Treatment Area

Activity Results

Annual Volume Results

Open Heart Surgery

576 (actual volume)

200 (coalition threshold)

Percutaneous Coronary Intervention

2296 (actual volume)

400 (coalition threshold)

Abdominal Aortic Aneurysm Repair

145 (actual volume)

20 (coalition threshold)

Carotid Endarterectomy Surgery

223 (actual volume)

50 (coalition threshold)

Esophagectomy

n/a

Low Birthweight Infants

n/a

Infants with Congenital Anomalies

n/a

Intensive Care Unit Physician Staffing (IPS)

n/a

Open Heart Surgery

- Participation in Michigan STS BMC2 initiative - Attendance at State Meetings - Use of National Quality Forum and BMC2 indicators for the CQI process - CVA chart audits and reviews at Michigan STS meetings - Phase of Care Mortality Analysis 2005 reviewed and discussed at Mortality Roundtable at MI STS annual meeting - Quarterly review of data with cardiac surgeons including National, Regional and Ascension Health - Review of IMA usage statistics and discussion among surgeons - Added custom field to database to document contraindications for use of IMA

Percutaneous Coronary Intervention

Door to Balloon time has been/is a departmental goal for FY 2006 2007. Evaluations of these data are comprised of ongoing review of times among transfer and non transfers. These data reported to Cardiac Leadership as well as CVL and Cardiac Short Stay staff. Validation occurred with registration regarding actual Borgess “Door” time, its location in the record for consistent use. This was initially complete in January 2004 and revised as of August 2006. Began participation in state level Door to balloon time initiative as a Fast Track site since 2005. ETC staff educated regarding the initiative and targets. Data reviewed with Cardiac Short Stay and CVL Staff regarding the target times on a quarterly basis. Measurements began in late 2001 are on going to present. ASA prescribed at discharge: Discharge order sets revised in 2005 to include ASA and/or space to denote contraindications. Data being collected since late 2001, quarterly reports shared among cardiac leadership, Cardiology units and physicians, as well as the Cardiology Quality Improvement Council. Scorecard data for this variable and other Core measures shared monthly at hospital director’s council.

Abdominal Aortic Aneurysm Repair

Brought to the Department of Surgery Meeting which then instructed Surgical IQC to develop further. Being reviewed by the Surgical Integrated Quality Committee (IQC) in preparation for SCIP. Discussion and planning initiated at the May 23, 2006 meeting.

Intensive Care Unit Physician Staffing (IPS)

Our telemedicine (VICU) system monitors all critical care patients 24/7 and responds to alerts that are triggered by our telemedicine system.

Root Cause Analisys

RCA information is shared at our Administration Safety Council and our Board Quality Council as well as with the Patient Safety Council which is comprised of all clinical directors and other leadership involved with the patient's safety.

General Comments on Patient Safety Activities

Mortality Reduction - Rapid Response Team - SBAR - Chart Reviews Falls Prevention Pressure Ulcer Reduction VAP BSI Glycemic Control Culture of Safety Days Electronic Medical Records implementaion in all ICU units - FY2007 - Plan to implement to all other Patient Care Units