2015 General Thoracic Surgery 3-Star Quality Rating
The Society of Thoracic Surgeons has a comprehensive rating system that allows for comparisons regarding the quality of cardiac surgery among hospitals across the country. Approximately 10% of hospitals receive the "3 star" rating, which denotes the highest category of quality. In the current analysis of national data covering the period from January, 2015 through December, 2015, the cardiac surgery performance of our hospital was found to lie in the highest quality tier, thereby receiving an STS 3 star rating.
2018 ACTION Registry®–GWTG™ Platinum Performance Achievement
To receive the ACTION Registry–GWTG Platinum Performance Achievement Award, this hospital consistently followed the treatment guidelines in the ACTION Registry–GWTG Premier for eight consecutive quarters and met a performance standard of 90% for specific performance measures. ACTION Registry-GWTG empowers health care provider teams to consistently treat heart attack patients according to the most current, science-based guidelines and establishes a national standard for understanding and improving the quality, safety and outcomes of care provided for patients with coronary artery disease, specifically high-risk heart attack patients.
2018 Get With The Guidelines® Heart Failure - Gold Plus Honor Roll
The American Heart Association recognizes this hospital for achieving 85% or higher compliance with all Get With The Guidelines® Heart Failure Achievement Measures and 75% or higher compliance with four or more Get With The Guidelines Heart Failure Quality Measures for two or more consecutive years and for documentation of all three Target: Heart Failure℠ care components for 50% or more of eligible patients with hear failure discharged from the hospital to improve quality of patient care.
2018 Get With The Guidelines® Stroke - Gold Plus Honor Roll Elite
The American Heart Association/American Stroke Association recognizes this hospital for achieving 85% or higher compliance with all Get With The Guidelines® Stroke Achievement Measures and 75% or higher compliance with five or more Get With The Guidelines® Stroke Quality Measures for two or more consecutive years and achieving Time to Thrombolytic Therapy ≤ 60 minutes 75% ore more of applicable acute ischemic stroke patients to improve the quality of patient care and outcomes.
2019 Get With The Guidelines® Stroke - Gold Plus Honor Roll Elite Plus
The American Heart Association/American Stroke Association recognizes this hospital for achieving 85% or higher compliance with all Get With The Guidelines® Stroke Achievement Measures and 75% or higher compliance with five or more Get With The Guidelines® Stroke Quality Measures for two or more consecutive years and achieving Thrombolytic Therapy ≤ 60 minutes 75% and ≤ 45 minutes in 50% of applicable acute ischemic stroke patients improve the quality of patient care and outcomes.
2020 Patient Safety Excellence Award™
This hospital has been designated for superior performance in preventing the occurrence of serious, potentially avoidable complications for patients during hospital stays. The distinction places it among the top percent of all short-term acute care hospitals reporting patient safety data for its excellent performance as evaluated by Healthgrades, the leading online resource for comprehensive information about physicians and hospitals.
Top 10%: Research Medical Center, Belton Regional Medical Center
Top 5%: Menorah Medical Center, Centerpoint Medical Center
Breast Imaging Center of Excellence
By awarding facilities the status of a Breast Imaging Center of Excellence, the ACR recognizes breast imaging centers that have earned accreditation in mammography, stereotactic breast biopsy, and breast ultrasound (including ultrasound-guided breast biopsy). Peer-review evaluations, conducted in each breast imaging modality by board-certified physicians and medical physicists who are experts in the field, have determined that this facility has achieved high practice standards in image quality, personnel qualifications, facility equipment, quality control procedures, and quality assurance programs.
Accreditations and Certifications
Advanced Certification in Heart Failure
The Joint Commission has developed an advanced level of certification for programs that must meet the requirements for Disease-Specific Care Certification plus additional, clinically-specific requirements and expectations. This certification improves the quality of care provided to patients, demonstrates commitment to a higher standard of service, provides a framework for organizational structure and management, provides a competitive edge in the marketplace, enhances staff recruitment and development and is recognized by insurers and other third parties.
Blue Distinction Center for Knee and Hip Replacement
Using objective information and input from the medical community, the Blues® have designated hospitals as Blue Distinction Centers that are proven to outperform their peers in the areas that matter to you – quality, safety and, in the case of Blue Distinction Centers+, efficiency.
Blue Distinction Centers for Knee and Hip Replacement and Blue Distinction Centers+ for Knee and Hip Replacement® provide comprehensive inpatient knee and hip replacement services, including total knee replacement and total hip replacement surgeries.
CAP Laboratory Accreditation
The CAP Laboratory Accreditation Program is an internationally recognized program and the only one of its kind that utilizes teams of practicing laboratory professionals as inspectors. Designed to go well beyond regulatory compliance, the program helps laboratories achieve the highest standards of excellence to positively impact patient care. The program is based on rigorous accreditation standards that are translated into detailed and focused checklist requirements. The checklists, which provide a quality practice blueprint for laboratories to follow, are used by the inspection teams as a guide to assess the overall management and operation of the laboratory.
Certified Cardiac Rehabilitation Program
The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) certification demonstrates that this hospital's program is aligned with current guidelines as approved by the AACVPR for the appropriate and effective early outpatient care of patients with cardiac or pulmonary issues. Certified AACVPR programs are recognized as leaders in the field of cardiovascular and pulmonary rehabilitation because they offer the most advanced practices available.
Accreditation by the Intersocietal Accreditation Commission (IAC) means that this hospital has undergone a thorough review of its operational and technical components by a panel of experts. The IAC grants accreditation only to those facilities that are found to be providing quality patient care, in compliance with national standards through a comprehensive application process including detailed case study review. IAC accreditation is a “seal of approval” that patients can rely on as an indication that the facility has been carefully critiqued on all aspects of its operations considered relevant by medical experts in the field of Echocardiography.
MBSAQIP Bariatric Surgery Program Accreditation
To earn the MBSAQIP designation, this hospital met essential criteria for staffing, training and facility infrastructure and protocols for care, ensuring its ability to support patients with severe obesity. The hospital also participates in a national data registry that yields semiannual reports on the quality of its processes and outcomes, identifying opportunities for continuous quality improvement. The standards are specified in the MBSAQIP Resources for Optimal Care of the Metabolic and Bariatric Surgery Patient 2014, published by the ACS and ASMBS.
National Accreditation Program for Breast Centers (NAPBC)
As the gold standard for breast center accreditation, NAPBC evaluates strengths across a wide spectrum of services, including prevention, early detection, diagnosis, support staff, staging, cancer treatment, rehabilitation, the quality of the multidisciplinary team and genetic counseling. To receive accreditation, breast centers must undergo a rigorous evaluation and review of their performance and adherence to NAPBC standards. Based on these stringent, nationally recognized, evidence-based quality measures, accreditation is granted only to those centers that commit to providing the best possible comprehensive care to patients with diseases of the breast.
Sleep Medicine Accreditation
American Academy of Sleep Medicine accreditation is the gold standard by which the medical community and the public can evaluate sleep medicine services. The Standards for Accreditation ensure that sleep medicine providers display and maintain proficiency in areas such as testing procedures and policies, patient safety and follow-up, and physician and staff training.
The Commission on Cancer Accreditation
The Commission on Cancer (CoC) Accreditation Program encourages hospitals, treatment centers, and other facilities to improve their quality of patient care through various cancer-related programs. These programs focus on prevention, early diagnosis, pretreatment evaluation, staging, optimal treatment, rehabilitation, surveillance for recurrent disease, support services, and end-of-life care. The availability of a full range of medical services along with a multidisciplinary team approach to patient care at accredited cancer programs has resulted in approximately 80 percent of all newly diagnosed cancer patients being treated in CoC-accredited cancer programs.
The Joint Commission National Quality Approval
This hospital has earned The Joint Commission’s Gold Seal of Approval® for accreditation by demonstrating compliance with The Joint Commission’s national standards for health care quality and safety in hospitals. The accreditation award recognizes this hospital’s dedication to continuous compliance with The Joint Commission’s state-of-the-art standards.
The ACR gold seal of accreditation represents the highest level of image quality and patient safety. It is awarded only to facilities meeting ACR Practice Guidelines and Technical Standards after a peer-review evaluation by board-certified physicians and medical physicists who are experts in the field. Image quality, personnel qualifications, adequacy of facility equipment, quality control procedures, and quality assurance programs are assessed. The findings are reported to the ACR Committee on Accreditation, which subsequently provides the practice with a comprehensive report they can use for continuous practice improvement.