Survey Results for St. John Hospital & Medical Center
In the Annual Volume Results column, the lower bar always represents the Coalition's recommended volume and the upper bar always represents the hospital's volume. The actual volume numbers are displayed below the bars.
Click the links in the Treatment Area column to view the survey results for a specific treatment.
Hospital Comments
Open Heart Surgery |
St John Hospital & Medical Center has earned the Blue Cross Blue Shield of Michigan Cardiac Center of Excellence designation for the last several years. |
Percutaneous Coronary Intervention |
Regarding the improvement of PCI timing, St John Hospital & Medical Center has developed a team consisting of members from the Emergency Department, Cardiac Catheterization Lab, the Cardiology Quality Department and the Nurse Practitioner for the AMI core measures. This team is using Six Sigma Lean methods/tools to improve the timing of the current door-to-balloon PCI process. A timeline has been developed to achieve PCI timing within 90 minutes. |
Abdominal Aortic Aneurysm Repair |
D-2 Beta blocker assessment and standing orders will be implemented for all surgical patients in October 2006 as part of the Surgical Care Improvement Project (SCIP Card-2).
St John Hospital & Medical Center actively participates in the American College of Surgeons (ACS) - sponsored National Surgical Quality Improvement Program (NSQIP), a national, validated, outcomes-based and risk-adjusted program for the measurement and improvement of surgical care. This participation results in the use of comparative performance measurements with national performance to drive continuous quality improvement through identification of variance in observed to expected results, active networking with peer organizations, improvement projects based on data-driven priorities and validation of/adoption of best practices. |
Carotid Endarterectomy Surgery |
St John Hospital & Medical Center actively participates in the American College of Surgeons (ACS) - sponsored National Surgical Quality Improvement Program (NSQIP), a national, validated, outcomes-based and risk-adjusted program for the measurement and improvement of surgical care. This participation results in the use of comparative performance measurements with national performance to drive continuous quality improvement through identification of variance in observed to expected results, active networking with peer organizations, improvement projects based on data-driven priorities and validation of/adoption of best practices. |
Esophagectomy |
C-2: The benefits of submitting clinical data on esophagectomies to the Society for Thoracic Surgery database is achieved by another option not included in this survey. St John Hospital & Medical Center actively participating in the American College of Surgeons (ACS) - sponsored National Surgical Quality Improvement Program (NSQIP), a national, validated, outcomes-based and risk-adjusted program for the measurement and improvement of surgical care. This participation results in the use of comparative performance measurements with national performance to drive continuous quality improvement through identification of variance in observed to expected results, active networking with peer organizations, improvement projects based on data-driven priorities and validation of/adoption of best practices. |
Low Birthweight Infants and Infants with Congenital Anomalies |
D-4: For ten, 24-hour periods per month, there is in-house coverage by a board-certified neonatologist qualified in the intensive care of newborns. For the remaining days in the month, senior Pediatric residents are on call and present in house and neonatologists are available on call via phone or arrive at the hospital within 30 minutes of call. D-5: On an ongoing trial basis, for one 24-hour period per week, a neonatal nurse practitioner covers the NICU under the direct supervision of an in-house neonatologist. |
Intensive Care Unit Physician Staffing (IPS) |
St John Hospital & Medical Center has actively participated in the MHA Keystone initiative in all adult ICUs since 2004 In additiion to certified intensivist presence and coverage, the Surgical Intensive Care Unit has certified physician assistant coverage 40 hours/week (8 hours/day for 5 days per week). In addition to certified intensivist presence and coverage, the Medicine Intensive Care Unit has certified physician assistant coverage 24 hours/day, 7 days per week. |
Root Cause Analisys |
After careful analysis, an event that is a failure to diagnose may end up in the domain of peer review with no risk reduction activity identified. |
General Comments on Patient Safety Activities |
The Patient Safety Plan for 2006 and 2007 represents our call to ensure that the principal activity of Ascension Health - providing healthcare - is delivered in a safe environment. Ascension Health has established safety as a priority throughout our system with the goal being 'no preventable deaths or injuries.' Healthcare That Is Safe is a part of Ascension Health's Call to Action and is the foundation for the 2006-2007 patient Safety Plan at St John Hospital and Medical Center. This is also supported through defined strategies for the Priorities for Action in support of the IHI 100,000 Lives Campaign and Michigan Keystone Center for patient Safety, and includes Reducing Harm in the Intensive Care Unit, Prevention of Falls and Fall Injuries, Perinatal Safety, Prevention of Pressure Ulcers, use of Rapid Response Teams, Prevention of Surgical complications, Medication Safety, JCAHO-ORYX initiatives, participation in numerous Blue Cross Blue Shield of Michigan collaborative quality initiatives and participation in various MPRO-sponsored initiatives including the Governor's Award for Excellence and Surgical Care Improvement Project. The Plan also takes into consideration the NQF 30 Safe Practices, JCAHO National Patient Safety Goals, promoting a non-punitive culture, encourages reporting of errors using a web-based application, and includes review of sentinel events and near misses. The Plan is approved and monitored through the patient Safety Committee, the Quality Committee and the Board of Trustees. The Patient Safety Committee is an interdisciplinary committee and has membership from Nursing, Medicine, laboratory, Pharmacy, Radiology, Nursing Education and Administration. The Patient Safety Committee facilitates communication of achievements through the hospital and rewards and recognizes reporting of concerns and suggestions for improvement. |
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