Quality Report


Quality Report

Memorial Regional Hospital

DBA: Memorial Regional Hospital
HCO ID: 6811
3501 Johnson Street
Hollywood, FL, 33021
(954) 265-2000
www.mhs.net
Summary of Quality Information

Accreditation Programs

Gold Seal
Behavioral Health Care and Human Services
Accreditation Decision
Effective Date
7/13/2021
Last Full Survey Date
7/12/2021
Last On-Site Survey Date
7/12/2021
Gold Seal
Home Care
Accreditation Decision
Effective Date
7/22/2017
Last Full Survey Date
7/16/2021
Last On-Site Survey Date
7/16/2021
Gold Seal
Hospital
Accreditation Decision
Effective Date
7/15/2017
Last Full Survey Date
7/16/2021
Last On-Site Survey Date
7/16/2021
Gold Seal
Laboratory
Accreditation Decision
Effective Date
11/9/2019
Last Full Survey Date
11/8/2019
Last On-Site Survey Date
11/8/2019

Advanced Certification Programs

Gold Seal
Certification Decision
Effective Date
3/6/2019
Last Full Survey Date
3/5/2019
Last On-Site Survey Date
3/5/2019
Gold Seal
Certification Decision
Effective Date
3/27/2021
Last Full Survey Date
3/26/2021
Last On-Site Survey Date
3/26/2021

Sites

Cypress Creek Outpatient Rehab
2122 W. Cypress Creek Road Suite #220
Fort Lauderdale, FL, 33320

Available Services

  • Outpatient Clinics (Outpatient )

Joe DiMaggio Children's Health Specialty Center
3377 South State Road 7 Wellington
Lake Worth, FL, 33449

Available Services

  • Outpatient Clinics (Outpatient )

MCI- Chemotherapy
DBA: Memorial Cancer Institute
1150 N. 35th Avenue #270
Hollywood, FL, 33021

Available Services

  • Administration of Blood Product (Outpatient )
  • Administration of High Risk Medications (Outpatient )
  • General Laboratory Tests
  • Single Specialty Practitioner (Outpatient )

MCI- Oncolgy Physician Practice
DBA: Memorial Cancer Institute
1150 N 35 th Ave #330 and 345
Hollywood, FL, 33021

Available Services

  • General Laboratory Tests
  • Single Specialty Practitioner (Outpatient )

MCI- Oncology Physician Practice/Chemotherapy
DBA: Memorial Cancer Institute
20801 Biscayne Blvd #200
Aventura, FL, 33180

Available Services

  • Administration of Blood Product (Outpatient )
  • Administration of High Risk Medications (Outpatient )
  • Single Specialty Practitioner (Outpatient )

Memoiral Primary Care Adult Mobile Health Center
4105 Pembroke Road
Hollywood, FL, 33021

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

Memorial Breast Cancer Center
1150 N. 35th Ave Suite #170
Hollywood, FL, 33021

Available Services

  • General Laboratory Tests

Memorial Breast Cancer Center (Practice/Chemotherapy)
1150 N 35th Ave Suite 170
Hollywood, FL, 33021

Available Services

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

Memorial Kidney Transplant Clinic Adult/Pediatrics
1150 N 35th Ave Suite 390
Hollywood, FL, 33021

Available Services

  • General Laboratory Tests
  • Single Specialty Practitioner (Outpatient )

Memorial Outpatient Behavioral Health
3400 N. 29th Avenue
Hollywood, FL, 33021

Available Services

  • Addiction Services
  • Addiction Services (Detox - Adult )
  • Behavioral Health (Day Programs - Adult )
  • Behavioral Health (Partial Hospitalization - Adult )
  • Chemical Dependency (Day Programs - Adult )
  • Chemical Dependency (Partial Hospitalization - Adult )
  • Chemical Dependency (Detox - Adult )
  • General Laboratory Tests

Memorial Primary Care @ East Hollywood
3700 Johnson Street
Hollywood, FL, 33021

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

Memorial Primary Care at Dania Beach
140 S. Federal Highway
Dania, FL, 33004

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

Memorial Primary Care at Hallandale
1750 E Hallandale Beach Blvd
Hallandale, FL, 33009

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

Memorial Primary Care at Pembroke Road
4105 Pembroke Road
Hollywood, FL, 33021

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

Memorial Primary Care Childrens Mobile Health Center
4105 Pembroke Road
Hollywood, FL, 33021

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

Memorial Regional Hospital Fitness and Rehabilitation Center
300 Hollywood Way
Hollywood, FL, 33021

Available Services

  • Outpatient Clinics (Outpatient )

Memorial Regional Hospital South
3600 Washington Street
Hollywood, FL, 33021

Available Services

  • CT Scanner (Imaging/Diagnostic Services )
  • 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 )
  • Inpatient Unit (Inpatient )
  • Interventional Radiology (Inpatient )
  • Interventional Radiology (Imaging/Diagnostic Services )
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services )
  • Medical /Surgical Unit (Inpatient )
  • Non-Sterile Medication Compounding (Inpatient )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Orthopedic Surgery (Surgical Services )
  • Plastic Surgery (Surgical Services )
  • Rehabilitation Unit (Inpatient )
  • Rehabilitation Unit (24-hour Acute Care/Crisis Stabilization )
  • Sterile Medication Compounding (Inpatient )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )

Memorial Regional Pathology Services
9581 Premier Parkway, Miramar
Hollywood, FL, 33025

Available Services

  • General Laboratory Tests

Pediatric Transplant Clinic
1150 North 35th Avenue Suite 445
Hollywood, FL, 33021

South Broward Hospital District
DBA: Memorial Home Infusion
9579 Premier Parkway
Miramar, FL, 33025

Available Services

  • Durable Medical Equipment
  • Enteral Equipment and/or Supplies
  • Enteral Nutrients
  • External Infusion Pumps
  • High Risk Sterile Medication Compounding (Outpatient )
  • Infusion Pharmacy
  • Outpatient Clinics (Outpatient )
  • Parenteral Equipment and/or Supplies
  • Parenteral Nutrients
  • Pharmacy, Clinical Consulting Services
  • Pharmacy/Dispensary,General Services
  • Sterile Medication Compounding
  • Supplies

South Broward Hospital District
DBA: Memorial Regional Hospital
3501 Johnson Street
Hollywood, FL, 33021

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 )
  • Eating Disorders
  • Eating Disorders (Outpatient )
  • 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 )
  • Hematology/Oncology Unit (Inpatient )
  • 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 )
  • 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 Cardiac Catheterization (Inpatient - Child/Youth )
  • Pediatric Cardiac Catheterization (Outpatient - Child/Youth )
  • Pediatric Cardiology (Inpatient - Child/Youth )
  • Pediatric Cardiology (Outpatient - Child/Youth )
  • Pediatric Cardiothoracic Surgery (Inpatient - Child/Youth )
  • Pediatric Cardiothoracic Surgery (Outpatient - Child/Youth )
  • Pediatric Dentistry (Inpatient - Child/Youth )
  • Pediatric Dentistry (Outpatient - Child/Youth )
  • Pediatric Dermatology (Inpatient - Child/Youth )
  • Pediatric Emergency Medicine (Inpatient - Child/Youth )
  • Pediatric Emergency Medicine (Outpatient - Child/Youth )
  • Pediatric Endocrinology (Inpatient - Child/Youth )
  • Pediatric Endocrinology (Outpatient - Child/Youth )
  • Pediatric Gastroenterology (Inpatient - Child/Youth )
  • Pediatric Gastroenterology (Outpatient - Child/Youth )
  • Pediatric General Surgery (Inpatient - Child/Youth )
  • Pediatric General Surgery (Outpatient - Child/Youth )
  • Pediatric Nephrology (Inpatient - Child/Youth )
  • Pediatric Nephrology (Outpatient - Child/Youth )
  • Pediatric Neurosurgery (Inpatient - Child/Youth )
  • Pediatric Neurosurgery (Outpatient - Child/Youth )
  • Pediatric Ophthalmology (Inpatient - Child/Youth )
  • Pediatric Ophthalmology (Outpatient - Child/Youth )
  • Pediatric Oral/Maxofacial Surgery (Inpatient - Child/Youth )
  • Pediatric Oral/Maxofacial Surgery (Outpatient - Child/Youth )
  • Pediatric Otolaryngology (Inpatient - Child/Youth )
  • Pediatric Otolaryngology (Outpatient - Child/Youth )
  • Pediatric Plastic Surgery (Inpatient - Child/Youth )
  • Pediatric Plastic Surgery (Outpatient - Child/Youth )
  • Pediatric Unit (Inpatient )
  • Pediatric Urology (Inpatient - Child/Youth )
  • Pediatric Urology (Outpatient - Child/Youth )
  • Plastic Surgery (Surgical 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 )
  • Surgical Unit (Inpatient )
  • Thoracic Surgery (Surgical Services )
  • Toxicology
  • Transplant Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )
  • Wound Care

Certification Programs

  • Advanced Comprehensive Stroke Center
  • Ventricular Assist Device

U-18 MRI
5830 Coral Ridge Drive #110
Coral Springs, FL, 33076

Available Services

  • Outpatient Clinics (Outpatient )

U-18 Rehab Program
5830 Coral Ridge Drive #207
Coral Springs, FL, 33076

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

Organization Commentary

Mr. Peter Powers, CEO

Additional quality awards: 1. Bariatric Center of Excellence as designated by the Surgical Review Corporation and the American Society for Metabolic and Bariatric Surgery. 2. Bronze Award for the American Stroke Association Get With The Guidelines.

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 2017 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Home Care 2017 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Laboratory 2019 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
Reporting Period: January 2019 - December 2019
Emergency Department National Comparison: nd 2 Statewide Comparison: nd 2
Hospital-Based Inpatient Psychiatric Services 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.