The Joint Commission
Quality Check
Quality Report

Summary of Accreditation Quality Information
Portage Hospital, LLC
DBA: UP Health System Portage
Org ID: 2827
500 Campus Drive
Hancock, MI  49930
(906)483-1000
www.portagehealth.org


Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full Survey Date Last On-Site Survey Date
Home Care
Accredited 11/1/2014 10/31/2014   10/31/2014  
Hospital
Accredited 11/1/2014 10/31/2014   12/12/2014  
Laboratory Accreditation Program
Accredited 4/17/2014 4/16/2014   4/16/2014  


Accreditation programs recognized by the Centers for Medicare and Medicaid Services (CMS)
Pathology and Clinical Laboratory
Hospital






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  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.
This measure is not applicable for this organization.
Not displayed
  Footnote Key
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 pending resubmission of updated data.
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.
National Patient Safety Goals and National Quality Improvement Goals
    Compared to other Joint Commission Accredited Organizations
    Nationwide Statewide
Home Care
2014 National Patient Safety Goals See Detail
This organization’s performance is similar to the target range/value.
This Goal is not applicable for this organization.
*
Hospital
2014 National Patient Safety Goals See Detail
This organization’s performance is similar to the target range/value.
This Goal is not applicable for this organization.
*
National Quality Improvement Goals:    
Reporting Period:
Jan  2014 -
Dec  2014
Emergency Department See Detail
Not displayed.
2
Not displayed.
2
Heart Attack Care See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
Heart Failure Care See Detail
Not displayed.
3
Not displayed.
3
Immunization See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
Pneumonia Care See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is above the target range/value.
Surgical Care Improvement Project (SCIP)    
SCIP - Cardiac See Detail
   
SCIP - Infection Prevention
For All Reported Procedures:
See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
  • Colon/Large Intestine Surgery
See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
  • Hip Joint Replacement
See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is above the target range/value.
  • Hysterectomy
See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
  • Knee Replacement
See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
SCIP – Venous Thromboembolism (VTE) See Detail
   
Venous Thromboembolism (VTE) See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
Laboratory Accreditation Program
2014 National Patient Safety Goals See Detail
This organization’s performance is similar to the target range/value.
This Goal is not applicable for this organization.
*
 
National Quality Forum The Joint Commission only reports measures endorsed by the National Quality Forum.
 
* State results are not calculated for the National Patient Safety Goals.

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Sites and Services
* Primary Location

An organization may provide services not listed here. For more information refer to the Quality Report User Guide .

Locations of Care Available Services
Portage Hospital, LLC  *
DBA:  UP Health System Portage
500 Campus Drive
Hancock, MI  49930
Other Clinics/Practices located at this site:
  • Portage Physician Practices
  • UP Health System Portage Dialysis Center
Services:
  • Canes and Crutches
  • Contracture Treatment: Dynamic Splint
  • CT Scanner (Imaging/Diagnostic Services)
  • Custom Orthotics
  • Durable Medical Equipment
  • Ear/Nose/Throat Surgery (Surgical Services)
  • EEG/EKG/EMG Lab (Imaging/Diagnostic Services)
  • Gastroenterology (Surgical Services)
  • General Laboratory Tests
  • Gynecological Surgery (Surgical Services)
  • Gynecology (Inpatient)
  • Heat/Cold Applications
  • Inpatient Unit (Inpatient)
  • Interventional Radiology (Imaging/Diagnostic Services)
  • Labor & Delivery (Inpatient)
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services)
  • Medical /Surgical Unit (Inpatient)
  • Medical ICU (Intensive Care Unit)
  • Normal Newborn Nursery (Inpatient)
  • Nuclear Medicine (Imaging/Diagnostic Services)
  • Off The Shelf Orthotics
  • Ophthalmology (Surgical Services)
  • Orthopedic Surgery (Surgical Services)
  • Orthotics - Non-Customized
  • Outpatient Clinics (Outpatient)
  • Post Anesthesia Care Unit (PACU) (Inpatient)
  • Sleep Laboratory (Sleep Laboratory)
  • Supplies
  • Surgical Dressings
  • Surgical ICU (Intensive Care Unit)
  • Surgical Unit (Inpatient)
  • Teleradiology (Imaging/Diagnostic Services)
  • Toxicology
  • Ultrasound (Imaging/Diagnostic Services)
  • Urology (Surgical Services)
Portage Hospital, LLC
DBA:  UP Health System Home Care and Hospice Portage
821 West Water Street
Hancock, MI  49930
    Services:
    • General Laboratory Tests
    • Home Health Aides
    • Home Health, Non-Hospice Services
    • Hospice Care
    • Medical Social Services
    • Occupational Therapy
    • Physical Therapy
    • Skilled Nursing Services
    • Speech Language Pathology
    Portage Hospital, LLC
    56901 S. Sixth Street, Suite 4
    Calumet, MI  49913
      Services:
      • General Laboratory Tests
      • Outpatient Clinics (Outpatient)
      Portage Hospital, LLC
      921 W. Sharon Avenue
      Houghton, MI  49931
        Services:
        • General Laboratory Tests
        • Single Specialty Practitioner (Outpatient)
        Portage Hospital, LLC
        600 MacInnes Dr.
        Houghton, MI  49931
          Services:
          • General Laboratory Tests
          • Outpatient Clinics (Outpatient)

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