Quality Report


Quality Report

Memorial Hospital of Sweetwater County

DBA: Acute Care Hospital
HCO ID: 9352
1200 College Drive
Rock Springs, WY, 82901
(307) 362-3711
sweetwatermemorial.com
Summary of Quality Information

Accreditation Programs

Gold Seal
Hospital
Accreditation Decision
Effective Date
5/8/2021
Last Full Survey Date
5/7/2021
Last On-Site Survey Date
5/7/2021
Gold Seal
Laboratory
Accreditation Decision
Effective Date
11/16/2019
Last Full Survey Date
11/15/2019
Last On-Site Survey Date
11/15/2019

Sites

Clinics of Memorial Hospital of Sweetwater County
DBA: Medical Office Building
3000 College Drive
Rock Springs, WY, 82901

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

Memorial Hospital Clinics
DBA: Outpatient Ambulatory Clinic
1180 College Drive
Rock Springs, WY, 82901

Available Services

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

Other Clinics/Practices Located at This Site:

  • Rock Springs Family Practice
  • Sweetwater Plastic Surgery
  • University of Utah Clinic

Memorial Hospital of Sweetwater County
DBA: Acute Care Hospital
1200 College Drive
Rock Springs, WY, 82901

Available Services

  • CT Scanner (Imaging/Diagnostic Services )
  • Ear/Nose/Throat Surgery (Surgical Services )
  • EEG/EKG/EMG Lab (Imaging/Diagnostic Services )
  • Gastroenterology (Surgical Services )
  • General Laboratory Tests
  • Gynecological Surgery (Surgical Services )
  • Hazardous Medication Compounding (Inpatient )
  • Inpatient Unit (Inpatient )
  • Labor & Delivery (Inpatient )
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services )
  • Medical /Surgical Unit (Inpatient )
  • Medical ICU (Intensive Care Unit )
  • Non-Sterile Medication Compounding (Inpatient )
  • Normal Newborn Nursery (Inpatient )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Nuclear Pharmacy (Inpatient )
  • Orthopedic Surgery (Surgical Services )
  • Positron Emission Tomography (PET) (Imaging/Diagnostic Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Sleep Laboratory (Sleep Laboratory )
  • Sterile Medication Compounding (Inpatient )
  • Surgical Unit (Inpatient )
  • Teleradiology (Imaging/Diagnostic Services )
  • Toxicology
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )

National Patient Safety Goals and National Quality Improvement Goals

Symbol Key

  • starThis organization achieved the best possible results
  • plusThis organization's performance is above the target range/value
  • checkThis organization's performance is similar to the target range/value
  • minusThis organization's performance is below 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.

Symbol Key

  • starThis organization achieved the best possible results
  • plusThis organization's performance is above the target range/value
  • checkThis organization's performance is similar to the target range/value
  • minusThis organization's performance is below 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.

The Joint Commission only reports measures endorsed by the National Quality Forum.
* 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.

Laboratory 2019 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Hospital 2021 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Reporting Period: January 2019 - December 2019
Emergency Department National Comparison: nd 2 Statewide Comparison: nd 2
Perinatal Care National Comparison: nd 2 Statewide Comparison: nd 2

New Changes to Quarterly Measure

Download Quarterly Measure Results

The Joint Commission only reports measures endorsed by the National Quality Forum.
* State results are not calculated for the National Patient Safety Goals.