Quality Report


Quality Report

Baptist Health System, Inc.

DBA: Baptist Health Hardin
HCO ID: 7738
913 North Dixie Avenue
Elizabethtown, KY, 42701
(270) 737-1212
www.baptisthealth.com
Summary of Quality Information

Accreditation Programs

View Accreditation History
Gold Seal
Hospital
Accreditation Decision
Effective Date
1/7/2022
Last Full Survey Date
1/6/2022
Last On-Site Survey Date
1/6/2022
Gold Seal
Laboratory
Accreditation Decision
Effective Date
3/24/2023
Last Full Survey Date
3/23/2023
Last On-Site Survey Date
3/23/2023

Advanced Certification Programs

View Certification History
Gold Seal
Advanced Total Hip and Total Knee Replacement
Certification Decision
Effective Date
5/12/2023
Last Full Survey Date
5/11/2023
Last On-Site Survey Date
5/11/2023
Gold Seal
Primary Stroke Center
Certification Decision
Effective Date
4/26/2023
Last Full Survey Date
4/25/2023
Last On-Site Survey Date
4/25/2023

Sites

Baptist Health Diabetes Care Clinic
110 Layman Lane
Elizabethtown, KY, 42701

Available Services

  • Outpatient Clinics (Outpatient )

Baptist Health Elizabethtown Diagnostics
108 Financial Drive
Elizabethtown, KY, 42701

Available Services

  • Laboratory Draw Station (Outpatient )

Baptist Health System, Inc.
DBA: Baptist Health Hardin
913 North Dixie Avenue
Elizabethtown, KY, 42701

Available Services

  • Allergen Extract (Inpatient )
  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult )
  • Brachytherapy (Imaging/Diagnostic Services )
  • Cardiac Catheterization Lab (Surgical Services )
  • 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 )
  • Inpatient Unit (Inpatient )
  • Interventional Radiology (Imaging/Diagnostic Services )
  • Labor & Delivery (Inpatient )
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services )
  • Medical /Surgical 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 Unit (Inpatient )
  • Plastic Surgery (Surgical Services )
  • Positron Emission Tomography (PET) (Imaging/Diagnostic Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Radiation Oncology (Imaging/Diagnostic Services )
  • Rehabilitation Services
  • Skilled Nursing Care
  • Sterile Medication Compounding (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Surgical Unit (Inpatient )
  • Toxicology
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Advanced Total Hip and Total Knee Replacement
  • Primary Stroke Center

Other Clinics/Practices Located at This Site:

  • Complex Care Clinic

Bardstown Medical Plaza
3615 E. John Rowen Blvd
Bardstown, KY, 40004

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

  • Bardstown Diagnostic Center
  • Bardstown Diagnostic Lab
  • Bardstown Diagnostics
  • Bardstown Lab

Brandenburg Diagnostic Center
100 Commerce Drive
Brandenburg, KY, 40108

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

Cancer Care Center
521 Robinbrooke Boulevard
Elizabethtown, KY, 42701

Available Services

  • Administration of Blood Product (Outpatient )
  • Administration of High Risk Medications (Outpatient )
  • General Laboratory Tests
  • Hazardous Medication Compounding (Outpatient )
  • Outpatient Clinics (Outpatient )

Elizabethtown Diagnostic Imaging
2409 Ring Road
Elizabethtown, KY, 42701

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

  • Elizabethtown Diagnostic Imaging
  • Elizabethtown Diagnostic Imaging
  • Sleep Disorders Center

Hodgenville Diagnostics
145 Lincoln Drive
Hodgenville, KY, 42748

Available Services

  • Outpatient Clinics (Outpatient )

Wound Care and Vascular Center
1010 Woodland Drive
Elizabethtown, KY, 42701

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

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.

Hospital 2022 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Laboratory 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.