Treatment Area

Activity Results

Annual Volume Results

Open Heart Surgery

246 (actual volume)

200 (coalition threshold)

Percutaneous Coronary Intervention

1198 (actual volume)

400 (coalition threshold)

Abdominal Aortic Aneurysm Repair

33 (actual volume)

20 (coalition threshold)

Carotid Endarterectomy Surgery

76 (actual volume)

50 (coalition threshold)

Esophagectomy

1 (actual volume)

7 (coalition threshold)

Low Birthweight Infants

n/a

Infants with Congenital Anomalies

n/a

Intensive Care Unit Physician Staffing (IPS)

n/a

Open Heart Surgery

St. John Macomb Hospital (SJMH)has participated and submitted 100% of their open heart data to the STS Adult Cardiac Database beginning January 2004. SJMH also actively participates with the MSTCVS?BCBSM Quality Improvement collaboration.

Percutaneous Coronary Intervention

St. John Macomb Hospital (SJMH) has participated and submitted data on 100% of the PCI procedures perfromed beginning July 2004. SJMH will begin participation in the BCBSM BMC2 Quality Improvment Project

Carotid Endarterectomy Surgery

Working with MASCOTS Stroke Initiative and Quality Review to decrease the threat of post-operative complications.

Healthcare Failure Mode and Effect Analysis

With each Six Sigma process improvement project a HFMEA is completed

Root Cause Analisys

Efforts are being put in place to (1) better share RCA findings and process improvements systems hospital wide and (2) Improve the evaluation process for developing improvements

General Comments on Patient Safety Activities

Eliminating Dangerous Abbreviation Campaign Keystone ICU Initiative Mortality Reduction Initiative Eligibility Audits Medication Reconciliation Process Implementing National Patient Safety Goals Six Sigma Initiatives on Throughput and Eliminating Waste