Quality Report


Quality Report

Maury Regional Hospital

DBA: Maury Regional Medical Center
HCO ID: 7820
1224 Trotwood Ave.
Columbia, TN, 38401
(931) 381-1111
www.mauryregional.com
Summary of Quality Information

Accreditation Programs

Gold Seal
Home Care
Accreditation Decision
Effective Date
9/1/2022
Last Full Survey Date
8/31/2022
Last On-Site Survey Date
8/31/2022
Gold Seal
Hospital
Accreditation Decision
Effective Date
9/3/2022
Last Full Survey Date
9/2/2022
Last On-Site Survey Date
3/14/2024

Advanced Certification Programs

Gold Seal
Certification Decision
Effective Date
4/30/2022
Last Full Survey Date
4/29/2022
Last On-Site Survey Date
4/29/2022
Gold Seal
Certification Decision
Effective Date
2/4/2023
Last Full Survey Date
2/3/2023
Last On-Site Survey Date
2/3/2023

Core Certification Programs

Gold Seal
Certification Decision
Effective Date
2/16/2022
Last Full Survey Date
2/15/2022
Last On-Site Survey Date
2/15/2022
Gold Seal
Certification Decision
Effective Date
2/16/2022
Last Full Survey Date
2/15/2022
Last On-Site Survey Date
2/15/2022

Sites

Chapel Hill Physical Therapy
4700 Nashville Highway
Chapel Hill, TN, 37034

Available Services

  • Outpatient Clinics (Outpatient )

Lewis Health Center Imaging
617 West Main Street
Hohenwald, TN, 38462

Available Services

  • Outpatient Clinics (Outpatient )

Lewis Health Center Physical Medicine
621 West Main
Hohenwald, TN, 38462

Available Services

  • Outpatient Clinics (Outpatient )

Maury Outpatient PT, Columbia Orthopedics
1412 Trotwood Avenue, Suite 82
Columbia, TN, 38401

Available Services

  • Outpatient Clinics (Outpatient )

Maury Outpatient PT, Physical Therapy Center
858 West James Campbell Blvd.
Columbia, TN, 38401

Available Services

  • Outpatient Clinics (Outpatient )

Maury Regional Cancer Center
808 S. James Campbell Boulevard
Columbia, TN, 38401

Available Services

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

Maury Regional Home Services
800 South James Campbell Boulevard, Suiter 12
Columbia, TN, 38401

Available Services

  • Home Health Aides
  • Home Health, Non-Hospice Services
  • Medical Social Services
  • Occupational Therapy
  • Physical Therapy
  • Skilled Nursing Services

Maury Regional Hospital
DBA: Maury Regional Medical Center
1224 Trotwood Avenue
Columbia, TN, 38401

Available Services

  • Brachytherapy (Imaging/Diagnostic Services )
  • Cardiac Catheterization Lab (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 )
  • 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 )
  • Neurosurgery (Surgical Services )
  • Non-Sterile Medication Compounding (Inpatient )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Ophthalmology (Surgical Services )
  • Orthopedic Surgery (Surgical Services )
  • Orthopedic/Spine Unit (Inpatient )
  • Plastic Surgery (Surgical Services )
  • Positron Emission Tomography (PET) (Imaging/Diagnostic Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Radiation Oncology (Imaging/Diagnostic Services )
  • Sleep Laboratory (Sleep Laboratory )
  • Sterile Medication Compounding (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Surgical Unit (Inpatient )
  • Teleradiology (Imaging/Diagnostic Services )
  • Thoracic Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Joint Replacement - Hip
  • Joint Replacement - Knee
  • Perinatal Care Certification
  • Primary Stroke Center

Maury Regional Out Patient Pavilion
1220 Trotwood Avenue
Columbia, TN, 38401

Available Services

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

Maury Regional Physical Therapy Pulaski
425 West College Street
Pulaski, TN, 38478

Available Services

  • Outpatient Clinics (Outpatient )

Maury Regional Wound Center
1218 Trotwood Avenue
Columbia, TN, 38401

Available Services

  • Outpatient Clinics (Outpatient )

MRMC Sleep Center
1407 North Locust Avenue Suite 102
Lawrenceburg, TN, 38464

Available Services

  • Outpatient Clinics (Outpatient )

Spring Hill Physical Therapy
1003 Reserve Boulevard Suite 310
Spring Hill, TN, 37174

Available Services

  • Outpatient Clinics (Outpatient )

Organization Commentary

Dr. Martin Chaney, CEO

Maury Regional Hospital strongly supports making quality data available to the public. Maury Regional Hospital is comfortable with the quality of care delivered to our patients; however, the documentation of the care given was not as extensive as required for this report. The two areas on the report that need additional review—providing discharge instructions and prescribing ACE inhibitors at the time of discharge—have been and continue to be addressed. To better reflect the true quality provided at the hospital, a process has been developed to communicate to the hospital and medical staff the documentation required in the patient’s medical chart. We have conducted training sessions and have already seen improvements in our 2004 data. We will continue these efforts and anticipate positive changes as the report is updated. For more information, contact: Charles A. Ball, M.D. Medical Director Maury Regional Hospital 931.381.1111, x 1154

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 2022 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Home Care 2022 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.