Treatment Area

Activity Results

Annual Volume Results

Open Heart Surgery

n/a

Percutaneous Coronary Intervention

n/a

Abdominal Aortic Aneurysm Repair

3 (actual volume)

20 (coalition threshold)

Carotid Endarterectomy Surgery

50 (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

Abdominal Aortic Aneurysm Repair

Outcome data shared with the Dept of Surgery. Elective AAA cases are no longer being performed routinely, rather are referred to a tertiary care center. Beta Blocker protocol has been approved by the Dept of Anesthesia, with scheduled implementation date of 12/06.

Carotid Endarterectomy Surgery

Outcome measures and m/m data shared with the Dept of Surgery and individual surgeons. 100% review of all cases ongoing.

Intensive Care Unit Physician Staffing (IPS)

Care is coordinated with board certified internists on the majority of ICU patients, but is currently not required. We are participating in the Keystone ICU project and have seen significant decreases in BSI and VAP rates since we joined the project.

General Comments on Patient Safety Activities

LEAN/Six Sigma Pilot program participant through a grant from Gov Granholm. 9 staff members trained as LEAN Champions or Six Sigma Black Belts. LEAN Kaizen events held quarterly have improved ED flow and throughput,Laboratory turnaround time, JCAHO preparedness/pt safety initiatives(Speak Up Campaign), CDM process redesign.