The Joint Commission
Quality Check


  Symbol Key
This organization achieved the best possible results
This organization’s performance is above the target range/value.
This organization’s performance is similar to the target range/value.
This organization’s performance is below the target range/value.
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Quality Report
Hospital
University of Michigan Health System
Org ID: 7457

National Quality Improvement Goals: Surgical Care Improvement Project (SCIP)

Reporting Period: April 2013 - March 2014

  Compared to other Joint Commission Accredited Organizations
Measure Area
Nationwide Statewide
SCIP - Infection Prevention
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This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.

  Compared to other Joint Commission Accredited Organizations
  Nationwide Statewide
Measure Hospital
Results
Top 10% Scored at Least : Average Rate: Top 10% Scored at Least: Average Rate:
Patients having a surgery who received medicine to prevent infection (an antibiotic) within one hour before the skin was surgically cut.*
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(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 99% 100% 99%
99% of
1644 eligible Patients
Patients having surgery who received the appropriate medicine (antibiotic) which is shown to be effective for the type of surgery performed.*
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(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 99% 100% 99%
99% of
1646 eligible Patients
Patients who had surgery and received appropriate medicine that prevents infection (antibiotic) and the antibiotic was stopped within 24 hours after the surgery ended.*
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(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 98% 100% 98%
98% of
1585 eligible Patients
 
Patients Having Blood Vessel Surgery*
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(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 98% 100% 98%
98% of
252 eligible Patients
Patients having blood vessel surgery who received medicine to prevent infection (an antibiotic) within one hour before the skin was surgically cut.*
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(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 98% 100% 98%
99% of
87 eligible Patients
Patients having blood vessel surgery who received the appropriate medicine (antibiotic) which is shown to be effective for this type of surgery.*
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(See Quarterly Results)
This organization’s performance is similar to the target range/value.
100% 99% 100% 99%
99% of
87 eligible Patients
Patients who had blood vessel surgery and received appropriate medicine that prevents infection (antibiotic) and the antibiotic was stopped within 24 hours after the surgery ended.*
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(See Quarterly Results)
This organization’s performance is similar to the target range/value.
100% 96% 100% 97%
95% of
78 eligible Patients
 
Patients Having Colon/Large Intestine Surgery*
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(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 97% 100% 97%
98% of
574 eligible Patients
Patients having colon/large intestine surgery who received medicine to prevent infection (an antibiotic) within one hour before the skin was surgically cut. *
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(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 98% 100% 98%
99% of
195 eligible Patients
Patients having colon/large intestine surgery who received the appropriate medicine (antibiotic) which is shown to be effective for this type of surgery.*
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(See Quarterly Results)
This organization’s performance is similar to the target range/value.
100% 96% 100% 96%
95% of
195 eligible Patients
Patients who had colon/large intestine surgery and received appropriate medicine that prevents infection (antibiotic) and the antibiotic was stopped within 24 hours after the surgery ended.*
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(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 96% 100% 96%
98% of
184 eligible Patients
 
Patients Having Coronary Artery Bypass Graft Surgery*
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(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 99% 100% 99%
99% of
378 eligible Patients
Patients having coronary artery bypass graft surgery who received medicine to prevent infection (an antibiotic) within one hour before the skin was surgically cut.*
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(See Quarterly Results)
This organization achieved the best possible results.
100% 99% 100% 98%
100% of
128 eligible Patients
Patients having coronary artery bypass graft surgery who received the appropriate medicine (antibiotic) which is shown to be effective for this type of surgery.*
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(See Quarterly Results)
This organization achieved the best possible results.
100% 100% 100% 100%
100% of
128 eligible Patients
Patients who had coronary artery bypass graft surgery and received appropriate medicine that prevents infection (antibiotic) and the antibiotic was stopped within 48 hours after the surgery ended.*
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(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 99% 100% 99%
99% of
122 eligible Patients
 
Patients Having Hip Joint Replacement Surgery*
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(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 99% 100% 99%
99% of
1157 eligible Patients
Patients having hip joint replacement surgery who received medicine to prevent infection (an antibiotic) within one hour before the skin was surgically cut.*
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(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 99% 100% 99%
99% of
391 eligible Patients
Patients having hip joint replacement surgery who received the appropriate medicine (antibiotic) which is shown to be effective for this type of surgery.*
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(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 100% 100% 100%
99% of
391 eligible Patients
Patients who had hip joint replacement surgery and received appropriate medicine that prevents infection (antibiotic) and the antibiotic was stopped within 24 hours after the surgery ended.*
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(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 98% 100% 98%
98% of
375 eligible Patients
 
Patients Having a Hysterectomy*
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(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 98% 100% 99%
99% of
378 eligible Patients
Patients having hysterectomy surgery who received medicine to prevent infection (an antibiotic) within one hour before the skin was surgically cut.*
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(See Quarterly Results)
This organization achieved the best possible results.
100% 99% 100% 99%
100% of
125 eligible Patients
Patients having hysterectomy surgery who received the appropriate medicine (antibiotic) which is shown to be effective for this type of surgery.*
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(See Quarterly Results)
This organization achieved the best possible results.
100% 98% 100% 99%
100% of
127 eligible Patients
Patients who had hysterectomy surgery and received appropriate medicine that prevents infection (antibiotic) and the antibiotic was stopped within 24 hours after the surgery ended.*
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(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 98% 100% 99%
99% of
126 eligible Patients
 
Patients Having Knee Joint Replacement Surgery*
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(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 99% 100% 99%
99% of
690 eligible Patients
Patients having knee joint replacement surgery who received medicine to prevent infection (an antibiotic) within one hour before the skin was surgically cut.*
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(See Quarterly Results)
This organization achieved the best possible results.
100% 99% 100% 99%
100% of
231 eligible Patients
Patients having knee joint replacement surgery who received the appropriate medicine (antibiotic) which is shown to be effective for this type of surgery.*
Read More


(See Quarterly Results)
This organization achieved the best possible results.
100% 100% 100% 100%
100% of
231 eligible Patients
Patients who had knee joint replacement surgery and received appropriate medicine that prevents infection (antibiotic) and the antibiotic was stopped within 24 hours after the surgery ended.*
Read More


(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 99% 100% 99%
99% of
228 eligible Patients
 
Patients Having Open Heart Surgery other than Coronary Artery Bypass Graft*
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(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 99% 100% 99%
99% of
1446 eligible Patients
Patients having open heart surgery other than coronary artery bypass graft who received medicine to prevent infection (an antibiotic) within one hour before the skin was surgically cut.*
Read More


(See Quarterly Results)
This organization achieved the best possible results.
100% 99% 100% 99%
100% of
487 eligible Patients
Patients having open heart surgery other than coronary artery bypass graft who received the appropriate medicine (antibiotic) which is shown to be effective for this type of surgery.*
Read More


(See Quarterly Results)
This organization achieved the best possible results.
100% 100% 100% 100%
100% of
487 eligible Patients
Patients who had open heart surgery other than coronary artery bypass graft and received appropriate medicine that prevents infection (antibiotic) and the antibiotic was stopped within 48 hours after the surgery ended.*
Read More


(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 99% 100% 99%
98% of
472 eligible Patients
 
Heart surgery patients with controlled blood sugar after surgery.
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(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 96% 100% 97%
98% of
666 eligible Patients
Surgery patients with proper hair removal.
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(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 100% 100% 100%
99% of
2249 eligible Patients
Urinary Catheter Removed
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(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 98% 100% 98%
99% of
1514 eligible Patients
National Quality Forum The Joint Commission only reports measures endorsed by the National Quality Forum.  
* This information can also be viewed at www.hospitalcompare.hhs.gov.
---- Null value or data not displayed.

1 - The measure or measure set was not reported.
2 - The measure set does not have an overall result.
3 - The number is not enough for comparison purposes.
4 - The measure meets the Privacy Disclosure Threshold rule.
5 - The organization scored above 90% but was below most other organizations.
6 - The measure results are not statistically valid.
7 - The measure results are based on a sample of patients.
8 - The number of months with measure data is below the reporting requirement.
9 - The measure results are temporarily suppressed.
10 - Test Measure: a measure being evaluated for reliability of the individual data elements or awaiting National Quality Forum Endorsement.
11 - There were no eligible patients that met the denominator criteria.


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