Quality Report


Quality Report

Bethesda Hospital, Inc.

DBA: Bethesda North Hospital
HCO ID: 6985
625 Eden Park Drive
Cincinnati, OH, 45202
(513) 865-1221
www.trihealth.com
Summary of Quality Information

Accreditation Programs

View Accreditation History
Gold Seal
Home Care
Accreditation Decision
Effective Date
11/19/2022
Last Full Survey Date
11/18/2022
Last On-Site Survey Date
2/24/2023
Gold Seal
Hospital
Accreditation Decision
Effective Date
6/21/2023
Last Full Survey Date
11/18/2022
Last On-Site Survey Date
6/20/2023

Advanced Certification Programs

View Certification History
Gold Seal
Acute Stroke Ready Hospital
Certification Decision
Effective Date
4/19/2023
Last Full Survey Date
4/18/2023
Last On-Site Survey Date
4/18/2023
Gold Seal
Advanced Certification in Perinatal Care
Certification Decision
Effective Date
4/16/2024
Last Full Survey Date
2/21/2024
Last On-Site Survey Date
2/21/2024
Gold Seal
Inpatient Diabetes
Certification Decision
Effective Date
4/20/2022
Last Full Survey Date
4/19/2022
Last On-Site Survey Date
4/19/2022
Gold Seal
Primary Stroke Center
Certification Decision
Effective Date
8/26/2023
Last Full Survey Date
8/25/2023
Last On-Site Survey Date
8/25/2023
Gold Seal
Thrombectomy-Capable Stroke Center
Certification Decision
Effective Date
8/25/2023
Last Full Survey Date
8/24/2023
Last On-Site Survey Date
8/24/2023

Core Certification Programs

Gold Seal
Hip Fracture
Certification Decision
Effective Date
11/9/2022
Last Full Survey Date
11/8/2022
Last On-Site Survey Date
11/8/2022
Gold Seal
Joint Replacement - Hip
Certification Decision
Effective Date
8/19/2023
Last Full Survey Date
8/18/2023
Last On-Site Survey Date
8/18/2023
Gold Seal
Joint Replacement - Knee
Certification Decision
Effective Date
8/19/2023
Last Full Survey Date
8/18/2023
Last On-Site Survey Date
8/18/2023
Gold Seal
Patient Blood Management
Certification Decision
Effective Date
11/2/2023
Last Full Survey Date
11/1/2023
Last On-Site Survey Date
11/1/2023

Sites

Bethesda Hospital Inc.
DBA: Bethesda Imaging Thomas Center
10500 Montgomery Road
Cincinnati, OH, 45242

Available Services

  • Outpatient Clinics (Outpatient )

Bethesda Hospital Inc.
DBA: Bethesda North Interventional Pain Center
10550 Montgomery Rd, Suite 14
Cincinnati, OH, 45242

Available Services

  • Ambulatory Surgery Center (Outpatient )
  • Anesthesia (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Bethesda Hospital Inc.
DBA: Bethesda Diagnostics - Kenwood
8240 Northcreek Drive, Suite LL300
Cincinnati, OH, 45236

Available Services

  • Outpatient Clinics (Outpatient )

Bethesda Hospital Inc.
DBA: Bethesda North Outpatient Laboratory - Thomas Center
10506A Montgomery Road, Suite 101
Cincinnati, OH, 45242

Available Services

  • Laboratory Draw Station (Outpatient )

Bethesda Hospital, Inc
DBA: Bethesda North Sleep Center
10475 Montgomery Road Suite 1-D
Cincinnati, OH, 45242

Available Services

  • Outpatient Clinics (Outpatient )

Bethesda Hospital, Inc
DBA: Bethesda Montgomery Sleep Center
10535 Montgomery Road, Suite 200
Cincinnati, OH, 45242

Available Services

  • Outpatient Clinics (Outpatient )

Bethesda Hospital, Inc
DBA: Bethesda Butler - Physical Therapy
3055 Hamilton Mason Rd, Suite 100
Hamilton, OH, 45011

Available Services

  • Outpatient Clinics (Outpatient )

Bethesda Hospital, Inc
DBA: Bethesda OB/GYN Center
10495 Montgomery Rd Suite 25
Cincinnati, OH, 45242

Available Services

  • Outpatient Clinics (Outpatient )

Bethesda Hospital, Inc
DBA: Bethesda Physical Therapy - Loveland
10675 Loveland-Madeira Road
Loveland, OH, 45140

Available Services

  • Outpatient Clinics (Outpatient )

Bethesda Hospital, Inc
DBA: Bethesda Butler - Sleep Center
3055 Hamilton Mason Road, Suite 200
Hamilton, OH, 45011

Available Services

  • Outpatient Clinics (Outpatient )

Bethesda Hospital, Inc
DBA: Bethesda Alcohol and Drug Treatment Program - Blue Ash
4410 Carver Woods Dr., Suite 206
Cincinnati, OH, 45242

Available Services

  • Chemical Dependency (Day Programs - Adult )
  • Chemical Dependency (Partial Hospitalization - Adult )
  • Chemical Dependency (Non-detox - Adult )
  • Community Integration (Non 24 Hour Care )
  • Peer Support (Non 24 Hour Care )

Bethesda Hospital, Inc
DBA: Bethesda Surgery Center
10615 Montgomery Road, Suite 300
Cincinnati, OH, 45242

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Ambulatory Surgery Center (Outpatient )
  • Anesthesia (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Bethesda Hospital, Inc.
DBA: TriHealth Fitness and Health Pavilion
6200 Pfeiffer Road
Cincinnati, OH, 45242

Available Services

  • Outpatient Clinics (Outpatient )

Bethesda Hospital, Inc.
DBA: Bethesda Cardiac Testing - Montgomery
10506A Montgomery Road Suite 201
Cincinnati, OH, 45242

Available Services

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

Bethesda Hospital, Inc.
DBA: Bethesda Butler Hospital
3125 Hamilton Mason Road
Hamilton, OH, 45011

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 (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 )
  • Ophthalmology (Surgical Services )
  • Orthopedic Surgery (Surgical Services )
  • Outpatient Clinics (Outpatient )
  • Plastic Surgery (Surgical Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Sterile Medication Compounding (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Primary Stroke Center

Bethesda Hospital, Inc.
DBA: Bethesda North Hospital
10500 Montgomery Road
Cincinnati, OH, 45242-4415

Available 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 )
  • 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 Unit (Inpatient )
  • Neurosurgery (Surgical Services )
  • Newborn Nursery
  • 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 )
  • Plastic Surgery (Surgical Services )
  • Positron Emission Tomography (PET) (Imaging/Diagnostic Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Special Care Nursery (Level 2 Neonatal Intensive Care Unit)
  • Sterile Medication Compounding (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Surgical Unit (Inpatient )
  • Thoracic Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Advanced Certification in Perinatal Care
  • Hip Fracture
  • Inpatient Diabetes
  • Joint Replacement - Hip
  • Joint Replacement - Knee
  • Patient Blood Management
  • Thrombectomy-Capable Stroke Center

Bethesda Hospital, Inc.
DBA: Bethesda Radiation Oncology - Thomas Center
10506A Montgomery Road, Suite 104
Cincinnati, OH, 45242

Available Services

  • Outpatient Clinics (Outpatient )

Bethesda Hospital, Inc.
DBA: Bethesda Medical Center at Arrow Springs
100 Arrow Springs Blvd.
Lebanon, OH, 45036

Available Services

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

Certification Programs

  • Acute Stroke Ready Hospital

Bethesda Hospital, Inc.
DBA: Bethesda Radiation Oncology - Kenwood
8240 Northcreek Drive, Suite LL200
Cincinnati, OH, 45236

Available Services

  • Outpatient Clinics (Outpatient )

Bethesda Hospital, Inc.
DBA: Bethesda Cardiovascular Testing - Kenwood
8240 Northcreek Drive, Suite 4200
Cincinnati, OH, 45236

Available Services

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

Hospice of Cincinnati, Inc.
DBA: Hospice of Cincinnati - North Field Office
1010 Eaton Avenue
Hamilton, OH, 45013

Available Services

  • Hospice Care

Hospice of Cincinnati, Inc.
DBA: Hospice of Hamilton
1010 Eaton Avenue
Hamilton, OH, 45013

Available Services

  • Hospice Care

Hospice of Cincinnati, Inc.
DBA: Hospice of Cincinnati - Blue Ash
4310 Cooper Road
Cincinnati, OH, 45242

Available Services

  • Hospice Care

Hospice of Cincinnati, Inc.
DBA: Hospice of Cincinnati - Eastgate Field Office
7691 Five Mile Road
Cincinnati, OH, 45230

Available Services

  • Hospice Care

Hospice of Cincinnati, Inc.
DBA: Hospice of Cincinnati - West Field Office
Twin Towers Health Pavilion, 2nd Floor, 5343 Hamilton Ave
Cincinnati, OH, 45224

Available Services

  • Hospice Care

Hospice of Cincinnati, Inc.
DBA: Hospice of Cincinnati - Western Hills
Twin Towers Health Paviliion, 2nd Floor, 5343 Hamilton Ave
Cincinnati, OH, 45224

Available Services

  • Hospice Care

Hospice of Cincinnati, Inc.
DBA: Hospice of Cincinnati - Central Field Office
4360 Cooper Road
Cincinnati, OH, 45242

Available Services

  • Hospice Care

Hospice of Cincinnati, Inc.
DBA: Hospice of Cincinnati at The Christ Hospital
2139 Auburn Avenue, 5 - Level West Wing
Cincinnati, OH, 45219

Available Services

  • Hospice Care

Hospice of Cincinnati, Inc.
DBA: Hospice of Cincinnati - East
7691 Five Mile Road
Cincinnati, OH, 45230

Available Services

  • Hospice Care

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

  • 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.

Home Care 2022 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Hospital 2023 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Reporting Period: January 2022 - December 2022
Perinatal Care National Comparison: nd 2 Statewide Comparison: nd 2

New Changes to Quarterly Measure

Download Quarterly Measure Results

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