Quality Report


Quality Report

North Carolina Baptist Hospital

DBA: Wake Forest Baptist Medical Center
HCO ID: 6571
Medical Center Boulevard
Winston Salem, NC, 27157
(336) 716-2011
www.wakehealth.edu
Summary of Quality Information

Accreditation Programs

Gold Seal
Hospital
Accreditation Decision
Effective Date
7/24/2021
Last Full Survey Date
7/23/2021
Last On-Site Survey Date
10/19/2021

Advanced Certification Programs

Gold Seal
Certification Decision
Effective Date
3/12/2022
Last Full Survey Date
3/11/2022
Last On-Site Survey Date
3/11/2022
Gold Seal
Certification Decision
Effective Date
10/16/2021
Last Full Survey Date
10/15/2021
Last On-Site Survey Date
10/15/2021

Core Certification Programs

Gold Seal
Certification Decision
Effective Date
10/14/2021
Last Full Survey Date
10/13/2021
Last On-Site Survey Date
10/13/2021
Gold Seal
Certification Decision
Effective Date
10/12/2021
Last Full Survey Date
10/11/2021
Last On-Site Survey Date
10/11/2021
Gold Seal
Certification Decision
Effective Date
10/13/2021
Last Full Survey Date
10/12/2021
Last On-Site Survey Date
10/12/2021
Gold Seal
Certification Decision
Effective Date
5/8/2021
Last Full Survey Date
5/7/2021
Last On-Site Survey Date
5/7/2021
Gold Seal
Certification Decision
Effective Date
5/8/2021
Last Full Survey Date
5/7/2021
Last On-Site Survey Date
5/7/2021
Gold Seal
Certification Decision
Effective Date
7/11/2022
Last Full Survey Date
5/20/2022
Last On-Site Survey Date
5/20/2022

Sites

Dermatology Surgery - Country Club
4618 Country Club Road
Winston Salem, NC, 27104

Available Services

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

Other Clinics/Practices Located at This Site:

  • General Dermatology NCBH Outpatient Clinic

Dialysis Access Group - Miller
120 Miller Street
Winston Salem, NC, 27103

Available Services

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

Downtown Health Plaza
1200 N Martin Luther King Jr., Drive
Winston Salem, NC, 27101

Available Services

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

Other Clinics/Practices Located at This Site:

  • Adult Medicine-Downtown Health Plaza
  • Care Plus
  • Dermatology-Downtown Health Plaza
  • Neurology-Downtown Health Plaza
  • Obstetrics and Gynecology-Downtown Health Plaza
  • Pediatrics-Downtown Health Plaza
  • Renal-Downtown Health Plaza

Hematology and Oncology - Elkin
401 Eldon Parks Dr.
Elkin, NC, 28621

Available Services

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

Hematology and Oncology - Lexington
107 West Medical Park Drive Suite 101
Lexington, NC, 27292

Available Services

  • Administration of Blood Product (Outpatient )
  • Administration of High Risk Medications (Outpatient )
  • Hazardous Medication Compounding (Outpatient )
  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Hematology and Oncology - Mt. Airy
450 Price Street
Mount Airy, NC, 27030

Available Services

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

Medical Plaza Clemmons NCBH Clinics
2311 Lewisville-Clemmons Road
Clemmons, NC, 27012

Available Services

  • Administration of Blood Product (Outpatient )
  • Administration of High Risk Medications (Outpatient )
  • Hazardous Medication Compounding (Outpatient )
  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Other Clinics/Practices Located at This Site:

  • Allergy, Asthma and Immunology-Clemmons
  • Brenner Children's Specialty Services-Clemmons
  • Cancer Survivorship
  • Hematology and Oncology-Clemmons
  • Rheumatology

Medical Plaza Clemmons of NCBH Clinics
2341 Lewisville-Clemmons Road
Clemmons, NC, 27012

Available Services

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

Other Clinics/Practices Located at This Site:

  • Breast Care Services-Clemmons
  • Cancer Survivorship
  • ENT/Head and Neck Surgery-Clemmons
  • Obstetrics and Gynecology-Clemmons
  • Spine Center-Clemmons
  • Vein Services-Clemmons

Medical Plaza Country Club
4610 Country Club Road
Winston Salem, NC, 27104

Available Services

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

Other Clinics/Practices Located at This Site:

  • Cardiology
  • Diabetes and Endocrinology Center - Adult
  • Diabetes Center - Pediatrics

Medical Plaza-Miller
131 Miller Street
Winston Salem, NC, 27103

Available Services

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

Certification Programs

  • Osteoporosis

Other Clinics/Practices Located at This Site:

  • ENT/Head and Neck Surgery - Comp Rehab
  • Family Medicine-Sports Medicine
  • General Neurology
  • Neuropsychology
  • Orthopaedics - Multispecialty Clinic Medical Plaza Miller
  • Physical Medicine and Rehab
  • Plastic Surgery
  • Rheumatology

North Carolina Baptist Hospital
Medical Center Boulevard
Winston Salem, NC, 27157

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 )
  • Burn Unit (Inpatient )
  • Cardiac Catheterization Lab (Surgical Services )
  • Cardiac Surgery (Surgical Services )
  • Cardiothoracic Surgery (Surgical Services )
  • Cardiovascular Unit (Inpatient )
  • Community Integration (Non 24 Hour Care )
  • 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 )
  • Family Support (Non 24 Hour Care )
  • Gastroenterology (Surgical Services )
  • 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 )
  • 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 )
  • Rehabilitation Unit (Inpatient )
  • Rehabilitation Unit (24-hour Acute Care/Crisis Stabilization )
  • Sterile Medication Compounding (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Surgical Unit (Inpatient )
  • Thoracic Surgery (Surgical Services )
  • Transplant Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Acute Myocardial Infarction
  • Advanced Comprehensive Stroke Center
  • Chest Pain
  • Heart Failure
  • Joint Replacement - Hip
  • Joint Replacement - Knee
  • Ventricular Assist Device

Other Clinics/Practices Located at This Site:

  • 3rd Floor CC - Cardiology, Pulmonary Medicine, Rad Onc
  • 9th Floor JT Neuropsychology and Neurology
  • Abdominal Organ Transplant
  • Apheresis
  • Bone Marrow Transplant Outpatient Clinic
  • Brenner Children's Hospital, Pediatric Otolaryngology (ENT)
  • Cancer Survivorship Clinic 2 CC
  • Device
  • Diagnostic Neurology & Sleep Lab - Main Floor RT
  • Eye Center - Janeway
  • General Neurology 4JT
  • Geriatrics Clinic
  • Hematology Oncology Clinic and Neuropsychology 3CC
  • Internal Medicine Multispecialty Clinics - 7JT
  • Interventional Radiology Clinic
  • Lactation & OB Care Clinic - MC AW Main Floor
  • Neurology Pediatrics
  • Neurosurgery 4JT
  • Pediatric Hem/Onc, Neurosurgery, Neuropsychology
  • Pediatric Specialties - BCH 7th Floor
  • Physical Medicine and Rehab
  • Preoperative Assessment Clinic
  • Radiation Oncology 1st Floor CC
  • Surgery Multispecialty Clinics 5JT
  • Surgical Oncology - CT, Ortho, Endocrinology, General, GYN,
  • Wound Care and Hyperbaric Chamber

Pain Services - Brookstown
605 Cotton Street
Winston Salem, NC, 27101

Available Services

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

Stratford Executive Park
500 Shepherd St. Suites 200, 201, 300
Winston Salem, NC, 27103

Available Services

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

Other Clinics/Practices Located at This Site:

  • Comprehensive Fetal Care Center
  • Gastroenterology, Rheumatology, Neurology - Shepherd Street
  • General Surgery
  • Obstetrics & Gynecology
  • Pediatric Neonatology
  • Pediatric Urology
  • Sleep clinic

Winston East Pediatrics of Baptist Hospital
2295 E. 14th Street
Winston Salem, NC, 27101

Available Services

  • Outpatient Clinics (Outpatient )

Special Quality Awards

   Due to our commitment to accurate data reporting, The Joint Commission is suspending the practice of updating Special Quality Awards until
  further notice
  • 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program
  • 2014 Gold Plus Get With The Guidelines - Stroke
  • 2010 Silver - The Medal of Honor for Organ Donation

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 2021 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Reporting Period: April 2020 - March 2021
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.