The Joint Commission
Quality Check
Quality Report

Summary of Quality Information
North Carolina Baptist Hospital
DBA: Wake Forest Baptist Medical Center
Org ID: 6571
Medical Center Boulevard
Winston Salem, NC  27157
(336)716-2011
wakehealth.edu


Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full Survey Date Last On-Site Survey Date
Hospital
Accredited 12/10/2011 12/9/2011   12/9/2011  


Accreditation programs recognized by the Centers for Medicare and Medicaid Services (CMS)
Hospital


Advanced Certification
Programs
Certification
Decision
Effective
Date
Last Full
Review Date
Last On-Site
Review Date
Advanced Comprehensive Stroke Center
Certification 5/24/2013  3/26/2013  3/26/2013 
Ventricular Assist Device
Certification 8/14/2013  8/13/2013  8/13/2013 



Certified
Programs
Certification
Decision
Effective
Date
Last Full
Review Date
Last On-Site
Review Date
Acute Myocardial Infarction
Certification 7/12/2012  7/11/2012  7/11/2012 
Heart Failure
Certification 7/11/2012  7/10/2012  7/10/2012 
Joint Replacement - Hip
Certification 9/12/2012  9/11/2012  9/11/2012 
Joint Replacement - Knee
Certification 9/12/2012  9/11/2012  9/11/2012 


Certification programs recognized by the Centers for Medicare and Medicaid Services (CMS)
Ventricular Assist Device


Other Accredited Programs / Services
Hospital  -  Accredited by American College of Surgeons-Commission on Cancer (ACoS-COC)


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  Symbol Key
This organization achieved the best possible results
This organization’s performance is above the target range/value.
This organization’s performance is similar to the target range/value.
This organization’s performance is below the target range/value.
This measure is not applicable for this organization.
Not displayed
  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.
National Patient Safety Goals and National Quality Improvement Goals
    Compared to other Joint Commission Accredited Organizations
    Nationwide Statewide
Hospital
2011 National Patient Safety Goals See Detail
This organization’s performance is similar to the target range/value.
This Goal is not applicable for this organization.
*
National Quality Improvement Goals:    
Reporting Period:
Jan  2013 -
Dec  2013
Children's Asthma Care See Detail
This organization’s performance is below the target range/value.
This organization’s performance is similar to the target range/value.
Heart Attack Care See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
Heart Failure Care See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
Pneumonia Care See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
Surgical Care Improvement Project (SCIP)    
SCIP - Cardiac See Detail
   
SCIP - Infection Prevention
For All Reported Procedures:
See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
  • Blood Vessel Surgery
See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
  • Colon/Large Intestine Surgery
See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
  • Coronary Artery Bypass Graft
See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
  • Hip Joint Replacement
See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
  • Hysterectomy
See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
  • Knee Replacement
See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
  • Open Heart Surgery
See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
SCIP – Venous Thromboembolism (VTE) See Detail
   
 
National Quality Forum The Joint Commission only reports measures endorsed by the National Quality Forum.
 
* State results are not calculated for the National Patient Safety Goals.

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Sites and Services
* Primary Location

An organization may provide services not listed here. For more information refer to the Quality Report User Guide .

Locations of Care Available Services
Abdominal Organ Transplant of NC Baptist Hospital
DBA:  Transplant Clinic
140 Charloiss Blvd.
Winston Salem, NC  27103
    Services:
    • Outpatient Clinics (Outpatient)
    CompRehab
    DBA:  Outpatient Clinics
    131 Miller Street
    Winston Salem, NC  27157
    Other Clinics/Practices located at this site:
    • NC Baptist Hospital Outpatient Clinic, Orthopedics and Multi
    • NC Baptist Hospital, Otolaryngology
    Services:
    • Outpatient Clinics (Outpatient)
    Dermatology & Mohs Surgery NCBH Outpatient Clinic
    DBA:  Provider Based Clinics
    4618 Country Club Road
    Winston Salem, NC  27104
    Other Clinics/Practices located at this site:
    • General Dermatology NCBH Outpatient Clinic
    Services:
    • Outpatient Clinics (Outpatient)
    • Perform Invasive Procedure (Outpatient)
    Downtown Health Plaza
    DBA:  Outpatient Clinics
    1200 Martin Luther King, Jr., Drive
    Winston Salem, NC  27101
    Other Clinics/Practices located at this site:
    • Adult Medicine-Downtown Health Plaza
    • Obstetrics and Gynecology-Downtown Health Plaza
    • Pediatrics-Downtown Health Plaza
    Services:
    • Outpatient Clinics (Outpatient)
    Family Medicine NC Baptist Hospital Outpatient Clinic
    DBA:  Provider Based Clinic
    1920 West First Street
    Winston Salem, NC  27157
      Services:
      • Outpatient Clinics (Outpatient)
      Hematology and Oncology-Mt. Airy NCBH Clinics
      DBA:  Provider Based Clinic
      450 Pine Street
      Mount Airy, NC  27030
        Services:
        • Administration of Blood Product (Outpatient)
        • Administration of High Risk Medications (Outpatient)
        • Outpatient Clinics (Outpatient)
        Medical Plaza Clemmons NCBH Clinics
        DBA:  Provider Based Clinics
        2311 Lewisville-Clemmons Road
        Clemmons, NC  27012
        Other Clinics/Practices located at this site:
        • Allergy, Asthma and Immunology-Clemmons
        • Brenner Children's Specialty Services-Clemmons
        • Hematology and Oncology-Clemmons
        • Pediatrics-Clemmons
        • University Internal Medicine-Clemmons
        Services:
        • Administration of Blood Product (Outpatient)
        • Administration of High Risk Medications (Outpatient)
        • Outpatient Clinics (Outpatient)
        Medical Plaza Clemmons of NCBH Clinics
        DBA:  Provider Based Clinic
        2341 Lewisville-Clemmons Road
        Clemmons, NC  27012
        Other Clinics/Practices located at this site:
        • Breast Care Services-Clemmons
        • ENT/Head and Neck Surgery-Clemmons
        • Neurology-Clemmons
        • Obstetrics and Gynecology-Clemmons
        • Spine Center-Clemmons
        • Vein Services-Clemmons
        Services:
        • Administration of High Risk Medications (Outpatient)
        • Anesthesia (Outpatient)
        • Outpatient Clinics (Outpatient)
        • Perform Invasive Procedure (Outpatient)
        Medical Plaza Country Club NCBH Clinics
        DBA:  Provider Based Clinic
        4610 Country Club Road
        Winston Salem, NC  27104
        Other Clinics/Practices located at this site:
        • Joslin Diabetes Center -- Pediatrics
        • Joslin Diabetes Center --Adult
        Services:
        • Outpatient Clinics (Outpatient)
        North Carolina Baptist Hospital  *
        DBA:  Wake Forest Baptist Medical Center
        Medical Center Boulevard
        Winston Salem, NC  27157
        Joint Commission Advanced Certification Programs:
        • Advanced Comprehensive Stroke Center
        • Ventricular Assist Device
        Joint Commission Certified Programs:
        • Acute Myocardial Infarction
        • Heart Failure
        • Joint Replacement - Hip
        • Joint Replacement - Knee
        Other Clinics/Practices located at this site:
        • Breast Care Center, Surgical Oncology Unit
        • Brenner Children's Hospital & Health Services
        • Brenner Children's Hospital, Pediatric Otolaryngology (ENT)
        • Geriatrics Clinic
        • Hematology and Oncology
        • Neurology
        • Neurosurgery Clinic
        • Pediatric Hematology and Oncology Clinic
        • Preoperative Assessment Clinic
        • Radiation Oncology
        • Wake Forest University Eye Center
        • Wake Forest University Physicians Medicine
        • Wake Forest University Physicians Surgical Clinics
        • Wound Care and Hyperbaric Chamber
        Services:
        • Brachytherapy (Imaging/Diagnostic Services)
        • Burn Unit (Inpatient)
        • Cardiac Catheterization Lab (Surgical Services)
        • Cardiac Surgery (Surgical Services)
        • Cardiothoracic Surgery (Surgical Services)
        • Cardiovascular Unit (Inpatient)
        • Coronary Care Unit (Inpatient)
        • CT Scanner (Imaging/Diagnostic Services)
        • Dialysis Unit (Inpatient)
        • 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)
        • Hematology/Oncology Unit (Inpatient)
        • Inpatient Unit (Inpatient)
        • Interventional Radiology (Imaging/Diagnostic Services)
        • Magnetic Resonance Imaging (Imaging/Diagnostic Services)
        • Medical /Surgical Unit (Inpatient)
        • Medical ICU (Intensive Care Unit)
        • Neuro/Spine ICU (Intensive Care Unit)
        • Neuro/Spine Unit (Inpatient)
        • Neurosurgery (Surgical Services)
        • Nuclear Medicine (Imaging/Diagnostic Services)
        • Ophthalmology (Surgical Services)
        • Orthopedic Surgery (Surgical Services)
        • Orthopedic/Spine Unit (Inpatient)
        • Outpatient Clinics (Outpatient)
        • Pediatric Unit (Inpatient)
        • Plastic Surgery (Surgical Services)
        • Positron Emission Tomography (PET) (Imaging/Diagnostic Services)
        • Post Anesthesia Care Unit (PACU) (Inpatient)
        • Radiation Oncology (Imaging/Diagnostic Services)
        • Rehabilitation Unit (Inpatient, 24-hour Acute Care/Crisis Stabilization)
        • Sleep Laboratory (Sleep Laboratory)
        • Surgical ICU (Intensive Care Unit)
        • Surgical Unit (Inpatient)
        • Teleradiology (Imaging/Diagnostic Services)
        • Thoracic Surgery (Surgical Services)
        • Transplant Surgery (Surgical Services)
        • Ultrasound (Imaging/Diagnostic Services)
        • Urology (Surgical Services)
        • Vascular Surgery (Surgical Services)
        Pain Services - Brookstown NCBH Clinic
        DBA:  Provider Based Clinic
        605 Cotton Street
        Winston Salem, NC  27101
          Services:
          • Administration of High Risk Medications (Outpatient)
          • Anesthesia (Outpatient)
          • Outpatient Clinics (Outpatient)
          • Perform Invasive Procedure (Outpatient)
          Stratford Executive Park
          DBA:  Provider Based Clinics
          500 Shepherd St. Suites 200, 201, 300
          Winston Salem, NC  27103
          Other Clinics/Practices located at this site:
          • Comprehensive Fetal Care Center
          • NCBH Internal Medicine
          • Obstetrics & Gynecology
          Services:
          • Outpatient Clinics (Outpatient)
          University Internal Medicine-Country Club NC Baptist Hospita
          DBA:  Provider Based Clinic
          4614 Country Club Road
          Winston Salem, NC  27104
          Other Clinics/Practices located at this site:
          • Cardiology-Country Club NC Baptist Hospital Clinics
          • Weight Management Center-Country Club NC Baptist Hospital Cl
          Services:
          • Outpatient Clinics (Outpatient)
          Winston East Pediatrics of Baptist Hospital
          DBA:  Provider Based Clinic
          2795 E. 14th Street
          Winston Salem, NC  27101
            Services:
            • Outpatient Clinics (Outpatient)

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