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Quality Report

Summary of Quality Information
St. John Macomb-Oakland Hospital
Org ID: 7481
11800 East Twelve Mile Road
Warren, MI  48093
(586)573-5443
WWW.STJOHN.ORG

Accreditation
Programs		 Accreditation
Decision		 Effective
Date		 Last Full Survey Date Last On-Site Survey Date  
Behavioral Health Care
Accredited 1/19/2008 1/18/2008 1/18/2008  
Hospital
Accredited 1/19/2008 1/18/2008 1/18/2008  

Advanced Certification
Programs		 Certification
Decision		 Effective
Date		 Last Full
Review Date		 Last On-Site
Review Date
Primary Stroke Center
Certification 1/19/2008  3/3/2009  3/3/2009 



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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 of patients 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.
National Patient Safety Goals and National Quality Improvement Goals
    Compared to other Joint Commission Accredited Organizations
    Nationwide Statewide
Behavioral Health Care
2008 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
2008 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:
Jul  2008 -
Jun  2009
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
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 similar to 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.
  • Blood Vessel 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.
  • 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.
  • Coronary Artery Bypass Graft
 See Detail
Not displayed.
8
Not displayed.
8
  • Hip Joint Replacement
 See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
  • Hysterectomy
 See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above 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.
  • Open Heart Surgery
 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
   
  30 Day Risk Adjusted Mortality Rates (see details)
  30 Day Hospital Readmission Rates (see details)
  Survey of Patients' Hospital Experiences (see details)
 
Hospitals voluntarily participate in the Survey of Patients' Hospital Experiences(HCAHPS).
Pediatric and psychiatric hospitals are not eligible to participate in the HCAHPS survey based on their patient population.
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
SHMOH Macomb Breast Center
28363 Hoover
Warren, MI  48093
  • General Outpatient Services (Outpatient)
SJMOH NRS (Neurological Recovery Systems)
27450 Schoenherr , Suite 100A
Warren, MI  48088
  • General Outpatient Services (Outpatient)
SJMOH Clinton Township Satellite
37400 Garfield Road, Suite 200
Clinton Township, MI  48036
  • General Outpatient Services (Outpatient)
SJMOH Oakland Physical Rehab Therapy/Weight Loss Clinic
27483 Dequindre Road Suites 102/204
Madison Heights, MI  48071
  • General Outpatient Services (Outpatient)
SJMOH Oakland Primary Care Center
27472 Schoenherr, Suite 130
Warren, MI  48088
  • General Outpatient Services (Outpatient)
SJMOH Partial Day Program
27550 Schoenherr Road, Suite 250
Warren, MI  48088
  • Behavioral Health (Day Programs - Adult)
SJMOH Warren Satellite Physical Therapy (Schoenherr)
27450 Schoenherr Road
Warren, MI  48088
  • General Outpatient Services (Outpatient)
SJMOH Windermere Park Rehab
31700 Van Dyke # 160
Warren, MI  48093
  • General Outpatient Services (Outpatient)
St. John Macomb-Oakland Hospital Macomb Center  *
11800 East Twelve Mile Road
Warren, MI  48093
Joint Commission Advanced Certification Programs:
  • Primary Stroke Center
Services:
  • Abdominal Aortic Aneurysm (Inpatient)
  • Acute Coronary Syndrome (Inpatient, Outpatient)
  • Acute Myocardial Infarction (Inpatient, Outpatient)
  • Anxiety/panic disorders (Inpatient, Outpatient)
  • Arthritis (Inpatient, Outpatient)
  • Asthma (Inpatient)
  • Asthma, Pediatrics (Inpatient)
  • Atrial Fibrillation (Inpatient, Outpatient)
  • Audiology (Inpatient, Outpatient)
  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult)
  • Benign prostatic hyperplasia (BPH) (Inpatient, Outpatient)
  • Bipolar disorder (Inpatient)
  • Breast Cancer (Inpatient, Outpatient)
  • Cancer Center/Oncology (Inpatient, Outpatient)
  • Cardiac Catheterization Lab (Inpatient, Outpatient)
  • Cardiac Surgery (Inpatient)
  • Cardiac Unit/Cardiology (Inpatient)
  • Cellulitis (Inpatient)
  • Cerebral Bleeding (Inpatient, Outpatient)
  • Chronic Kidney Disease (Inpatient, Outpatient)
  • Chronic Obstructive Pulmonary Disease (Inpatient, Outpatient)
  • Coagulopathy Treatment (Inpatient)
  • Colon/Rectal Cancer (Inpatient, Outpatient)
  • Coronary Artery Disease (Inpatient, Outpatient)
  • Crohn's Disease (Inpatient, Outpatient)
  • CT Scanner (Inpatient, Outpatient)
  • Depression (Inpatient)
  • Diabetes Mellitus (Inpatient, Outpatient)
  • Dialysis (Inpatient)
  • EEG/EKG/EMG Lab (Inpatient, Outpatient)
  • Electroconvulsive Therapy (Inpatient)
  • Emergency Room (Outpatient)
  • Emphysema (Inpatient, Outpatient)
  • End Stage Renal Disease (Inpatient)
  • Esophageal Cancer (Inpatient, Outpatient)
  • Finger Joint Replacement (Inpatient, Outpatient)
  • Gastroesophageal Reflux Disease (Inpatient, Outpatient)
  • General Medical Services (Inpatient, Outpatient)
  • General Surgery (Inpatient, Outpatient)
  • GI or Endoscopy Lab (Inpatient, Outpatient)
  • Gynecology (Inpatient)
  • Head Injury (Inpatient)
  • Health Social Work (Inpatient)
  • Heart Failure (Inpatient, Outpatient)
  • Hepatitis B/C (Inpatient)
  • Hip Joint Replacement (Inpatient, Outpatient)
  • HIV/AIDS (Inpatient)
  • Hodgkin's disease (Inpatient, Outpatient)
  • Hyperbilirubinemia (Inpatient)
  • Hyperlipidemia (Inpatient)
  • Hypertension (Inpatient)
  • Hyperthyroidism/Hypothyroidism (Inpatient)
  • Imaging/Radiology (Inpatient, Outpatient)
  • Infectious Diseases (Inpatient)
  • Infusion Services (Inpatient)
  • Inpatient Diabetes (Inpatient)
  • Inpatient Intake (Inpatient)
  • Intensive Care Unit (Inpatient)
  • Internal Medicine (Inpatient)
  • Interventional Cardiac Catheterization (Inpatient, Outpatient)
  • Interventional Radiology (Inpatient, Outpatient)
  • Intraventricular hemorrhage (Inpatient)
  • Irritable Bowel Syndrome (Inpatient, Outpatient)
  • Ischemic Heart Disease (Inpatient, Outpatient)
  • Joint Replacement - Knee (Inpatient, Outpatient)
  • Labor & Delivery (Inpatient)
  • Laminectomy (Inpatient, Outpatient)
  • Leukemia (Inpatient, Outpatient)
  • Liver Diseases (Inpatient)
  • Low Back Pain (Inpatient, Outpatient)
  • Lung Cancer (Inpatient, Outpatient)
  • Magnetic Resonance Imaging (Inpatient, Outpatient)
  • Mental Health (Inpatient, 24-hour Acute Care/Crisis Stabilization)
  • Migraine Headache (Inpatient)
  • Multiple Sclerosis (Inpatient)
  • Necrotizing Enteral Colitis (Inpatient, Outpatient)
  • Nephrology (Inpatient)
  • Nuclear Medicine (Inpatient, Outpatient)
  • Nursery (Inpatient)
  • Obstetrics (Inpatient)
  • Occupational Health (Outpatient)
  • Operating Room (Inpatient)
  • Oral Maxillofacial Surgery (Inpatient)
  • Orthopedic Surgery (Inpatient, Outpatient)
  • Osteopathic Care (Inpatient, Outpatient)
  • Osteoporosis (Inpatient)
  • Outpatient Surgery (Outpatient)
  • Pancreatic Cancer (Inpatient, Outpatient)
  • Pancreatitis (Inpatient)
  • Parkinsons Disease (Inpatient)
  • Pathology (Inpatient)
  • Pediatric Orthopedics (Outpatient - Child/Youth)
  • Pelvic Inflammatory Disease (Inpatient)
  • Pneumonia (Inpatient)
  • Post Anesthesia Care Unit (PACU) (Inpatient, Outpatient)
  • Prostate Cancer (Inpatient, Outpatient)
  • Pulmonary Function Lab (Inpatient, Outpatient)
  • Radiation Oncology (Inpatient, Outpatient)
  • Rehabilitation (Inpatient)
  • Respiratory Care (Ventilator) (Inpatient)
  • Respiratory Failure (Inpatient)
  • Schizophrenia (Inpatient)
  • Sexually Transmitted Disease (Inpatient)
  • Sickle Cell Disease (Inpatient)
  • Sports Medicine (Inpatient, Outpatient)
  • Stroke Rehabilitation (Inpatient)
  • Systemic Lupus Erythematosis (Inpatient)
  • Telemetry (Inpatient)
  • Thoracic Surgery (Inpatient)
  • Tobacco Treatment / Cessation (Inpatient)
  • Trauma (Inpatient)
  • Tuberculosis (Inpatient)
  • Ulcerative Colitis (Inpatient, Outpatient)
  • Ultrasound (Inpatient, Outpatient)
  • Urgent Care/Emergency Medicine (Outpatient)
  • Vascular Surgery (Inpatient)
  • Women's Health (Inpatient, Outpatient)
  • Wound Care (Inpatient, Outpatient)
St. John Macomb-Oakland Hospital Oakland Center
27351 Dequindre Road
Madison Heights, MI  48071
Joint Commission Advanced Certification Programs:
  • Primary Stroke Center
Services:
  • Acute Coronary Syndrome (Inpatient, Outpatient)
  • Acute Myocardial Infarction (Outpatient)
  • Arthritis (Inpatient, Outpatient)
  • Asthma (Inpatient, Outpatient)
  • Asthma, Pediatrics (Inpatient, Outpatient)
  • Atrial Fibrillation (Outpatient)
  • Bariatric Surgery (Inpatient, Outpatient)
  • Behavioral Health (Day Programs - Adult)
    (24-hour Acute Care/Crisis Stabilization - Adult)
  • Benign prostatic hyperplasia (BPH) (Outpatient)
  • Bipolar disorder (Inpatient, Outpatient)
  • Cardiac Catheterization Lab (Inpatient)
  • Cellulitis (Inpatient, Outpatient)
  • Cerebral Bleeding (Inpatient, Outpatient)
  • Chronic Kidney Disease (Inpatient)
  • Chronic Obstructive Pulmonary Disease (Inpatient, Outpatient)
  • Coagulopathy Treatment (Inpatient)
  • Colon/Rectal Cancer (Inpatient)
  • Coronary Artery Disease (Inpatient, Outpatient)
  • Crohn's Disease (Inpatient)
  • CT Scanner (Outpatient)
  • Depression (Inpatient, Outpatient)
  • Diabetes Mellitus (Inpatient, Outpatient)
  • Dialysis (Inpatient)
  • Eating Disorders (Inpatient, Outpatient)
  • EEG/EKG/EMG Lab (Inpatient)
  • Emergency Room (Outpatient)
  • Emphysema (Outpatient)
  • End Stage Renal Disease (Inpatient, Outpatient)
  • Epilepsy (Inpatient)
  • Esophageal Cancer (Inpatient, Outpatient)
  • Family Practice (Inpatient, Outpatient)
  • Gastroenterology (Inpatient)
  • Gastroesophageal Reflux Disease (Inpatient)
  • General Medical Services (Inpatient)
  • General Surgery (Inpatient)
  • GI or Endoscopy Lab (Inpatient)
  • Head Injury (Inpatient)
  • Heart Failure (Inpatient)
  • Hematology/Blood Treatment (Inpatient)
  • Hyperbilirubinemia (Inpatient)
  • Hyperlipidemia (Inpatient)
  • Hypertension (Inpatient, Outpatient)
  • Hyperthyroidism/Hypothyroidism (Inpatient)
  • Imaging/Radiology (Inpatient, Outpatient)
  • Infectious Diseases (Inpatient)
  • Inpatient Diabetes (Inpatient)
  • Intensive Care Unit (Inpatient)
  • Internal Medicine (Inpatient, Outpatient)
  • Interventional Cardiac Catheterization (Inpatient, Outpatient)
  • Interventional Radiology (Inpatient, Outpatient)
  • Irritable Bowel Syndrome (Inpatient)
  • Ischemic Heart Disease (Inpatient, Outpatient)
  • Leukemia (Inpatient, Outpatient)
  • Liver Diseases (Inpatient)
  • Low Back Pain (Outpatient)
  • Lung Cancer (Inpatient)
  • Migraine Headache (Outpatient)
  • Morbid Obesity (Inpatient, Outpatient)
  • Multiple Sclerosis (Inpatient)
  • Nutrition Programs (Inpatient, Outpatient)
  • Occupational Health (Outpatient)
  • Operating Room (Inpatient, Outpatient)
  • Orthopedic Surgery (Inpatient, Outpatient)
  • Osteoporosis (Inpatient)
  • Outpatient Surgery (Outpatient)
  • Pancreatitis (Inpatient, Outpatient)
  • Perimenopause (Outpatient)
  • Pneumonia (Inpatient, Outpatient)
  • Prostate Cancer (Inpatient, Outpatient)
  • Rehabilitation (Outpatient)
  • Respiratory Care (Ventilator) (Inpatient)
  • Respiratory Failure (Inpatient, Outpatient)
  • Schizophrenia (Outpatient)
  • Self Injury (Inpatient, Outpatient)
  • Sexually Transmitted Disease (Inpatient, Outpatient)
  • Sickle Cell Disease (Outpatient)
  • Sleeping Disorder (Inpatient, Outpatient)
  • Stroke Rehabilitation (Outpatient)
  • Systemic Lupus Erythematosis (Outpatient)
  • Telemetry (Inpatient)
  • Tobacco Treatment / Cessation (Inpatient, Outpatient)
  • Trauma (Outpatient)
  • Tuberculosis (Outpatient)
  • Ulcerative Colitis (Inpatient)
  • Ultrasound (Inpatient, Outpatient)
  • Urgent Care/Emergency Medicine (Outpatient)
  • Urology (Inpatient, Outpatient)
  • Weight Loss (Inpatient, Outpatient)
  • Wound Care (Inpatient, Outpatient)

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