Quality Report


Quality Report

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

Accreditation Programs

Gold Seal
Home Care
Accreditation Decision
Effective Date
11/17/2018
Last Full Survey Date
11/16/2018
Last On-Site Survey Date
12/19/2018
Gold Seal
Hospital
Accreditation Decision
Effective Date
11/17/2018
Last Full Survey Date
11/16/2018
Last On-Site Survey Date
12/28/2018

Advanced Certification Programs

Gold Seal
Certification Decision
Effective Date
11/10/2018
Last Full Survey Date
11/9/2018
Last On-Site Survey Date
11/9/2018
Gold Seal
Certification Decision
Effective Date
9/11/2018
Last Full Survey Date
9/10/2018
Last On-Site Survey Date
9/10/2018

Core Certification Programs

Gold Seal
Certification Decision
Effective Date
11/9/2018
Last Full Survey Date
11/8/2018
Last On-Site Survey Date
11/8/2018

Sites

Decatur Memorial Hospital
DBA: Arthur Medical Center
650 W. Columbia,
Arthur, IL, 61911

Available Services

  • Single Specialty Practitioner (Outpatient )

Decatur Memorial Hospital
DBA: DMH Medical Equipment Company
2875 N Water St
Decatur, IL, 62526

Available Services

  • Blood Glucose Monitors (non-mail order)
  • Breast Prostheses and Accessories
  • Canes and Crutches
  • Clinical Respiratory
  • Commodes
  • Continuous Passive Motion (CPM) Device
  • Continuous Positive Airway Pressure
  • Custom Orthoses Fabricated
  • Durable Medical Equipment
  • Enteral Equipment and/or Supplies
  • Enteral Nutrients
  • Hospital Beds - Electric
  • Off The Shelf Orthoses
  • Ostomy Supplies
  • Oxygen
  • Patient Lifts and Accessories
  • Penile Pumps
  • Prosthetics (Home Medical Equipment)
  • Respiratory Assist Devices
  • Respiratory Equipment
  • Seat Lift Mechanisms
  • Suction Pump
  • Supplies
  • Support Surfaces for Beds (New)
  • Support Surfaces for Beds (Used)
  • Surgical Dressings
  • Tracheostomy Supplies
  • Traction Equipment
  • Ultaviolet Light Devices
  • Urological Supplies
  • Ventilators All Types
  • Voice Prostheses
  • Walkers, Canes and Crutches
  • Wheelchairs - Manual Non-Custom
  • Wheelchairs-Standard Manual Related Accessories and Repairs

Decatur Memorial Hospital
DBA: DMH Shelbyville Medical Clinic
415 North Cedar
Shelbyville, IL, 62565

Available Services

  • Single Specialty Practitioner (Outpatient )

Decatur Memorial Hospital
DBA: Forsyth Imaging Center
389 West Weaver Road
Forsyth, IL, 62535

Available Services

  • Outpatient Clinics (Outpatient )

Decatur Memorial Hospital
DBA: Rock Springs Medical Center
330 N. Wyckles Road
Decatur, IL, 62522

Available Services

  • Single Specialty Practitioner (Outpatient )

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

Available Services

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

Other Clinics/Practices Located at This Site:

  • Bailey and Gilman
  • DMH Lung Center
  • George Liu MD Surgery
  • Urology Associates of Decatur
  • West Hay Family Medicine
  • Women's Health and Breast Center

Decatur Memorial Hospital
DBA: DMH Outpatient Senior Behvaioral Health
441 West Hay Street
Decatur, IL, 62526

Available Services

  • Behavioral Health (Day Programs - Adult )
  • Behavioral Health (Partial - Adult )
  • Peer Support (Non 24 Hour Care )

Decatur Memorial Hospital
DBA: South Shores Medical Center
550 Southland Drive
Decatur, IL, 62521

Available Services

  • Single Specialty Practitioner (Outpatient )

Decatur Memorial Hospital
DBA: Sullivan Medical Center
1220 West Jackson Street
Sullivan, IL, 61951

Available Services

  • Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

  • Physical Therapy at Sullivan
  • Sullivan Medical Center

Decatur Memorial Hospital
DBA: Physician Plaza East
1 Memorial Drive
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:

  • DMH Vein and Vascular Institute
  • Jordan Youngerman M.D.

Decatur Memorial Hospital
DBA: DMH Corporate Health Services
2120 North 27th Street
Decatur, IL, 62526

Available Services

  • Outpatient Clinics (Outpatient )

Decatur Memorial Hospital
DBA: DMH Home Health Services
2870 N Main St
Decatur, IL, 62526

Available Services

  • Home Health Aides
  • Home Health, Non-Hospice Services
  • Hospice Care
  • Medical Social Services
  • Occupational Therapy
  • Physical Therapy
  • Skilled Nursing Services
  • Speech Language Pathology

Other Clinics/Practices Located at This Site:

  • DMH Home Health Services-Hospice

Decatur Memorial Hospital
DBA: West Hay Medical Center
304 West Hay Street
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:

  • Center for Advanced Surgery
  • DMH Millennium Pain Center
  • Infectious Disease Specialists of Central Illniois
  • Internal Medicine Associates of Decatur

Decatur Memorial Hospital
DBA: Center for Advanced Surgery
304 W Hay Street Suite 313
Decatur, IL, 62526

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Ambulatory Surgery Center (Outpatient )
  • Anesthesia (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Decatur Memorial Hospital
DBA: Express Care East
4455 U.S. Route 36
Decatur, IL, 62521

Available Services

  • Single Specialty Practitioner (Outpatient )

Decatur Memorial Hospital
DBA: Physical Therapy at East Gate
1830 South 44th Street
Decatur, IL, 62521

Available Services

  • Outpatient Clinics (Outpatient )

Decatur Memorial Hospital
DBA: Millikin Clinic
150 South Fairview Ave.
Decatur, IL, 62522

Available Services

  • Single Specialty Practitioner (Outpatient )

Decatur Memorial Hospital
DBA: Physician Plaza West
2 Memorial Drive
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
  • DMG Gastroenterology
  • DMH Digestive Disease Center
  • DMH Podiatry

Decatur Memorial Hospital
DBA: DMH Monticello Medical Center
777 W. Bridge Street
Monticello, IL, 61856

Available Services

  • Single Specialty Practitioner (Outpatient )

Decatur Memorial Hospital
DBA: South Shores Imaging Center
1689 South Franklin
Decatur, IL, 62521

Available Services

  • Single Specialty Practitioner (Outpatient )

Decatur Memorial Hospital
DBA: Cancer Care Institute
210 West McKinley
Decatur, IL, 62526

Available Services

  • Outpatient Clinics (Outpatient )

Decatur Memorial Hospital
DBA: Decatur Internal Medicine
2975 N Water St
Decatur, IL, 62526

Available Services

  • Outpatient Clinics (Outpatient )

Decatur Memorial Hospital
DBA: ENTA Allergy, Head and Neck Institute
101 West McKinley Ave
Decatur, IL, 62526

Available Services

  • Single Specialty Practitioner (Outpatient )

Decatur Memorial Hospital
DBA: Express Care North
3131 N. Water Street
Decatur, IL, 62526

Available Services

  • Single Specialty Practitioner (Outpatient )

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

Available Services

  • Outpatient Clinics (Outpatient )

Decatur Memorial Hospital
2300 North Edward Street
Decatur, IL, 62526

Available Services

  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult )
  • Brachytherapy (Imaging/Diagnostic Services )
  • Cardiac Catheterization Lab (Surgical Services )
  • Cardiac Surgery (Surgical Services )
  • Cardiothoracic Surgery (Surgical Services )
  • 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 )
  • 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 )
  • 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

  • Chronic Obstructive Pulmonary Disease
  • Chronic Obstructive Pulmonary Disease
  • Primary Stroke Center

Other Clinics/Practices Located at This Site:

  • Illinois Heart Specialists

Decatur Memorial Hospital
DBA: Gowdar and Gowdar Family Practice
741 Pershing Road
Decatur, IL, 62526

Available Services

  • Single Specialty Practitioner (Outpatient )

Decatur Memorial Hospital
DBA: Forsyth Medical Center
241 West Weaver Road
Forsyth, IL, 62535

Available Services

  • Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

  • Forsyth Family Medicine
  • Kidney Specialists of Central Illinois
  • PT at Forsyth Medical Center
  • Quershi Family Practice
  • Scribner Family Practice
  • Senior Life Encrichment Center
  • Wall Family Practice

Decatur Memorial Hospital
DBA: DMH Family Medicine
4775 E. Maryland Street
Decatur, IL, 62521

Available Services

  • Single Specialty Practitioner (Outpatient )

Cooperative Agreements

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 2016 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Home Care 2018 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Reporting Period: January 2018 - December 2018
Emergency Department National Comparison: nd 2 Statewide Comparison: nd 2
Hospital-Based Inpatient Psychiatric Services National Comparison: nd 2 Statewide Comparison: nd 2
Immunization National Comparison: nd 2 Statewide Comparison: nd 2
Perinatal Care 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.