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Quality of Care

We are committed to continuous improvement and accountability. We report data made publicly available by CMS Hospital Compare, as well as our most current corresponding internal data.

Colonoscopy Follow-Up

Preventive Care

Oct 2016 - March 2017
  National Average BGH Hospital Compare CGH Latest Compare Dyersburg Hospital Compare MGH Hospital Compare Volunteer Martin Hospital Compare
Assessed and Given Influenza Vaccination 93 91 99 100 98 99
Healthcare workers given influenza vaccination 88 90 N/A 83 80 73

Assessed and Given Influenza Vaccination

Flu shots reduce the risk of influenza, a serious and sometimes deadly lung infection that can spread quickly in a community or facility

Blood Clot

Oct 2016 - June 2017
National Average JMCGH Hospital Compare JMCGH Latest Internal Data
Patients who developed a blood clot while in the hospital who did not get treatment that could have prevented it.
(Scale 2-12%)
2% 5% 3%*
* Represents 4 Patients
Patients with blood clots who were discharged on a blood thinner medicine and received written instructions about that medicine.

Educating patients about how to take the medicine and its possible side effects can help prevent problems that could bring them back to the hospital. Before leaving the hospital, patients with a blood clot, who are taking a blood thinner medicine, and their caregiver should receive information about the following topics: how to follow medication instructions, how to eat a healthy diet and avoid foods that interfere with blood thinners, monitoring their blood thinner medicine, adverse drug reactions, and when to call your health care provider.

Pregnancy and Delivery Rate

Oct 2016 - June 2017
  National Average JMCGH Hospital Compare Data JMCGH Latest Internal Data
Percent of newborns whose deliveries were scheduled too early (1-3 weeks early), when a scheduled delivery was not medically necessary. 2% 0% 0%

Percent of newborns whose deliveries were scheduled too early (1-3 weeks early), when a scheduled delivery was not medically necessary

Guidelines developed by doctors and researchers say it’s best to wait until the 39th completed week of pregnancy to deliver your baby because important fetal development takes place in your baby’s brain and lungs during the last few weeks of pregnancy.

National Surgical Quality Improvement Project

  July 2016 - June 2017
Death or Serious Morbidity (Complications of Care) Average
Return to Operating Room Average
Colon Surgical Outcomes Meets American College of Surgeons Expectations (Hospital Compare)
Outcomes in Surgeries for Patients 65 Years or Older Meets American College of Surgeons Expectations

Emergency Department Care

Timely Emergency Department Care
Average (median) time patients spent in the emergency department, before they were admitted to the hospital as an inpatient.
Medicare Definition
This number only includes patients who were admitted to the hospital as an inpatient. It doesn't include those people who went home. Long stays in an emergency department before a patient is admitted may be a sign that the emergency department is understaffed or overcrowded. This may result in delays in treatment or lower quality care.
National Average Oct 2016-Sept 2017 JMCGH Hospital Compare Data Oct 2016-Sept 2017 JMCGH Latest Internal Data Oct 2016-Sept 2017
Clock 334 minutes Clock 263 minutes Clock 268 minutes
Timely Emergency Department Care
Average (median) time patients spent in the emergency department, after the doctor decided to admit them as an inpatient before leaving the emergency department for their inpatient room.
Medicare Definition
Delays in transferring emergency department patients to an inpatient unit may be a sign that there's not enough staff or there's poor coordination among hospital departments. Long delays can also create more stress for patients and families.
National Average Oct 2016-Sept 2017 JMCGH Hospital Compare Data Oct 2016-Sept 2017 JMCGH Latest Internal Data Oct 2016-Sept 2017
Clock 140 minutes Clock 89 minutes Clock 90 minutes
Timely Emergency Department Care
Average (median) time patients spent in the emergency department before leaving from the visit.
Medicare Definition
Long stays in the emergency department before a patient is sent home may be a sign that the emergency department is understaffed or overcrowded. This may result in delays in treatment, increased suffering for those who wait, and unpleasant treatment environments.
National Average Oct 2016-Sept 2017 JMCGH Hospital Compare Data Oct 2016-Sept 2017 JMCGH Latest Internal Data Oct 2016-Sept 2017
Clock 171 minutes Clock 183 minutes Clock 184 minutes
Timely Emergency Department Care
Average (median) time patients spent in the emergency department before they were seen by a healthcare professional.
Medicare Definition
Delays in being seen by a healthcare provider may be a sign that the emergency department is understaffed or overcrowded. This may result in delays in treatment or lower quality care. In addition, long delays can create more stress for patients and families.
National Average Oct 2016-Sept 2017 JMCGH Hospital Compare Data Oct 2016-Sept 2017 JMCGH Latest Internal Data Oct 2016-Sept 2017
Clock 26 minutes Clock 23 minutes Clock 24 minutes
Timely Emergency Department Care
Average (median) time patients who came to the emergency department with broken bones had to wait before receiving pain medication.
Medicare Definition
Long waits before a patient is treated may be a sign that the emergency department is understaffed or overcrowded. For patients with broken bones, long waits without pain medication cause unnecessary increased suffering.
National Average Oct 2016-Sept 2017 JMCGH Hospital Compare Data Oct 2016-Sept 2017 JMCGH Latest Internal Data Oct 2016-Sept 2017
Clock 48 minutes Clock 51 minutes Clock 50 minutes
Timely Emergency Department Care
Percentage of patients who left the emergency department before being seen.
Medicare Definition
Lower percentages are better.
National Average Oct 2016-Sept 2017 JMCGH Hospital Compare Data Oct 2016-Sept 2017 JMCGH Latest Internal Data Oct 2016-Sept 2017
2% 3% N/A
Timely Emergency Department Care
Percentage of patients who came to the emergency department with stroke symptoms who received brain scan results within 45 minutes of arrival.
Medicare Definition
Higher percentages are better.
National Average Oct 2016-Sept 2017 JMCGH Hospital Compare Data Oct 2016-Sept 2017 JMCGH Latest Internal Data Oct 2016-Sept 2017
74% 64% 78%

Accreditations

Accreditations Organization
Blue Distinction Center+ for Cardiac Care Blue Cross Blue Shield
Blue Distinction Center+ for Maternity Care Blue Cross Blue Shield
Blue Distinction Center+ for Hip & Knee Replacement Programs Blue Cross Blue Shield
Hip & Knee Replacement Surgery The Joint Commission and HealthGrades 5-Star Hospital
Chest Pain Center with PCI Society of Chest Pain Centers
Primary Stroke Center The Joint Commission
Comprehensive Community Cancer Center American College of Surgeon's Commission on Cancer
Accredited Commission on the Accreditation of Rehab Facilities
Accredited American Academy of Sleep Disorders
CAP, CAP Forensic Urine Drug Testing, and CAP System Integration College of American Pathologists
Lab Accredited Drug Enforcement Administration
Lab Accredited American Society of Histocompatibility and Immunogenetics

All of the above data is from the CMS Hospital Compare Website except for the internal data, which has been submitted but is not yet available on Hospital Compare.

Colonoscopy Follow-Up

Jan 2016 - Dec 2016
  National Average BGH Hospital Compare Data CGH Hospital Compare Data Dyersburg Hospital Compare Data MGH Hospital Compare Data Volunteer Martin Hospital Compare Data
Percentage of patients receiving appropriate recommendation for follow-up screening colonoscopy 85 100 N/A 100 81 53
Percentage of patients with history of polyps receiving follow-up colonoscopy in the appropriate timeframe 90 N/A N/A 100 93 99

Preventive Care

Oct 2016 - March 2017
National Average BGH Hospital Compare CGH Latest Compare Dyersburg Hospital Compare MGH Hospital Compare Volunteer Martin Hospital Compare
Assessed and Given Influenza Vaccination 93 91 99 100 98 99
Healthcare workers given influenza vaccination 88 90 N/A 83 80 73
Assessed and Given Influenza Vaccination

Flu shots reduce the risk of influenza, a serious and sometimes deadly lung infection that can spread quickly in a community or facility

Emergency Department Care

2016 - 2017
Timely Emergency Department Care Medicare Definition Additional Information National Average BGH Hospital Compare Data CGH Hospital Compare Data Dyersburg Hospital Compare Data MGH Hospital Compare Data Volunteer Martin Hospital Compare Data
Average (median) time patients spent in the emergency department, before they were admitted to the hospital as an inpatient. This number only includes patients who were admitted to the hospital as an inpatient. It doesn't include those people who went home. Long stays in an emergency department before a patient is admitted may be a sign that the emergency department is understaffed or overcrowded. This may result in delays in treatment or lower quality care. 208 minutes 226 minutes 235 minutes 226 minutes 227 minutes 190 minutes
Average (median) time patients spent in the emergency department, after the doctor decided to admit them as an inpatient before leaving the emergency department for their inpatient room. Delays in transferring emergency department patients to an inpatient unit may be a sign that there's not enough staff or there's poor coordination among hospital departments. Long delays can also create more stress for patients and families. 55 minutes 77 minutes 63 minutes 81 minutes 59 minutes 46 minutes
Average (median) time patients spent in the emergency department before leaving from the visit. Long stays in the emergency department before a patient is sent home may be a sign that the emergency department is understaffed or overcrowded. This may result in delays in treatment, increased suffering for those who wait, and unpleasant treatment environments. 111 minutes 125 minutes 124 minutes 169 minutes 124 minutes 110 minutes
Average time patients spent in the emergency department before they were seen by a healthcare professional. Delays in being seen by a healthcare provider may be a sign that the emergency department is understaffed or overcrowded. This may result in delays in treatment or lower quality care. In addition, long delays can create more stress for patients and families. 16 minutes 30 minutes 23 minutes 25 minutes 21 minutes 22 minutes
Average time patients who came to the emergency department with broken bones had to wait before receiving pain medication. Long waits before a patient is treated may be a sign that the emergency department is understaffed or overcrowded. For patients with broken bones, long waits without pain medication cause unnecessary increased suffering. 48 minutes 49 minutes 48 minutes 28 minutes 50 minutes 51 minutes
Percentage of patients who left the emergency department before being seen. Lower percentages are better. 2% 3% N/A 2% 3% 1%

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