Treatment Area

Activity Results

Annual Volume Results

Open Heart Surgery

512 (actual volume)

200 (coalition threshold)

Percutaneous Coronary Intervention

1008 (actual volume)

400 (coalition threshold)

Abdominal Aortic Aneurysm Repair

50 (actual volume)

20 (coalition threshold)

Carotid Endarterectomy Surgery

110 (actual volume)

50 (coalition threshold)

Esophagectomy

4 (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

Continuing monthly Cardiovascular Surgery Cardiac Data Review meetings. As of May, 2006, STS Michigan Audit revealed LIMA useage low; surgeons aware of standards to increase LIMA useage and document contraindications when necessary

Percutaneous Coronary Intervention

New AMI Core Measures Task Force initiated. Focus to be PCI's to cath lab with STMI's in under 90 minutes

Intensive Care Unit Physician Staffing (IPS)

MHA Keystone participant

Root Cause Analisys

Presently re-defining our process regarding conducting RCAT and related reporting-refined process is looking to expand sharing results (#5) and evaluating impact (#8)-at present conducting a 6 month follow-up, yet in process of redefining the evaluation o

General Comments on Patient Safety Activities

MHA Keystone IHI 100,000 Lives Campaign Standardized order sets JCAHO Accreditation and Continual Survey Readiness JCAHO National Patient Safety Goals compliance MPRO 8th Scope of Work Root Cause Analysis Teams FMEA's Medication Error Reduction Team Medication Reconcilliation Team Falling Star initative (fall reduction program)