Quality Report


Quality Report

Mount Carmel Health System

DBA: Mount Carmel Health
HCO ID: 7025
6001 East Broad Street
Columbus, OH, 43213
(614) 546-4533
www.mchs.com
Summary of Quality Information

Accreditation Programs

Gold Seal
Hospital
Accreditation Decision
Effective Date
10/11/2023
Last Full Survey Date
10/7/2022
Last On-Site Survey Date
10/10/2023

Advanced Certification Programs

Gold Seal
Certification Decision
Effective Date
3/3/2022
Last Full Survey Date
3/2/2022
Last On-Site Survey Date
3/2/2022
Gold Seal
Certification Decision
Effective Date
3/5/2022
Last Full Survey Date
3/4/2022
Last On-Site Survey Date
3/4/2022

Sites

Mount Carmel Pharmacy Outpatient Care Center
5965 E. Broad Street Suite 200
Columbus, OH, 43213

Available Services

  • Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

  • Mount Carmel East Rehab Center Suite 390
  • Mount Carmel East Wound Clinic Suite 120
  • Mount Carmel Heart Failure Clinic Suite 200
  • Mount Carmel Women's Health Center Suite 100

Mount Carmel Cardiac, Pulmonary, Vascular Rehab
150 Taylor Station Road Suite 350
Columbus, OH, 43213

Available Services

  • Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

  • Mount Carmel Outpatient lab Suite 130

Mount Carmel East Hospital
6001 East Broad Street
Columbus, OH, 43213

Available Services

  • 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 )
  • 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 )
  • 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 )
  • Ophthalmology (Surgical Services )
  • Orthopedic Surgery (Surgical Services )
  • Orthopedic/Spine Unit (Inpatient )
  • Outpatient Clinics (Outpatient )
  • Plastic Surgery (Surgical Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Radiation Oncology (Imaging/Diagnostic Services )
  • 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 Comprehensive Stroke Center

Mount Carmel Emergency Room Franklinton
120 South Green Street
Columbus, OH, 43222

Available Services

  • Anesthesia (Outpatient )
  • General Laboratory Tests

Mount Carmel Grove City
5300 N. Meadows Drive
Grove City, OH, 43123

Available Services

  • Brachytherapy (Imaging/Diagnostic Services )
  • Cardiac Catheterization Lab (Surgical Services )
  • Cardiac Surgery (Surgical Services )
  • Cardiothoracic Surgery (Surgical Services )
  • Cardiovascular 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 )
  • 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 )
  • Radiation Oncology (Imaging/Diagnostic Services )
  • Sterile Medication Compounding (Inpatient )
  • Surgical Unit (Inpatient )
  • Thoracic Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Primary Stroke Center

Other Clinics/Practices Located at This Site:

  • Mount Carmel Cardiac and Vascular Imaging Center at Grove Ci
  • Mount Carmel Cardiac, Pulmonary, Vascula Rehab at Grove City
  • Mount Carmel Graduate Medical Education Primary & Specialty,
  • Mount Carmel Grove City Medical Oncology Clinic
  • Mount Carmel Grove City Radiation Oncology, Suite 1900
  • Mount Carmel Heart Failure Clinic at Grove City Suite 280
  • Mount Carmel Outpatient IV Therapy, Suite 1900
  • Mount Carmel Pharmacy Outpatient Care Center at Suite 220
  • Mount Carmel Women's Health Center at Grove City
  • Pain Management Procedural Area Suite 2950

Mount Carmel Heart and Vascular Imaging Center
85 McNaughton Rd. Suite 300
Columbus, OH, 43213

Available Services

  • Outpatient Clinics (Outpatient )

Mount Carmel Heart and Vascular Imaging Center at Diley
7901 Diley Road Suite 230
Canal Winchester, OH, 43110

Available Services

  • Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

  • Mount Carmel Outpatient Lab at Diley Suite 205

Mount Carmel Imaging Center
5969 East .Broad Street, Suite 100
Columbus, OH, 43213

Available Services

  • Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

  • Mount Carmel East Radiation Oncology Suite 102
  • Mount Carmel East Surgery Practice Suite 306
  • Mount Carmel Pain Management Clinic Suite 306

Mount Carmel Imaging Hilliard Suite 1100
4674 Britton Parkway Hilliard Ohio 43026
Hilliard, OH, 43026

Available Services

  • Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

  • Mount Carmel Heart and Vascular Imaging Center Suite 2100
  • Mount Carmel Outpatient Lab at Hilliard Suite 1200
  • Mount Carmel Rehab Services - Hilliard Suite 1700
  • Mount Carmel Women's Health Center Hilliard Suite 1000

Mount Carmel Outpatient IV Therapy
5975 East Broad Street Suite 300
Columbus, OH, 43213

Available Services

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

Other Clinics/Practices Located at This Site:

  • Molunt Carmel East Diabetes Management

Mount Carmel Outpatient Lab Mount Carmel St. Ann's
495 Cooper Rd Suite 100
Westerville, OH, 43081

Available Services

  • Laboratory Draw Station (Outpatient )

Other Clinics/Practices Located at This Site:

  • Mount Carmel Outpatient Lab Suite 311

Mount Carmel Outpatient Lab at Big Run Health Center
4310 Clime Road Suite D
Columbus, OH, 43228

Available Services

  • Laboratory Draw Station (Outpatient )

Mount Carmel Outpatient Lab at Marble Cliff
2150 Marble Cliff Office Suite B
Columbus, OH, 43215

Available Services

  • Laboratory Draw Station (Outpatient )

Mount Carmel Outpatient Lab at MCMG Hoover Family Practice
6024 Hoover Rd A Grove City, Ohio 43123
Grove City, OH, 43123

Available Services

  • Laboratory Draw Station (Outpatient )

Mount Carmel Outpatient Lab at New Albany
55 North High Street
New Albany, OH, 43054

Available Services

  • Laboratory Draw Station (Outpatient )

Mount Carmel Outpatient Lab at Northtowne Family Practice
5910 Cleveland Ave
Columbus, OH, 43231

Available Services

  • Laboratory Draw Station (Outpatient )

Mount Carmel Outpatient Lab at Pickerington Medical Center
641 Hill Road North Suite D
Pickerington, OH, 43147

Available Services

  • Laboratory Draw Station (Outpatient )

Mount Carmel Outpatient Lab at Westerville North
237 Schrock Road suite A
Westerville, OH, 43082

Available Services

  • Laboratory Draw Station (Outpatient )

Mount Carmel Outpatient Lab Groveport
5343 Hendron Rd
Groveport, OH, 43125

Available Services

  • Laboratory Draw Station (Outpatient )

Mount Carmel Outpatient Laboratory
775 W. Broad Street, Suite 260, Columbus
Columbus, OH, 43222

Available Services

  • Laboratory Draw Station (Outpatient )

Mount Carmel Rehab Services at Grove City Suite 300
3000 Meadow Pond Ct.
Grove City, OH, 43123

Available Services

  • Outpatient Clinics (Outpatient )

Mount Carmel Reynoldsburg Emergency Room
2300 Baltimore-Reynoldsburg Rd, Suite 100
Reynoldsburg, OH, 43068

Available Services

  • Anesthesia (Outpatient )

Mount Carmel St. Ann's Family Practice
DBA: St. Ann's Family Practice
477 Cooper Rd Suite 300
Westerville, OH, 43081

Available Services

  • Outpatient Clinics (Outpatient )

Mount Carmel Wound Center
5500 N. Meadows Drive Suite 130
Grove City, OH, 43123

Available Services

  • Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

  • Mount Carmel Pain Management Clinic Suite 120

Outpatient Lab Services at Mount Carmel Fitness & Health
7100 Graphics Way Suite 1600
Lewis Center, OH, 43035

Available Services

  • Laboratory Draw Station (Outpatient )

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 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 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.