Quality Report


Quality Report

Dwight David Eisenhower Army Medical Center
HCO ID: 6665
Building 300, Hospital Road
Fort Gordon, GA, 30905-5650
(706) 787-5190
www.ddeamc.amedd.army.mil
Summary of Quality Information

Accreditation Programs

Gold Seal
Behavioral Health Care and Human Services
Accreditation Decision
Effective Date
5/2/2018
Last Full Survey Date
5/1/2018
Last On-Site Survey Date
5/1/2018
Gold Seal
Hospital
Accreditation Decision
Effective Date
5/4/2018
Last Full Survey Date
5/3/2018
Last On-Site Survey Date
5/3/2018

Core Certification Programs

Gold Seal
Certification Decision
Effective Date
7/17/2018
Last Full Survey Date
5/3/2018
Last On-Site Survey Date
5/3/2018

Sites

Army Health Clinic Southern Command
9301 NW 33rd Street
Doral, FL, 33172

Available Services

  • Outpatient Clinics (Outpatient )

Certification Programs

  • Primary Care Medical Home - Hospital

Other Clinics/Practices Located at This Site
Army Health Clinic Southern Command

Dwight David Eisenhower Army Medical Center
Building 300, Hospital Road
Fort Gordon, GA, 30905

Available Services

  • Behavioral Health (Day Programs - Adult )
  • Behavioral Health (Non 24 Hour Care - Adult )
  • Behavioral Health (Non 24 Hour Care - Child/Youth )
  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult )
  • Behavioral Health (Partial - Adult )
  • Cardiac Catheterization Lab (Surgical Services )
  • Chemical Dependency (Non 24 Hour Care - Adult )
  • Chemical Dependency (24-hour Acute Care/Crisis Stabilization - Adult )
  • Chemical Dependency (Non-detox - Adult )
  • CT Scanner (Imaging/Diagnostic Services )
  • Dialysis Unit (Inpatient )
  • 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 )
  • Hazardous Medication Compounding (Inpatient )
  • Inpatient Unit (Inpatient )
  • Interventional Radiology (Imaging/Diagnostic Services )
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services )
  • Medical /Surgical Unit (Inpatient )
  • Medical ICU (Intensive Care Unit )
  • Non-Sterile Medication Compounding (Inpatient )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Nuclear Pharmacy (Inpatient )
  • Ophthalmology (Surgical Services )
  • Orthopedic Surgery (Surgical Services )
  • Outpatient Clinics (Outpatient )
  • Peer Support (Non 24 Hour Care )
  • Plastic Surgery (Surgical Services )
  • Positron Emission Tomography (PET) (Imaging/Diagnostic Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Sleep Laboratory (Sleep Laboratory )
  • Sterile Medication Compounding (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Teleradiology (Imaging/Diagnostic Services )
  • Thoracic Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Primary Care Medical Home - Hospital

Other Clinics/Practices Located at This Site
Family Medicine Clinic

Internal Medicine Clinic

Troop Medical Clinic #4

Connelly Health Clinic

Rodriguez Army Health Clinic
Building 21
Fort Buchanan, PR, 00934

Available Services

  • Developmental Disabilities - Programs / Services (Non 24 Hour Care - Child/Youth )
  • Family Support (Non 24 Hour Care )
  • Outpatient Clinics (Outpatient )

Certification Programs

  • Primary Care Medical Home - Hospital

Other Clinics/Practices Located at This Site
Rodriguez Army Health Clinic

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 2018 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Behavioral Health Care and Human Services 2018 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Reporting Period: October 2018 - September 2019
Emergency Department 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.