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Quality Report
Bon Secours Memorial Regional Medical Center
HCO ID: 6385
8260 Atlee Road
Mechanicsville, VA, 23116
(804) 764-6000
w w w.bonsecours.com
Summary of Quality Information
Accreditation Programs
View Accreditation History
Hospital
Accreditation
Decision
Accredited
Effective
Date
4/30/2016
Last Full Survey
Date
4/29/2016
Last On-Site
Survey Date
4/29/2016
Advanced Certification Programs
View Certification History
Advanced Palliative
Care
Certification
Decision
Certification
Effective
Date
1/29/2016
Last Full Survey
Date
1/28/2016
Last On-Site
Survey Date
1/28/2016
Primary Stroke
Center
Certification
Decision
Certification
Effective
Date
12/4/2015
Last Full Survey
Date
12/3/2015
Last On-Site
Survey Date
12/3/2015
© 2016 The Joint Commission, All Rights Reserved.
Core Certification Programs
Joint Replacement - Certification
Hip
Decision
Certification
Effective
Date
12/15/2015
Last Full Survey
Date
12/14/2015
Last On-Site
Survey Date
12/14/2015
Joint Replacement - Certification
Knee
Decision
Certification
Effective
Date
12/15/2015
Last Full Survey
Date
12/14/2015
Last On-Site
Survey Date
12/14/2015
Sites
Aylett Medical Center
7864 Richmond-Tappahannock
Hwy.
Aylett, VA, 23009
Bon Secours Cancer Institute
8266 Atlee Road
Mechanicsville, VA, 23116
Bon Secours Memorial
Regional Medical Center
8260 Atlee Road
Mechanicsville, VA, 23116
Available Services
Outpatient Clinics (Outpatient )
Perform Invasive Procedure
(Outpatient )
Single Specialty Practitioner
(Outpatient )
Available Services
Outpatient Clinics (Outpatient )
Available Services
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 )
© 2016 The Joint Commission, All Rights Reserved.
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 )
Labor & Delivery (Inpatient )
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 )
Normal Newborn Nursery (Inpatient
)
Nuclear Medicine
(Imaging/Diagnostic Services )
Ophthalmology (Surgical Services )
Orthopedic Surgery (Surgical
Services )
Orthopedic/Spine Unit (Inpatient )
Outpatient Clinics (Outpatient )
Plastic Surgery (Surgical Services )
Positron Emission Tomography (PET)
(Imaging/Diagnostic Services )
Post Anesthesia Care Unit (PACU)
(Inpatient )
Surgical ICU (Intensive Care Unit )
Surgical Unit (Inpatient )
Teleradiology (Imaging/Diagnostic
Services )
Thoracic Surgery (Surgical Services
)
Ultrasound (Imaging/Diagnostic
Services )
Urology (Surgical Services )
Vascular Surgery (Surgical
© 2016 The Joint Commission, All Rights Reserved.
Services )
Certification Programs
Advanced Palliative Care
Joint Replacement - Hip
Joint Replacement - Knee
Primary Stroke Center
Bon Secours Physical Therapy Available Services
at MRMC
8200 Meadowbridge Road, Suite
102
Mechanicsville, VA, 23116
Bon Secours Richmond
Cardiology Associates
8243 Meadowbridge Road
Mechanicsville, VA, 23116
Bon Secours Sleep Disorders
Centers-MRMC
DBA: same
MOB II Suite 229, 8260 Atlee Road
Mechanicsville, VA, 23116
Crossridge Pediatrics and
Internal Medicine
10150 Staples Mill Road, Suite E
Glen Allen, VA, 23060
Laburnum Medical Center
4620 South Laburnum Avenue
Richmond, VA, 23231
Single Specialty Practitioner
(Outpatient )
Available Services
Administration of High Risk
Medications (Outpatient )
Outpatient Clinics (Outpatient )
Single Specialty Practitioner
(Outpatient )
Available Services
Single Specialty Practitioner
(Outpatient )
Available Services
Outpatient Clinics (Outpatient )
Perform Invasive Procedure
(Outpatient )
Available Services
Outpatient Clinics (Outpatient )
Perform Invasive Procedure
(Outpatient )
Single Specialty Practitioner
© 2016 The Joint Commission, All Rights Reserved.
(Outpatient )
Laburnum Medical Center
Memorial Regional Medical
Center Cam
Available Services
Outpatient Clinics (Outpatient )
8622 Atlee Road
Mechanicsville, VA, 23116
Memorial Medical Center
8200 Meadowbridge Rd Suite 203
Mechanicsville, VA, 23116
Memorial Regional Medical
Center Ambulatory Surgery
Unit
8262 Atlee Road, MOB III, Suite 100
Mechanicsville, VA, 23116
Memorial Wound Care Center
8237 Meadowbridge Road
Mechanicsville, VA, 23116
Theresa Thomas Medical
Center
635 North Washington Highway
Ashland, VA, 23005
Available Services
Single Specialty Practitioner
(Outpatient )
Available Services
Administration of Blood Product
(Outpatient )
Administration of High Risk
Medications (Outpatient )
Ambulatory Surgery Center
(Outpatient )
Anesthesia (Outpatient )
Perform Invasive Procedure
(Outpatient )
Available Services
Outpatient Clinics (Outpatient )
Perform Invasive Procedure
(Outpatient )
Available Services
Outpatient Clinics (Outpatient )
Single Specialty Practitioner
(Outpatient )
© 2016 The Joint Commission, All Rights Reserved.
Special Quality Awards
Due to our commitment to accurate data reporting, The Joint Commission is suspending the practice of
updating Special Quality Awards until
further notice
2015 Gold Get With The Guidelines - Resuscitation
2014 ACS National Surgical Quality Improvement Program
2014 Magnet Award
2014 Silver Plus Get With The Guidelines - Stroke
2013 Gold Get With The Guidelines - Heart Failure
Cooperative Agreements
Hospital - Accredited by American College of Surgeons-Commission on Cancer (ACoS-COC)
National Patient Safety Goals and National Quality Improvement Goals
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
Measures 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.
© 2016 The Joint Commission, All Rights Reserved.
Show Keys
+
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.
The Joint Commission only reports measures endorsed by the National Quality Forum.
* This information can also be viewed at Hospital Compare.
**
Indicates per 1000 hours of patient care.
*** The measure was not in effect for this quarter.
---- Null value or data not displayed.
Hospital
2016 National Patient
Safety Goals
Nationwide
Comparison:
Statewide
Comparison:
Reporting Period: January 2015 - December 2015
National Quality Improvement Goals:
Immunization
National Comparison:
2
Statewide
Comparison:
Perinatal Care
National Comparison:
Statewide
Comparison:
Venous
Thromboembolism (VTE)
National Comparison:
Statewide
Comparison:
New Changes to Quarterly Measure
Download Quarterly Measure Results
The Joint Commission only reports measures endorsed by the National Quality Forum.
* State results are not calculated for the National Patient Safety Goals.
© 2016 The Joint Commission, All Rights Reserved.
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