Accreditation Quality Report Version: 3 Date: 2/10/2017
Welcome to the Joint Commission's Quality Report. We know how important reliable information is to you and your family when making health care decisions. This Quality Report will help you make the right decisions to meet your needs. Since 1951, the Joint Commission has been the national leader in setting standards for health care organizations. When a health care organization seeks accreditation, it demonstrates commitment to giving safe, high quality health care and to continually working to improve that care. The Quality Report is only one way to determine whether a health care organization can meet your needs. Discuss this report with your doctor or with other professional acquaintances before making a care decision. In addition to the accreditation status of the organization, the Quality Report uses checks, pluses, and minuses in each of the following key areas to help you compare a health care organization with similar accredited organizations. National Patient Safety Goals - safety guidelines that target the prevention of medical errors such as surgery on the wrong side of the body and safe medication use. National Quality Improvement Goals - measures the care of patients with specific conditions such as heart failure or pregnancy. Not all measures are relevant to or available for all types of health care organizations. The Joint Commission will add relevant measures of health care quality as more measures become available. Your comments are just as important to us. The content and format of the Quality Report will be updated from time to time based on changes in the health care industry and your suggestions. Please call Customer Service at 630-792-5800 or e-mail the Joint Commission at qualityreport@jointcommission.org with your comments and suggestions. Mark R. Chassin, MD, MPP, MPH President of the Joint Commission
Summary of Quality Information Symbol Key The organization has met the National Patient Safety Goal. The organization has not met the National Patient Safety Goal. The Goal is not applicable for this organization. Accreditation Programs Accreditation Decision Effective Last Full Survey Last On-Site Date Date Survey Date Behavioral Health Care Accredited 11/11/2015 11/10/2015 11/10/2015 Hospital Accredited 11/14/2015 11/13/2015 2/19/2016 For further information and explanation of the Quality Report contents, refer to the "Quality Report User Guide." Accreditation programs recognized by the Centers for Medicare and Medicaid Services (CMS) Hospital Certification programs recognized by the Centers for Medicare and Medicaid Services (CMS) Ventricular Assist Device Advanced Certification Programs Advanced Comprehensive Stroke Center Certification Decision Effective Date Last Full Review Last On-Site Date Review Date Certification 1/31/2016 12/3/2015 12/3/2015 Inpatient Diabetes Certification 12/5/2015 12/4/2015 12/4/2015 Ventricular Assist Device Certification 9/14/2016 9/13/2016 9/13/2016 Certified Programs Certification Decision Effective Date Last Full Review Last On-Site Date Review Date Joint Replacement - Hip Certification 1/15/2015 1/14/2015 1/14/2015 Joint Replacement - Knee Certification 1/15/2015 1/14/2015 1/14/2015 Joint Replacement - Shoulder Certification 1/14/2015 2/9/2017 2/9/2017 Other Accredited Programs/Services Laboratory ( Accredited by American Society for Histocompatibility and Immunogenetics (ASHI)) Special Quality Awards 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program 2014 Gold Plus Get With The Guidelines - Heart Failure 2013 Gold Plus Get With The Guidelines - Stroke 2012 ACS National Surgical Quality Improvement Program 3 Copyright 2018, The Joint Commission
Summary of Quality Information Symbol Key The organization has met the National Patient Safety Goal. The organization has not met the National Patient Safety Goal. The Goal is not applicable for this organization. For further information and explanation of the Quality Report contents, refer to the "Quality Report User Guide." Behavioral Health Care Hospital 2015National Patient Safety Goals 2016National Patient Safety Goals Compared to other Joint Commission Accredited Organizations Nationwide Statewide * * 4 Copyright 2018, The Joint Commission
* Primary Location Ambulatory Care Procedures 735 Johnnie Dodds Blvd Mount Pleasant, SC 29464 Ashley River Tower 25 Courtenay Street Charleston, SC 29403 Available Services Anesthesia (Outpatient) Perform Invasive Procedure (Outpatient) Joint Commission Advanced Certification Programs: Inpatient Diabetes Ventricular Assist Device Cardiac Catheterization Lab (Surgical Cardiovascular Unit Coronary Care Unit EEG/EKG/EMG Lab Gastroenterology (Surgical GI or Endoscopy Lab Inpatient Unit Interventional Radiology Magnetic Resonance Imaging Medical /Surgical Unit Post Anesthesia Care Unit (PACU) Surgical ICU (Intensive Care Unit) Surgical Unit Thoracic Surgery (Surgical Transplant Surgery (Surgical Vascular Surgery (Surgical Children's Day Treatment 1001B. Michigan Avenue Charleston, SC 29404 Childrens Rehab Services Center 4480 Leeds Park West Charleston, SC 29414 Family Medicine 650 Ellis Oak Drive Charleston, SC 29412 HCC Mt. Pleasant Radiation Oncology 1180 Hospital Drive Mount Pleasant, SC 29464 Behavioral Health (Day Programs - Child/Youth) (Partial - Child/Youth) Family Support (Non 24 Hour Care) 5 Copyright 2018, The Joint Commission
* Primary Location Institute of Psychiatry 67 President Street Charleston, SC 29403 Available Services Joint Commission Advanced Certification Programs: Inpatient Diabetes Behavioral Health (Day Programs - Adult/Child/Youth) (24-hour Acute Care/Crisis Stabilization - Adult) (Partial - Adult/Child/Youth) Chemical Dependency (24-hour Acute Care/Crisis Stabilization - Adult) Family Support (Non 24 Hour Care) Mt. Pleasant Pediatrics After Hours Care and Day Clinics 2705 Highway 17 North, Suite 100 Mount Pleasant, SC 29464 Mt. Pleasant Physical & Occupational Therapy 1280 Hospital Drive, Mt. Pleasant Mount Pleasant, SC 29464 MUSC Cardiac Rehab 122 Bee Street, Suite 201 Charleston, SC 29401 MUSC Health East Cooper 1600 Midtown Avenue Mount Pleasant, SC 29464 6 Copyright 2018, The Joint Commission
* Primary Location MUSC Medical Center - Main University Hospital * 169 Ashley Avenue Charleston, SC 29425 Available Services Joint Commission Advanced Certification Programs: Advanced Comprehensive Stroke Center Inpatient Diabetes Joint Commission Certified Programs: Joint Replacement - Hip Joint Replacement - Knee Joint Replacement - Shoulder Other Clinics/Practices located at this site: Children's Hospital Clinical Sciences Building Hollings Cancer Center Rutledge Tower Storm Eye Institute Cardiac Catheterization Lab (Surgical Cardiac Surgery (Surgical Cardiothoracic Surgery (Surgical Cardiovascular Unit Coronary Care Unit CT Scanner Dialysis Unit Ear/Nose/Throat Surgery (Surgical EEG/EKG/EMG Lab Gastroenterology (Surgical Gynecological Surgery (Surgical Gynecology Hematology/Oncology Unit Inpatient Unit Interventional Radiology Labor & Delivery Magnetic Resonance Imaging Medical /Surgical Unit Medical ICU (Intensive Care Unit) Neuro/Spine ICU (Intensive Care Unit) Neuro/Spine Unit Neurosurgery (Surgical Normal Newborn Nursery Nuclear Medicine Orthopedic Surgery (Surgical Orthopedic/Spine Unit Pediatric Unit Plastic Surgery (Surgical Post Anesthesia Care Unit (PACU) Radiation Oncology Surgical ICU (Intensive Care Unit) Surgical Unit Thoracic Surgery (Surgical Transplant Surgery (Surgical Ultrasound Urology (Surgical Vascular Surgery (Surgical 7 Copyright 2018, The Joint Commission
* Primary Location North Area Infusion Services, Pharmacy, and Lab 2575 Elms Center Road, N. Charleston, SC 29405 Charleston, SC 29406 North Area Pediatrics After Hours Care and Day Clinics 2750 Dantzler Drive Charleston, SC 29406 Pediatric Eating Disorder Clinic Cannon Park Place, 261 Calhoun Street Charleston, SC 29401 ReVisions Adult Partial Hospitalization and Intensive 295 Calhoun Street Charleston, SC 29401 Summerville Pediatrics After Hours Care and Day Clinics 4330 Ladson Road Ladson, SC 29456 West Ashley Physical Therapy/Occupational Therapy 2125 Ashley Hall Blvd. Charleston, SC 29414 Women's Health 135 Cannon Street Charleston, SC 29425 Available Services Administration of Blood Product (Outpatient) Administration of High Risk Medications (Outpatient) Eating Disorders/Child/Youth) (Day Programs - Child/Youth) (Partial - Child/Youth) Family Support (Non 24 Hour Care) Behavioral Health (Day Programs - Adult) (Partial - Adult) Family Support (Non 24 Hour Care) Administration of High Risk Medications (Outpatient) Perform Invasive Procedure (Outpatient) 8 Copyright 2018, The Joint Commission
2015 National Patient Safety Goals Symbol Key The organization has met the National Patient Safety Goal. The organization has not met the National Patient Safety Goal. The Goal is not applicable for this organization. Behavioral Health Care Safety Goals Organizations Should Implemented Improve the accuracy of the identification of individuals served. Use of Two Identifiers For further information and explanation of the Quality Report contents, refer to the "Quality Report User Guide." Improve the safety of using medications. Reduce the risk of health care-associated infections. The organization identifies safety risks inherent in the population of the individuals it serves. Reconciling Medication Information Meeting Hand Hygiene Guidelines Identifying Individuals at Risk for Suicide 9 Copyright 2018, The Joint Commission
2016 National Patient Safety Goals Symbol Key The organization has met the National Patient Safety Goal. The organization has not met the National Patient Safety Goal. The Goal is not applicable for this organization. Hospital Safety Goals Organizations Should Implemented Improve the accuracy of patient identification. Use of Two Patient Identifiers Eliminating Transfusion Errors For further information and explanation of the Quality Report contents, refer to the "Quality Report User Guide." Improve the effectiveness of communication among caregivers. Improve the safety of using medications. Use Alarms Safely Reduce the risk of health care-associated infections. The organization identifies safety risks inherent in its patient population. Universal Protocol Timely Reporting of Critical Tests and Critical Results Labeling Medications Reducing Harm from Anticoagulation Therapy Reconciling Medication Information Use Alarms Safely on Medical Equipment Meeting Hand Hygiene Guidelines Preventing Multi-Drug Resistant Organism Infections Preventing Central-Line Associated Blood Stream Infections Preventing Surgical Site Infections Preventing Catheter-Associated Urinary Tract Infection Identifying Individuals at Risk for Suicide Conducting a Pre-Procedure Verification Process Marking the Procedure Site Performing a Time-Out 10 Copyright 2018, The Joint Commission