Treatment Area

Activity Results

Annual Volume Results

Open Heart Surgery

837 (actual volume)

200 (coalition threshold)

Percutaneous Coronary Intervention

2440 (actual volume)

400 (coalition threshold)

Abdominal Aortic Aneurysm Repair

79 (actual volume)

20 (coalition threshold)

Carotid Endarterectomy Surgery

195 (actual volume)

50 (coalition threshold)

Esophagectomy

2 (actual volume)

7 (coalition threshold)

Low Birthweight Infants

179 (actual volume)

70 (coalition threshold)

Infants with Congenital Anomalies

179 (actual volume)

70 (coalition threshold)

Intensive Care Unit Physician Staffing (IPS)

n/a

Open Heart Surgery

Door to Balloon time -Six Sigma Decrease time on Vent postoperatively Surgical Site infection prophylaxis

Percutaneous Coronary Intervention

six sigma project to improve time to PCI Door to Balloon

Carotid Endarterectomy Surgery

National Quality Surgical Database

Low Birthweight Infants and Infants with Congenital Anomalies

Standardized medication administration no compound medications on unit In line suctioning to reduce hospital induced PN 04/06

Root Cause Analisys

All Managers are required to go through an 8 hour RCA training class

General Comments on Patient Safety Activities

Culture of Safety Survey lager scale Improvment projects: SCIP ICU redesign/Keystone HAI Baldrige framework