Quality Report


Quality Report

The Lawrence Memorial Hospital

DBA: LMH Health
HCO ID: 8570
325 Maine Street
Lawrence, KS, 66044
(785) 505-5000
www.lmh.org
Summary of Quality Information

Accreditation Programs

View Accreditation History
Gold Seal
Hospital
Accreditation Decision
Effective Date
11/12/2022
Last Full Survey Date
11/11/2022
Last On-Site Survey Date
12/28/2022

Advanced Certification Programs

View Certification History
Gold Seal
Advanced Total Hip and Total Knee Replacement
Certification Decision
Effective Date
4/13/2023
Last Full Survey Date
4/12/2023
Last On-Site Survey Date
4/12/2023
Gold Seal
Primary Stroke Center
Certification Decision
Effective Date
4/19/2023
Last Full Survey Date
4/18/2023
Last On-Site Survey Date
4/18/2023

Sites

Lawrence Memorial Hospital
DBA: LMH Health Therapy Services Watkins
1200 Schwegler Drive
Lawrence, KS, 66045

Available Services

  • Outpatient Clinics (Outpatient )

LMH 6th and Maine Therapy Services
1112 W 6th St Suite 102
Lawrence, KS, 66049

Available Services

  • Outpatient Clinics (Outpatient )

LMH Baldwin Therapy Services
820 Ames St.
Baldwin City, KS, 66006

Available Services

  • Outpatient Clinics (Outpatient )

LMH Eudora Therapy Services
600 E. 20th Street, Suite 100
Eudora, KS, 66025

Available Services

  • Outpatient Clinics (Outpatient )

LMH Health West Campus
6265 Rock Chalk Drive
Lawrence, KS, 66049

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Other Clinics/Practices Located at This Site:

  • LMH Health West Imaging
  • LMH Health West Mammography
  • LMH Health West Therapy Services
  • LMH Health West Women's Therapy

LMH Imaging West
4525 W 6th St., #106
Lawrence, KS, 66049

Available Services

  • Outpatient Clinics (Outpatient )

LMH Tonganoxie Therapy
410 Woodfield Drive, Suite 100
Tonganoxie, KS, 66086

Available Services

  • Outpatient Clinics (Outpatient )

LMH Wound Care Center
1112 West 6th Street, Suite 109
Lawrence, KS, 66044

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

LMH-Sleep Lab
3510 Clinton Parkway Place
Lawrence, KS, 66047

Available Services

  • Outpatient Clinics (Outpatient )

The Lawrence Memorial Hospital
DBA: LMH Health
325 Maine Street
Lawrence, KS, 66044

Available Services

  • Cardiac Catheterization Lab (Surgical Services )
  • CT Scanner (Imaging/Diagnostic Services )
  • Dementia Care
  • 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 )
  • Medical ICU (Intensive Care Unit )
  • Neurosurgery (Surgical Services )
  • Non-Sterile Medication Compounding (Inpatient )
  • Normal Newborn Nursery (Inpatient )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • On Site Pharmacy
  • Ophthalmology (Surgical Services )
  • Orthopedic Surgery (Surgical Services )
  • Outpatient Clinics (Outpatient )
  • Pediatric Unit (Inpatient )
  • Plastic Surgery (Surgical Services )
  • Positron Emission Tomography (PET) (Imaging/Diagnostic Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Rehabilitation Services
  • Rehabilitation Unit (Inpatient )
  • Rehabilitation Unit (24-hour Acute Care/Crisis Stabilization )
  • Skilled Nursing Care
  • Sterile Medication Compounding (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Surgical Unit (Inpatient )
  • Teleradiology (Imaging/Diagnostic Services )
  • 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:

  • LMH Anticoagulation Clinic

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
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.