Malcolm Grow Medical Clinics and Surgery Center
Joint Base Andrews, Maryland 20762
Patient-Centered Care
Measure name | Leapfrog’s Standard | Progress Towards Meeting Leapfrog’s Standard |
---|---|---|
Billing Ethics |
Surgery centers should publish prices, and provide patients with complete billing information and access to a representative that can quickly resolve billing issues. In addition, surgery centers should not sue patients over late or unpaid bills. |
LIMITED ACHIEVEMENT |
This surgery center does not publish pricing information for common procedures. This surgery center provides a detailed bill within 30 days of receiving insurance payments: Yes This surgery center provides access to a representative who can quickly investigate billing errors and establish payment plans: Yes This surgery center sues patients: Yes |
||
Informed Consent |
Surgery centers should ensure that all patients are fully aware of risks and alternatives prior to tests, treatments, and procedures. |
LIMITED ACHIEVEMENT |
All staff involved in the informed consent process achieve the appropriate training: Yes Doctors explain expected difficulties and recovery time and allow patients to ask questions: No Doctors involved in the test, treatment, or procedure are listed on the consent form, and patients are notified if the doctor will be absent and if trainees will be involved: No Consent forms are written at a 6th grade reading level: No Staff ask patients about their preferred language for decision-making and make a trained medical interpreter available if appropriate: Yes Doctors use the "teach back method" to ensure patients understand what will be performed and what are the risks: Yes |
||
Responding to Never Events |
Surgery centers should have a never events policy that includes all nine (9) actions that should occur following a “never event,” which includes apologizing to the patient and not charging for costs associated with the never event. |
ACHIEVED THE STANDARD |
Preventing Patient Harm
Measure name | Leapfrog’s Standard | Progress Towards Meeting Leapfrog’s Standard | ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Percentage of Registered Nurses (RNs) who have a Bachelor’s Degree in Nursing |
Surgery centers should have a high proportion of highly trained and skilled registered nurses (RNs) who have an advanced nursing degree. |
ACHIEVED THE STANDARD |
||||||||||||
Effective Leadership to Prevent Errors |
Surgery centers should take meaningful steps to raise awareness about patient safety, hold leadership accountable for reducing unsafe practices, provide resources to implement a patient safety program, and develop systems and structures to support action to improve patient safety. |
ACHIEVED THE STANDARD |
||||||||||||
This surgery center scored 120.00 out of 120.00 possible points. |
||||||||||||||
Staff Work Together to Prevent Errors |
Surgery centers should have assessed their culture of safety and held leadership accountable for implementing policies, procedures, and staff education to improve the culture of safety. |
ACHIEVED THE STANDARD |
||||||||||||
This surgery center scored 120.00 out of 120.00 possible points. |
||||||||||||||
Staff Identify and Mitigate Risks Associated with Errors |
Surgery centers should use retrospective and prospective data sources, including patient reports, to identify and mitigate errors that harm patients including medication errors and infections. |
CONSIDERABLE ACHIEVEMENT |
||||||||||||
This surgery center scored 83.33 out of 100.00 possible points. |
||||||||||||||
Handwashing |
Surgery centers should regularly monitor hand hygiene practices for everyone interacting with patients, and give feedback to ensure compliance. Surgery centers foster a culture of good hand hygiene, offer training and education, and have provided equipment, such as paper towels, soap dispensers, and hand sanitizer. |
ACHIEVED THE STANDARD |
||||||||||||
|
Healthcare-Associated Infections
Measure name | Leapfrog’s Standard | Progress Towards Meeting Leapfrog’s Standard |
---|---|---|
Tracking and Reporting Accidents and Infections |
Surgery centers should track and report all applicable accidents such as burns, falls, errors, hospital admissions and surgical site infections, to a national database. |
LIMITED ACHIEVEMENT |
Medication Safety
Measure name | Leapfrog’s Standard | Progress Towards Meeting Leapfrog’s Standard | ||||||||
---|---|---|---|---|---|---|---|---|---|---|
Medication Documentation for Elective Outpatient Surgery Patients |
Surgery centers should document 90% or more of home medications, visit medications, and allergies/adverse reaction(s) in the patients’ clinical record. |
CONSIDERABLE ACHIEVEMENT |
||||||||
|
Total Joint Replacement
Measure name | Leapfrog’s Standard | Progress Towards Meeting Leapfrog’s Standard |
---|---|---|
Total Knee Replacement Surgery |
Surgery centers should perform at least 50 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 25 procedures annually. |
DOES NOT APPLY |
Total Hip Replacement Surgery |
Surgery centers should perform at least 50 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 25 procedures annually. |
DOES NOT APPLY |
Elective Outpatient Surgery - Adult
Gastroenterology (Stomach and Digestive)
Procedure | Number of Procedures Performed Annually |
---|---|
Lower GI Endoscopies | 325 |
Other Upper GI Procedures | 0 |
Upper GI Endoscopies | 155 |
General Surgery
Procedure | Number of Procedures Performed Annually |
---|---|
Cholecystectomies and Common Duct Explorations | 25 |
Hemorrhoid Procedures | 8 |
Inguinal and Femoral Hernia Repairs | 41 |
Laparoscopies | 5 |
Lumpectomies and Quadrantectomies of Breast | 4 |
Mastectomies | 1-3 |
Other Hernia Repairs | 1-3 |
Obstetrics and Gynecology
Procedure | Number of Procedures Performed Annually |
---|---|
Cervix Procedures | 10 |
Hysteroscopies | 75 |
Uterus and Adnexa Laparoscopies | 28 |
Ophthalmology (Eyes)
Procedure | Number of Procedures Performed Annually |
---|---|
Anterior Segment Eye Procedures | 275 |
Posterior Segment Eye Procedures | 6 |
Other Eye Procedures | 23 |
Orthopedic (Bones and Joints)
Procedure | Number of Procedures Performed Annually |
---|---|
Finger, Hand, Wrist, Forearm, and Elbow Procedures | 22 |
General Orthopedic Procedures | 10 |
Hip Procedures
(Does not include total hip replacements – see Total Joint Replacement)
|
0 |
Knee Procedures
(Does not include total hip replacements – see Total Joint Replacement)
|
55 |
Shoulder Procedures | 52 |
Spine Procedures | 0 |
Toe, Foot, Ankle, and Leg Procedures | 35 |
Otolaryngology (Ear, Nose, Mouth, and Throat)
Procedure | Number of Procedures Performed Annually |
---|---|
Ear Procedures | 17 |
Mouth Procedures | 15 |
Nasal and Sinus Procedures | 117 |
Plastic and Reconstructive Surgery
Procedure | Number of Procedures Performed Annually |
---|---|
Breast Repairs and Reconstructions | 13 |
Skin Grafts and Repairs | 22 |
Urology (Urinary Tract, Male Reproductive)
Procedure | Number of Procedures Performed Annually |
---|---|
Circumcisions | 5 |
Cystourethroscopies | 14 |
Male Genital Procedures | 1-3 |
Urethra Procedures | 4 |
Vaginal Repair Procedures | 0 |
Elective Outpatient Surgery - Pediatric
Ophthalmology (Eyes)
Procedure | Number of Procedures Performed Annually |
---|---|
Anterior Segment Eye Procedures | 0 |
Posterior Segment Eye Procedures | 0 |
Other Eye Procedures | 5 |
Orthopedic (Bones and Joints)
Procedure | Number of Procedures Performed Annually |
---|---|
Finger, Hand, Wrist, Forearm, and Elbow Procedures | 0 |
General Orthopedic Procedures | 0 |
Knee Procedures | 1-3 |
Shoulder Procedures | 0 |
Toe, Foot, Ankle, and Leg Procedures | 0 |
Otolaryngology (Ear, Nose, Mouth, and Throat)
Procedure | Number of Procedures Performed Annually |
---|---|
Ear Procedures | 42 |
Mouth Procedures | 0 |
Nasal and Sinus Procedures | 8 |
Pharynx, Adenoid, and Tonsil Procedures | 33 |
Care for Elective Outpatient Surgery Patients
Measure name | Leapfrog’s Standard | Progress Towards Meeting Leapfrog’s Standard |
---|---|---|
Elective Outpatient Surgery Recovery Staffing - Adult |
Surgery centers should ensure that a specially certified clinician and at least one physician or nurse anesthetist are present and immediately available while an adult patient is present until discharge. |
ACHIEVED THE STANDARD |
Elective Outpatient Surgery Recovery Staffing - Pediatric |
Surgery centers should ensure that a specially certified clinician and at least one physician or nurse anesthetist are present and immediately available while a pediatric patient is present until discharge. |
ACHIEVED THE STANDARD |
Safe Surgery Checklist - Elective Outpatient Surgery |
Surgery centers should go through all the elements of a complete safe surgery checklist on all patients every time a procedure is performed. |
ACHIEVED THE STANDARD |
Experience of Patients Undergoing Elective Outpatient Surgery |
Surgery centers should perform better than most on four (4) areas including: (a) facilities and staff (b) communication about the procedure, (c) patients’ overall rating of the facility, and (d) patients' willingness to recommend the facility. |
UNABLE TO CALCULATE
|
Unplanned Hospital Visits after Colonoscopy |
Unplanned hospital visits can occur when patients experience complications after a colonoscopy procedure. Facilities should have a rate of unplanned hospital visits that is lower than most hospitals and surgery centers. |
UNABLE TO CALCULATE
|
Unplanned Hospital Visits after Orthopedic Procedures |
Unplanned hospital visits can occur when patients experience complications after an orthopedic procedure. Facilities should have a rate of unplanned hospital visits that is lower than most surgery centers. |
UNABLE TO CALCULATE
|
Unplanned Hospital Visits after Urology Procedures |
Unplanned hospital visits can occur when patients experience complications after a urology procedure. Facilities should have a rate of unplanned hospital visits that is lower than most surgery centers. |
UNABLE TO CALCULATE
|
More Information
Patient Selection |
The surgery center has a screening protocol to determine whether a patient’s procedure can safely be performed on an outpatient basis, and the protocol includes the following components:
|
Malcolm Grow Medical Clinics and Surgery Center
1060 W Perimeter Rd
Joint Base Andrews, Maryland 20762
Map and Directions | |||||||||||||||||
More Information Hide More Information | |||||||||||||||||
|