Memorial Hospital
DBA: Memorial Care in Forsyth
241 W Weaver Rd
Forsyth, IL, 62535

Available Services

  • Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

  • Decatur Internal Medicine
  • DMG Internal Medicine
  • Forsyth Medical Center - Suite 145A
  • Forsyth Medical Center - Suite 145B
  • Forsyth Medical Center - Suite 145C
  • Forsyth Medical Center - Suite 145D
  • Forsyth Physical Therapy

Decatur Memorial Hospital
DBA: Memorial Care on East Maryland
4775 E Maryland St
Decatur, IL, 62521

Available Services

  • Outpatient Clinics (Outpatient )

Decatur Memorial Hospital
DBA: Sports Medicine & Physical Therapy
2122 N 27th Street
Decatur, IL, 62526

Available Services

  • 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.

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.