Quality Report

West Virginia University Hospitals, Inc.

HCO ID: 6444
One Medical Center Drive
Morgantown, WV, 26506
(304) 598-4200
http://wvumedicine.org

Summary of Quality Information

Accreditation Programs

View Accreditation History

Behavioral Health Care and Human Services	Accreditation Decision Accredited	Effective Date 12/15/2021	Last Full Survey Date 12/14/2021	Last On-Site Survey Date 12/14/2021
Hospital	Accreditation Decision Accredited	Effective Date 3/22/2024	Last Full Survey Date 12/17/2021	Last On-Site Survey Date 3/21/2024
Laboratory	Accreditation Decision Accredited	Effective Date 12/22/2023	Last Full Survey Date 12/21/2023	Last On-Site Survey Date 12/21/2023

Advanced Certification Programs

View Certification History

Advanced Comprehensive Stroke Center

Certification Decision

Certification

Effective Date

4/21/2022

Last Full Survey Date

4/20/2022

Last On-Site Survey Date

4/20/2022

Advanced Total Hip and Total Knee Replacement

Certification Decision

Certification

Effective Date

5/6/2023

Last Full Survey Date

5/5/2023

Last On-Site Survey Date

5/5/2023

Ventricular Assist Device

Certification Decision

Certification

Effective Date

8/17/2022

Last Full Survey Date

8/16/2022

Last On-Site Survey Date

8/16/2022

Sites

Center for Hope and Healing operated by WVU Hospitals, Inc.
751 Benefactor Drive
Morgantown, WV, 26501

Available Services

Chemical Dependency (Residential Care - Adult )
Chemical Dependency (Detox/Non-detox - Adult )
Community Integration (Non 24 Hour Care )
Family Support (Non 24 Hour Care )
General Laboratory Tests
Peer Support (Non 24 Hour Care )

Suncrest Towne Centre Clinic operated by WVU Hospitals, Inc.
600 Suncrest Towne Centre
Morgantown, WV, 26505

Available Services

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

Other Clinics/Practices Located at This Site:

Suncrest Towne Centre Department of Medicine Endocrinology C
Suncrest Towne Centre Department of Medicine Nephrology Clin
Suncrest Towne Centre Department of Medicine Rheumatology Cl

University Town Centre Clinic operated by WVU Hospitals, Inc
6040 University Town Centre Drive
Morgantown, WV, 26501

Available Services

Administration of Blood Product (Outpatient )
Administration of High Risk Medications (Outpatient )
General Laboratory Tests
Outpatient Clinics (Outpatient )
Perform Invasive Procedure (Outpatient )

Other Clinics/Practices Located at This Site:

University Town Centre Clark K. Sleeth Family Medicine Cente
University Town Centre Dermatology
University Town Centre Geriatrics
University Town Centre Imaging
University Town Centre Laboratory
University Town Centre Medicine
University Town Centre MGP
University Town Centre Obstetrics and Gynecology
University Town Centre Orthopaedics
University Town Centre Pediatric and Adolescent Practice
University Town Centre Pre-admission Testing

West Virginia University Hospitals, Inc.
DBA: Rockefeller Neuroscience Institute, Innovation Center
33 Medical Center Drive Suite 240 and 211
Morgantown, WV, 26506

Available Services

Anesthesia (Outpatient )
General Laboratory Tests
Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

RNIIC Behavioral Medicine Clinic
RNIIC Neurology Clinic
RNIIC Neurosurgery Clinic

West Virginia University Hospitals, Inc.
DBA: Fairmont Medical Center
1325 Locust Avenue
Fairmont, WV, 26554

Available Services

CT Scanner (Imaging/Diagnostic Services )
Dementia Care
Dialysis Unit (Inpatient )
GI or Endoscopy Lab (Imaging/Diagnostic Services )
Inpatient Unit (Inpatient )
Magnetic Resonance Imaging (Imaging/Diagnostic Services )
Medical /Surgical Unit (Inpatient )
On Site Pharmacy
Outpatient Clinics (Outpatient )
Post Anesthesia Care Unit (PACU) (Inpatient )
Rehabilitation Services
Skilled Nursing Care
Sleep Laboratory (Sleep Laboratory )
Sterile Medication Compounding (Inpatient )
Ultrasound (Imaging/Diagnostic Services )

Other Clinics/Practices Located at This Site:

Fairmont Medical Center Cardiology
Fairmont Medical Center Neurology
Fairmont Medical Center Pulmonary Clinic
Fairmont Medical Center Sleep Evaluation Center

West Virginia University Hospitals, Inc.
DBA: WVUH Specialty Pharmacy & Home Infusion
3040 University Ave
Morgantown, WV, 26505

Available Services

Infusion Pharmacy
Non-Sterile Medication Compounding
Pharmacy/Dispensary,General Services
Specialty Pharmacy
Sterile Medication Compounding

West Virginia University Hospitals, Inc.
DBA: Fairmont Regional Cancer Center
1325 Locust Avenue
Fairmont, WV, 26554-1435

Available Services

Outpatient Clinics (Outpatient )

West Virginia University Hospitals, Inc.
One Medical Center Drive
Morgantown, WV, 26506-8242

Available Services

Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult )
Behavioral Health (24-hour Acute Care/Crisis Stabilization - Child/Youth )
Brachytherapy (Imaging/Diagnostic Services )
Cardiac Catheterization Lab (Surgical Services )
Cardiac Surgery (Surgical Services )
Cardiothoracic Surgery (Surgical Services )
Cardiovascular Unit (Inpatient )
Coronary Care 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 )
General Laboratory Tests
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 )
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 )
Sterile Medication Compounding (Inpatient )
Surgical ICU (Intensive Care Unit )
Surgical Unit (Inpatient )
Thoracic Surgery (Surgical Services )
Toxicology
Transplant Surgery (Surgical Services )
Ultrasound (Imaging/Diagnostic Services )
Urology (Surgical Services )
Vascular Surgery (Surgical Services )

Certification Programs

Advanced Comprehensive Stroke Center
Advanced Total Hip and Total Knee Replacement
Ventricular Assist Device

Other Clinics/Practices Located at This Site:

Betty Puskar Breast Care Center
Bonnie's Bus
Children’s Hospital Maternal Fetal Medicine Clinic
Children’s Hospital Pediatric Clinics
Children’s Hospital Pediatric Infusion Clinic
Mary Babb Randolph Cancer Center
Physician Office Center Clark K. Sleeth Family Medicine Clin
Physician Office Center EEG/EMG
Physician Office Center ENT Clinic
Physician Office Center Lab
Physician Office Center Medical Center Pharmacy
Physician Office Center Medical Group Practice
Physician Office Center Medical Specialties Clinic
Physician Office Center Neurology Clinic
Physician Office Center Neurosurgery Clinic
Physician Office Center Orthopedics Clinic
Physician Office Center Pediatric Specialties Clinic
Physician Office Center Pre-admission Testing
Physician Office Center Radiology
Physician Office Center Surgical Specialties Clinic
Physician Office Center Ultrasound
Radiation Oncology
Ruby Transplant Alliance Clinic
Southeast Tower Cardiac and Pulmonary Rehab
Southeast Tower Heart and Vascular Institute Cardiology Clin
Southeast Tower Heart and Vascular Institute HVI Specialties
West Virginia University Eye Institute

West Virginia University Hospitals, Inc.
DBA: WVU Medicine Children’s Neurodevelopmental Center (NDC)
201 Baker’s Ridge Road
Morgantown, WV, 26508

Available Services

Outpatient Clinics (Outpatient )

WVU Cheat Lake Physicians operated by WVU Hospitals, Inc.
608 Cheat Road
Morgantown, WV, 26508

Available Services

General Laboratory Tests
Outpatient Clinics (Outpatient )
Perform Invasive Procedure (Outpatient )

Other Clinics/Practices Located at This Site:

Cheat Lake Family Medicine Clinic
Cheat Lake Lab
Cheat Lake OB/GYN Clinic
Cheat Lake Pediatric and Adult Allergy and Immunology
Cheat Lake Pediatric Clinic
Cheat Lake Radiology

WVU Pain Management Center operated by WVU Hospitals, Inc.
Suite 150 1075 VanVoorhis Road
Morgantown, WV, 26505

Available Services

Administration of High Risk Medications (Outpatient )
General Laboratory Tests
Outpatient Clinics (Outpatient )
Perform Invasive Procedure (Outpatient )

WVU Sleep Evaluation Center operated by WVU Hospitals, Inc.
205 Bakers Ridge Road
Morgantown, WV, 26508

Available Services

Outpatient Clinics (Outpatient )

WVU Spine Medicine Center operated by WVU Hospitals, Inc.
943 Maple Drive, Lower Level
Morgantown, WV, 26505

Available Services

Outpatient Clinics (Outpatient )

WVUH Chestnut Ridge Center operated by WVU Hospitals, Inc.
DBA: Intensive Treatment Clinic
3600 Collins Ferry Road
Morgantown, WV, 26505

Available Services

Assertive Community Treatment/Community Support Services (Non 24 Hour Care - Adult )
Behavioral Health (Day Programs - Adult )
Behavioral Health (Partial Hospitalization - Adult )
Community Integration (Non 24 Hour Care )
General Laboratory Tests

Other Clinics/Practices Located at This Site:

Assertive Community Treatment

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

This organization achieved the best possible results
This organization's performance is better than the target range/value
This organization's performance is similar to the target range/value
This organization's performance is worse than the target range /value
This measure is not applicable for this organization
Not displayed

Measures Footnote Key

The measure or measure set was not reported.
The measure set does not have an overall result.
The number is not enough for comparison purposes.
The measure meets the Privacy Disclosure Threshold rule.
The organization scored above 90% but was below most other organizations.
The measure results are not statistically valid.
The measure results are based on a sample of patients.
The number of months with measure data is below the reporting requirement.
The measure results are temporarily suppressed pending resubmission of updated data.
Test Measure: a measure being evaluated for reliability of the individual data elements or awaiting National Quality Forum Endorsement.
There were no eligible patients that met the denominator criteria.
The measure rate is within optimal range.

Symbol Key

This organization achieved the best possible results
This organization's performance is better than the target range/value
This organization's performance is similar to the target range/value
This organization's performance is worse than the target range/value
This measure is not applicable for this organization
Not displayed

Measures Footnote Key

The measure or measure set was not reported.
The measure set does not have an overall result.
The number is not enough for comparison purposes.
The measure meets the Privacy Disclosure Threshold rule.
The organization scored above 90% but was below most other organizations.
The measure results are not statistically valid.
The measure results are based on a sample of patients.
The number of months with measure data is below the reporting requirement.
The measure results are temporarily suppressed pending resubmission of updated data.
Test Measure: a measure being evaluated for reliability of the individual data elements or awaiting National Quality Forum Endorsement.
There were no eligible patients that met the denominator criteria.
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	2021 National Patient Safety Goals	Nationwide Comparison:	Statewide Comparison:
Laboratory	2023 National Patient Safety Goals	Nationwide Comparison:	Statewide Comparison:
Hospital	2024 National Patient Safety Goals	Nationwide Comparison:	Statewide Comparison:
	Reporting Period: January 2022 - December 2022 National Quality Improvement Goals:
	Hospital-Based Inpatient Psychiatric Services	National Comparison: 2	Statewide Comparison: 2
	Perinatal Care	National Comparison: 2	Statewide Comparison: 2

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* State results are not calculated for the National Patient Safety Goals.