Quality Report


Quality Report

Main Line Hospitals, Inc.

DBA: Bryn Mawr Hospital
HCO ID: 6030
130 South Bryn Mawr Avenue
Bryn Mawr, PA, 19010
(484) 337-3000
www.mainlinehealth.org
Summary of Quality Information

Accreditation Programs

Gold Seal
Behavioral Health Care and Human Services
Accreditation Decision
Effective Date
8/17/2022
Last Full Survey Date
8/16/2022
Last On-Site Survey Date
8/16/2022
Gold Seal
Hospital
Accreditation Decision
Effective Date
8/20/2022
Last Full Survey Date
8/19/2022
Last On-Site Survey Date
10/4/2022

Advanced Certification Programs

Gold Seal
Certification Decision
Effective Date
11/3/2022
Last Full Survey Date
11/2/2022
Last On-Site Survey Date
11/2/2022

Sites

Main Line Hospitals, Inc.
DBA: 101 South Bryn Mawr Ave
101 S. Bryn Mawr Ave
Bryn Mawr, PA, 19010

Available Services

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

Main Line Hospitals, Inc.
DBA: Women's Emotional Wellness Center
120 Valley Green Road, 6th Floor-Suite 660, King of Prussia
King Of Prussia, PA, 19406

Available Services

  • Behavioral Health (Day Programs - Adult )
  • Behavioral Health (Partial Hospitalization - Adult )
  • Community Integration (Non 24 Hour Care )

Main Line Hospitals, Inc.
DBA: Main Line Health Newtown Square
3855 West Chester Pike
Newtown Square, PA, 19073

Available Services

  • Behavioral Health (Day Programs - Adult )
  • Behavioral Health (Partial Hospitalization - Adult )
  • Laboratory Draw Station (Outpatient )

Main Line Hospitals, Inc.
DBA: Bryn Mawr Hospital
130 South Bryn Mawr Avenue
Bryn Mawr, PA, 19010

Available Services

  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult )
  • Cardiac Catheterization Lab (Surgical Services )
  • 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 )
  • 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 )
  • Pediatric Unit (Inpatient )
  • Plastic Surgery (Surgical 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

  • Thrombectomy-Capable Stroke Center

Other Clinics/Practices Located at This Site:

  • Observation Unit- 16beds
  • Telehealth
  • Wound Clinic

Organization Commentary

Mr. John Schwarz, President Bryn Mawr Hospital

Bryn Mawr Hospital's mission, vision, and values is centered in a Culature of Safety, providing the safest and highest quality of care that meets the needs of the patient and achieves the outcome of a superior patient experience. To achieve this, Bryn Mawr Hospital has continued to focus on implementation of best practice in the provision of care by the staff and physicians through accountability and leadership. Bryn Mawr Hospital follows the protocols and guidelines for the care of patients with HF, AMI, Pneumonia, COPD, and Stroke. These guidelines or core measures are based on medical evidence and their use has demonstrated improved clinical outcomes for patients with these common conditions. Our performance on compliance for these core measures is above 99% making us one of the top performing national facilities in the country. In addition to the above core measure, Bryn Mawr Hospital has focused on the care of the orthopedic patient receiving a joint replacement. Our orthopedic program participates in Healthgrades to assist us in improving our performance and making us one of the highest performing facilities in the area. Performing more than 1400 joint replacements per year, our physicians and the team are committed to helping patients resume their daily acitivities and promote self managment and return to home post-operatively. Infection rates are below the national average and our orthopedic department is diligent in complying to the best practice of the Surgical Care Improvement Project which focuses on prevention of infection and post- operative venous thromboses.We are proud to be an accredited Hip and Knee Replacement Program by the Joint Commission and display our Gold Seal proudly. Another area of focus is the care of the Stroke patient. Bryn Mawr Hospital is proud to be the Neurovascular Center for the Main Line Health System collaborating with Jefferson Health System Dept of Neurovascular Services. Additonally our interventional program provides both diagnostic and therapeutic care with 24/7 availalbility of the expertise of the neurovascular team. The BMH Stroke program is accredited by the Joint Commission for Stroke Care. Our Breast Center was one of the first centers on the Mainline and continues enhancements in the diagnosis and early treatment of patients with breast cancer. Our program is accredited by the Joint Comission for Breast cancer as well as certified by the NAPBC, another powerful certification received by hospitals that provide a level of expertise in breast cancer care. Our physicians are involved in research and strategies to improve the care and survivorship of our patients. Engaging the patient, family, and significant others through the availability of our nurse navigators and support groups enhances the overall holistic approach to care our patients need and deserve. Bryn Mawr Hospital has achieve MAGNET status for our Department of Nursing which impacts the entire organization through it self govenance and nursing research to improve the knowledge and skills of the clinical caregivers. Through the many nursing councils and the philosophy of our nursing PARTNERS model, the quality and safety of our patients is improved daily. .

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 2020 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Behavioral Health Care and Human Services 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.