Treatment Area

Activity Results

Annual Volume Results

Open Heart Surgery

302 (actual volume)

200 (coalition threshold)

Percutaneous Coronary Intervention

1019 (actual volume)

400 (coalition threshold)

Abdominal Aortic Aneurysm Repair

41 (actual volume)

20 (coalition threshold)

Carotid Endarterectomy Surgery

130 (actual volume)

50 (coalition threshold)

Esophagectomy

4 (actual volume)

7 (coalition threshold)

Low Birthweight Infants

72 (actual volume)

70 (coalition threshold)

Infants with Congenital Anomalies

72 (actual volume)

70 (coalition threshold)

Intensive Care Unit Physician Staffing (IPS)

n/a

Percutaneous Coronary Intervention

Rapid Improvement Event focusing on the improvment in PCI time from arrival.

Intensive Care Unit Physician Staffing (IPS)

Participated in the ICU Keystone initiative.

Healthcare Failure Mode and Effect Analysis

We have also used HFMEA's in our Six Sigma projects when designing solutions.

Root Cause Analisys

We have found the RCA process to be very successful with staff engagement to improve processes.

General Comments on Patient Safety Activities

Universal Protocol Patient Identification Medication error reduction Safety culture survey VTE prophylaxis SCIP Rapid Response Team Birth Trauma Bundle Keystone initiative in ICU Medication Reconciliation Mortality reduction