Quality Report


Quality Report

UPMC Carlisle

DBA: UPMC Carlisle
HCO ID: 6037
361 Alexander Spring Road
Carlisle, PA, 17015
(717) 249-1212
https://www.upmcpinnacle.com/Carlisle
Summary of Quality Information

Accreditation Programs

Gold Seal
Hospital
Accreditation Decision
Effective Date
7/17/2020
Last Full Survey Date
7/16/2020
Last On-Site Survey Date
7/16/2020
Gold Seal
Laboratory
Accreditation Decision
Effective Date
9/28/2020
Last Full Survey Date
8/28/2020
Last On-Site Survey Date
8/28/2020

Advanced Certification Programs

Gold Seal
Certification Decision
Effective Date
7/22/2020
Last Full Survey Date
7/21/2020
Last On-Site Survey Date
7/21/2020

Sites

UPMC Advanced Wound Healing
366 Alexander Spring Road
Carlisle, PA, 17015

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

UPMC Blood Donor Center
419 Village Drive Suite #7
Carlisle, PA, 17015

Available Services

  • Laboratory Draw Station (Outpatient )

UPMC Carlisle
DBA: UPMC Carlisle
361 Alexander Spring Road
Carlisle, PA, 17015

Available Services

  • Cardiac Catheterization Lab (Surgical 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 )
  • General Laboratory Tests
  • Gynecological Surgery (Surgical Services )
  • Inpatient Unit (Inpatient )
  • Interventional Radiology (Inpatient )
  • Interventional Radiology (Outpatient )
  • 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 )
  • Normal Newborn Nursery (Inpatient )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Nuclear Pharmacy (Inpatient )
  • Ophthalmology (Surgical Services )
  • Orthopedic Surgery (Surgical Services )
  • Outpatient Clinics (Outpatient )
  • Pediatric General Surgery (Outpatient - Child/Youth )
  • Pediatric Otolaryngology (Outpatient - Child/Youth )
  • Plastic Surgery (Surgical Services )
  • Positron Emission Tomography (PET) (Imaging/Diagnostic Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Radiation Oncology (Imaging/Diagnostic Services )
  • Rehabilitation Unit (Inpatient )
  • Rehabilitation Unit (24-hour Acute Care/Crisis Stabilization )
  • Sleep Laboratory (Sleep Laboratory )
  • Sterile Medication Compounding (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Teleradiology (Imaging/Diagnostic Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Primary Stroke Center

UPMC Hillman Center
25 Sprint Drive
Carlisle, PA, 17015

Available Services

  • Administration of Blood Product (Outpatient )
  • Administration of High Risk Medications (Outpatient )
  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

UPMC Imaging Services
2 Jennifer Court
Carlisle, PA, 17015

Available Services

  • Outpatient Clinics (Outpatient )

UPMC Shippensburg Lab Services
127 Walnut Bottom Rd.
Shippensburg, PA, 17257

Available Services

  • Laboratory Draw Station (Outpatient )

UPMC Sleep Disorder Center
1533 Commerce Ave Suite #3
Carlisle, PA, 17015

Available Services

  • Outpatient Clinics (Outpatient )

UPMC Surgery Center
31 Sprint Drive
Carlisle, PA, 17015

Available Services

  • Ambulatory Surgery Center (Outpatient )
  • Anesthesia (Outpatient )
  • General Laboratory Tests
  • Pediatric Gastroenterology (Outpatient - Child/Youth )
  • Pediatric Otolaryngology (Outpatient - Child/Youth )
  • Perform Invasive Procedure (Outpatient )

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 2020 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Laboratory 2020 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Reporting Period: January 2019 - December 2019
Emergency Department 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.