Quality Report


Quality Report

Evans Army Community Hospital
HCO ID: 9365
1650 Cochrane Circle, BLDG 7500
Fort Carson, CO, 80913-4604
(719) 526-7500
https://evans.tricare.mil/
Summary of Quality Information

Accreditation Programs

View Accreditation History
Gold Seal
Behavioral Health Care and Human Services
Accreditation Decision
Effective Date
3/16/2022
Last Full Survey Date
3/15/2022
Last On-Site Survey Date
3/15/2022
Gold Seal
Hospital
Accreditation Decision
Effective Date
3/19/2022
Last Full Survey Date
3/18/2022
Last On-Site Survey Date
3/18/2022

Core Certification Programs

View Certification History
Gold Seal
Primary Care Medical Home - Hospital
Certification Decision
Effective Date
3/19/2022
Last Full Survey Date
3/18/2022
Last On-Site Survey Date
3/18/2022

Sites

Butts Army Aviation Facility (BAAF)
3524 Airfield Road Building #9621 and #9622
Fort Carson, CO, 80913

Available Services

  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

DiRaimondo Primary Care Medical Clinic - Main
Building 1041, Barkeley Ave
Fort Carson, CO, 80913

Available Services

  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

DiRaimondo Primary Care Medical Clinic - Support
Building 1058 O'Connell Blvd
Fort Carson, CO, 80913

Available Services

  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Embedded Behavioral Health - Team 5
Bldg 1226, 1126 Felkins St
Fort Carson, CO, 80913

Available Services

  • Behavioral Health (Non 24 Hour Care - Adult )
  • Case Management (Non 24 Hour Care - Adult )
  • Community Integration (Non 24 Hour Care )

Embedded Behavioral Health - Aviation
Building 1657, 1848 Barkley Ave
Fort Carson, CO, 80913

Available Services

  • Behavioral Health (Non 24 Hour Care - Adult )
  • Case Management (Non 24 Hour Care - Adult )
  • Community Integration (Non 24 Hour Care )

Embedded Behavioral Health - Team 1
Bldg 2361, 6909 Titus BLVD
Fort Carson, CO, 80913

Available Services

  • Behavioral Health (Non 24 Hour Care - Adult )
  • Case Management (Non 24 Hour Care - Adult )
  • Community Integration (Non 24 Hour Care )

Embedded Behavioral Health - Team 10
Bldg 7490 - 4790 Sutherland Circle
Fort Carson, CO, 80913

Available Services

  • Behavioral Health (Non 24 Hour Care - Adult )
  • Case Management (Non 24 Hour Care - Adult )
  • Community Integration (Non 24 Hour Care )

Embedded Behavioral Health - Team 2
Bldg 9481, 2751 Wilderness Rd
Fort Carson, CO, 80913

Available Services

  • Behavioral Health (Non 24 Hour Care - Adult )
  • Case Management (Non 24 Hour Care - Adult )
  • Community Integration (Non 24 Hour Care )

Embedded Behavioral Health Team 3
Bldg 1150, 5886 Barkley Ave
Fort Carson, CO, 80913

Available Services

  • Behavioral Health (Non 24 Hour Care - Adult )
  • Case Management (Non 24 Hour Care - Adult )
  • Community Integration (Non 24 Hour Care )

Evans Army Community Hospital
1650 Cochrane Circle
Fort Carson, CO, 80913

Available Services

  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult )
  • Community Integration (Non 24 Hour Care )
  • CT Scanner (Imaging/Diagnostic Services )
  • 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 )
  • 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 )
  • Ophthalmology (Surgical Services )
  • Orthopedic Surgery (Surgical Services )
  • Outpatient Clinics (Outpatient )
  • Plastic Surgery (Surgical Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Sleep Laboratory (Sleep Laboratory )
  • Sterile Medication Compounding (Inpatient )
  • Teleradiology (Imaging/Diagnostic Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )

Other Clinics/Practices Located at This Site
Warrior Clinic

Forrest Resiliency Center (Army Wellness Center)
1891 Prussman Avenue Bldg 1843
Fort Carson, CO, 80913

Available Services

  • Single Specialty Practitioner (Outpatient )

Fort Carson Department of Public Health
6582 Magrath Ave Bldg 2059
Fort Carson, CO, 80913

Available Services

  • Single Specialty Practitioner (Outpatient )

Intrepid Spirit Center
Bldg 6492
Fort Carson, CO, 80913

Available Services

  • Outpatient Clinics (Outpatient )

Mountain Post Behavioral Health Clinic
6541 Specker Rd, Bldg 1830
Fort Carson, CO, 80913

Available Services

  • Behavioral Health (Non 24 Hour Care - Adult )
  • Case Management (Non 24 Hour Care - Adult )
  • Chemical Dependency (Non 24 Hour Care - Adult )
  • Chemical Dependency (Non-detox - Adult )
  • Community Integration (Non 24 Hour Care )
  • Technology-Based Behavioral Health Srvs (Non 24 Hour Care - Adult )

Other Clinics/Practices Located at This Site:

  • Abrams Elementary School, 600 Chiles Ave
  • Carson Middle School, 6200 Prussman
  • Moutainside Elementary School, 5506 Harr Ave
  • Patriot Elementary School, 7010 Harr Ave
  • Substance Use Disorder Clinical Care
  • Weikel Elementary School, 6565 Lindstom St

Outpatient Behavioral Health - Addiction Medicine IOP
O'Connell Blvd and Irwin Building 1059
Fort Carson, CO, 80913

Available Services

  • Addiction Services
  • Addiction Services (Non-detox - Adult )
  • Case Management (Non 24 Hour Care - Adult )
  • Chemical Dependency (Day Programs - Adult )
  • Chemical Dependency (Partial Hospitalization - Adult )
  • Chemical Dependency (Non-detox - Adult )
  • Community Integration (Non 24 Hour Care )

Outpatient Behavioral Health - Behavioral Health IOP
Building 1056 O'Connell Blvd
Fort Carson, CO, 80913

Available Services

  • Behavioral Health (Day Programs - Adult )
  • Behavioral Health (Partial Hospitalization - Adult )
  • Case Management (Non 24 Hour Care - Adult )
  • Community Integration (Non 24 Hour Care )

Robinson Primary Care Medicine Clinic
Building 7490, 7490 Sutherland Cir
Fort Carson, CO, 80913

Available Services

  • Perform Invasive Procedure (Outpatient )
  • Single Specialty Practitioner (Outpatient )

Soldier Family Care Center (SFCC)
1670 Cochrane Circle, Building 7503
Fort Carson, CO, 80913

Available Services

  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Other Clinics/Practices Located at This Site:

  • Child and Family Behavioral Health System
  • Ivy Clinic
  • Oral Surgery
  • Orthopedics/Podiatry
  • Pediatrics
  • Physical and Occupational Therapy

Soldier Readiness Center
6351 Wetzel Ave, Building 1525
Fort Carson, CO, 80913

Available Services

  • Outpatient Clinics (Outpatient )

United States Army Occupational Health Clinic
Bldg # 5116, 5116 Kister Ave
Dugway, UT, 84022

Available Services

  • Single Specialty Practitioner (Outpatient )

United States Army Occupational Health Clinic
Pueblo Chemical Depot
Pueblo, CO, 81001

Available Services

  • Single Specialty Practitioner (Outpatient )

United States Army Occupational Health Clinic
Tooele Army Depot Bldg # 400
Tooele, UT, 84074

Available Services

  • Single Specialty Practitioner (Outpatient )

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
Behavioral Health Care and Human Services 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.