Quality Report


Quality Report

Naval Hospital Beaufort
HCO ID: 6579
1 Pinckney Boulevard
Beaufort, SC, 29902-6148
(843) 228-5200
https://info.health.mil/navy/beau/SitePages/Home.aspx
Summary of Quality Information

Accreditation Programs

Gold Seal
Behavioral Health Care and Human Services
Accreditation Decision
Effective Date
12/8/2021
Last Full Survey Date
12/7/2021
Last On-Site Survey Date
12/7/2021
Gold Seal
Hospital
Accreditation Decision
Effective Date
12/11/2021
Last Full Survey Date
12/10/2021
Last On-Site Survey Date
12/10/2021

Core Certification Programs

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

Sites

BHA 2nd Recruit Training Battalion
598 Malecon St.
Beaufort, SC, 29902

Available Services

  • Outpatient Clinics (Outpatient )

BHA 3rd Recruit Training Battalion
686 3rd Battalion Rd
Beaufort, SC, 29902

Available Services

  • Outpatient Clinics (Outpatient )

BHA Crucible
283 Henderson St
Beaufort, SC, 29902

Available Services

  • Outpatient Clinics (Outpatient )

BHC Marine Corps Recruit Depot Parris Island-Dental
Bldg. 674 Blvd de France
Parris Island, SC, 29905

Available Services

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

BHC Marine Corps Recruit Depot Parris Island-Medical
Building 670 Boulevard DeFrance
Parris Island, SC, 29905

Available Services

  • Outpatient Clinics (Outpatient )

Branch Health Annex (BHA) 1st Recruit Training Battalion
592 Guantanamo St
Beaufort, SC, 29902

Available Services

  • Outpatient Clinics (Outpatient )

Branch Health Clinic (BHC) Marine Corps Air Station Beaufort
Building 598 Geiger Blvd
Beaufort, SC, 29902

Available Services

  • Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

  • Branch Dental Clinic Marine Corps AIr Station
  • Branch Health Clinic (BHC) Marine Corps Air Station Beaufort

Naval Hospital Beaufort
1 Pinckney Boulvard
Beaufort, SC, 29902-6148

Available Services

  • Behavioral Health (Non 24 Hour Care - Adult )
  • CT Scanner (Imaging/Diagnostic Services )
  • Developmental Disabilities - Programs / Services (Non 24 Hour Care - Child/Youth )
  • Employment Services (Non 24 Hour Care )
  • Inpatient Unit (Inpatient )
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services )
  • Medical /Surgical Unit (Inpatient )
  • Orthopedic Surgery (Surgical Services )
  • Outpatient Clinics (Outpatient )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Sterile Medication Compounding (Inpatient )
  • Teleradiology (Imaging/Diagnostic Services )
  • Ultrasound (Imaging/Diagnostic Services )

Other Clinics/Practices Located at This Site:

  • Naval Hospital Beaufort Medical Home Port

Organization Commentary

CAPT Lanny Littlejohn, XO

Naval Hospital Beaufort welcomes the National Quality Improvement Goals as an opportunity to continually strive to deliver the best healthcare. Through the standardization of evidenced-based care, we utilize guidelines that allow us to drill down into areas for improvement. The five Quality Indicators of Pneumonia Care measures are discussed. Measure: Adult smoking cessation advice/counseling Discussion: All patients (inpatients and outpatients) are assessed for tobacco usage at this facility. If a patient indicates tobacco usage, cessation assistance is offered. If a patient formerly used, but is currently not using tobacco products, no further intercession had been offered unless the patient requests it or clinical assessment warrants further action. Communication efforts to the clinical staff should address any confusion regarding the National Quality Indicator requirement of continuing the offer of tobacco cessation to patients who have already quit within the previous year. Measure: Antibiotic timing Discussion: Naval Hospital Beaufort continues to intercede early in antibiotic prescribing due to our unique population of large numbers of young men and women in close living quarters and intense exposure to outdoor elements. Consequently, an outpatient course of treatment is already in effect prior to admission. Measure: Blood Cultures Discussion: The Executive Committee of the Medical Staff (ECOMS) has determined that blood cultures are not required prior to diagnosing or treating Pneumonia. Diagnosis is based on clinical symptoms, evaluation of environment, and suspicion of Community Acquired Pneumonia. Measure: Oxygenation Discussion: Naval Hospital Beaufort continues to assess and document oxygen saturation of patients suspected of or confirmed with pneumonia. Measure: Pneumonia Vaccination Discussion: Naval Hospital Beaufort recognizes the effectiveness of vaccinating against pneumonia and the unique opportunity of inpatient status to assess and vaccinate. Our system provides for the outpatient medical record to be easily accessed within the facility and is usually available on the inpatient unit. While our clinical staff will refer to the outpatient record to verify the medical history, to include vaccinations status, the abstractor does not review outpatient records. In discussions with leadership, medical and nursing staffs, we have established a new policy to assess, vaccinate as appropriate, and document all patients, regardless of age, who are admitted with pneumonia.

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 2021 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Behavioral Health Care and Human Services 2021 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na

New Changes to Quarterly Measure

Download Quarterly Measure Results

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