The Joint Commission
Quality Check
Quality Report

Summary of Quality Information
Henry Ford Macomb Hospital
Org ID: 7559
15855 Nineteen Mile Road
Clinton Township, MI  48038
(586)263-2700
www.henryfordmacomb.com


Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full Survey Date Last On-Site Survey Date
Behavioral Health Care
Accredited 5/11/2013 5/10/2013   5/10/2013  
Hospital
Accredited 5/11/2013 5/10/2013   5/10/2013  


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


Advanced Certification
Programs
Certification
Decision
Effective
Date
Last Full
Review Date
Last On-Site
Review Date
Primary Stroke Center
Certification 6/6/2013  6/5/2013  6/5/2013 



Certified
Programs
Certification
Decision
Effective
Date
Last Full
Review Date
Last On-Site
Review Date
Joint Replacement - Hip
Certification 6/26/2013  6/25/2013  6/25/2013 
Joint Replacement - Knee
Certification 6/26/2013  6/25/2013  6/25/2013 



Other Accredited Programs / Services
Hospital  -  Accredited by American College of Surgeons-Commission on Cancer (ACoS-COC)


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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
Behavioral Health Care
2013 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
2013 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  2013 -
Jun  2014
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 above the target range/value.
This organization’s performance is similar to the target range/value.
Perinatal Care See Detail
Not displayed.
2
Not displayed.
2
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.
  • 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
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
  • Hip Joint Replacement
See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above 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
   
Venous Thromboembolism (VTE) See Detail
Not displayed.
8
Not displayed.
8
 
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
Center for Physical Medicine
16301 Nineteen Mile Road
Clinton Township, MI  48038
    Services:
    • Outpatient Clinics (Outpatient)
    Chesterfield Health Center
    30795 23 Mile Road
    New Baltimore, MI  48047
    Other Clinics/Practices located at this site:
    • Chesterfield Family Medicine
    • Chesterfield Health Center-Urgent Care
    • Chesterfield Wound Care
    • Henry Ford Macomb Chesterfield Rehab Services
    Services:
    • Outpatient Clinics (Outpatient)
    Chesterfield, OB/GYN
    51086 Fairchild Road
    New Baltimore, MI  48051
      Services:
      • Perform Invasive Procedure (Outpatient)
      • Single Specialty Practitioner (Outpatient)
      Fraser Health Center
      15717 Fifteen Mile Road
      Clinton Township, MI  48035
      Other Clinics/Practices located at this site:
      • Fraser Family Medicine, Internal Medicine and OB/GYN
      • Fraser Health Center-Urgent Care
      • Henry Ford Macomb Fraser Rehab Services
      Services:
      • Outpatient Clinics (Outpatient)
      • Perform Invasive Procedure (Outpatient)
      Henry Ford Fraser Rehab and Sports Medicine
      15595 15 Mile Rd, Clinton Twp, MI
      Clinton Township, MI  48035
          Henry Ford Macomb - Wound Care Services
          15520 19 Mile Ste 400
          Clinton Township, MI  48038
          Other Clinics/Practices located at this site:
          • Henry Ford Macomb Orthopedics
          Services:
          • Outpatient Clinics (Outpatient)
          • Perform Invasive Procedure (Outpatient)
          Henry Ford Macomb Family Medicine
          21250 Hall Road
          Clinton Township, MI  48038
            Services:
            • Single Specialty Practitioner (Outpatient)
            Henry Ford Macomb Family Medicine, Bruce Township Health Ctr
            80600 Van Dyke
            Romeo, MI  48065
              Services:
              • Outpatient Clinics (Outpatient)
              Henry Ford Macomb Health Center, Bruce Twnshp - Urgent Care
              80650 Van Dyke
              Romeo, MI  48065
              Other Clinics/Practices located at this site:
              • Henry Ford Macomb Bruce Township Rehabilitation Services
              Services:
              • Outpatient Clinics (Outpatient)
              Henry Ford Macomb Health Center- Washington Twp Primary Care
              12150 30 Mile Rd.
              Washington, MI  48095
              Other Clinics/Practices located at this site:
              • Henry Ford Macomb Orthopedics/Washington Township
              • Henry Ford Macomb Outpatient Rehabilitation
              Services:
              • Outpatient Clinics (Outpatient)
              Henry Ford Macomb Hospital  *
              15855 Nineteen Mile Road
              Clinton Township, MI  48038
              Joint Commission Advanced Certification Programs:
              • Primary Stroke Center
              Joint Commission Certified Programs:
              • Joint Replacement - Hip
              • Joint Replacement - Knee
                Services:
                • Cardiac Catheterization Lab (Surgical Services)
                • Cardiac Surgery (Surgical Services)
                • Cardiothoracic Surgery (Surgical Services)
                • Cardiovascular Unit (Inpatient)
                • Coronary Care Unit (Inpatient)
                • CT Scanner (Imaging/Diagnostic Services)
                • Ear/Nose/Throat Surgery (Surgical Services)
                • EEG/EKG/EMG Lab (Imaging/Diagnostic Services)
                • Gastroenterology (Surgical Services)
                • GI or Endoscopy Lab (Imaging/Diagnostic Services)
                • Gynecological Surgery (Surgical Services)
                • Gynecology (Inpatient)
                • Hematology/Oncology Unit (Inpatient)
                • 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)
                • Neuro/Spine Unit (Inpatient)
                • Neurosurgery (Surgical Services)
                • Normal Newborn Nursery (Inpatient)
                • Nuclear Medicine (Imaging/Diagnostic Services)
                • Ophthalmology (Surgical Services)
                • Orthopedic Surgery (Surgical Services)
                • Orthopedic/Spine Unit (Inpatient)
                • Outpatient Clinics (Outpatient)
                • Pediatric Unit (Inpatient)
                • Plastic Surgery (Surgical Services)
                • Positron Emission Tomography (PET) (Imaging/Diagnostic Services)
                • Post Anesthesia Care Unit (PACU) (Inpatient)
                • Radiation Oncology (Imaging/Diagnostic Services)
                • Rehabilitation Unit (Inpatient, 24-hour Acute Care/Crisis Stabilization)
                • Surgical ICU (Intensive Care Unit)
                • Surgical Unit (Inpatient)
                • Thoracic Surgery (Surgical Services)
                • Ultrasound (Imaging/Diagnostic Services)
                • Urology (Surgical Services)
                • Vascular Surgery (Surgical Services)
                Henry Ford Macomb OB/GYN Macomb Township
                16360 26 Mile Road
                Macomb, MI  48042
                  Services:
                  • Perform Invasive Procedure (Outpatient)
                  • Single Specialty Practitioner (Outpatient)
                  Henry Ford Macomb Orthopedics
                  25625 Schoenherr
                  Warren, MI  48088
                    Services:
                    • Single Specialty Practitioner (Outpatient)
                    Henry Ford Macomb Orthopedics
                    15520 19 Mile Road
                    Clinton Township, MI  48038
                      Services:
                      • Single Specialty Practitioner (Outpatient)
                      Henry Ford Macomb Plastic Surgery
                      43281 Commons Drive
                      Clinton Township, MI  48038
                        Services:
                        • Perform Invasive Procedure (Outpatient)
                        • Single Specialty Practitioner (Outpatient)
                        Henry Ford Macomb Seville Center
                        15400 19 Mile Road Ste150
                        Clinton Township, MI  48038
                        Other Clinics/Practices located at this site:
                        • Henry Ford Macomb Cardiac and Pulmonary Rehab
                        • Henry Ford Macomb Family Medicine
                        • Henry Ford Macomb Primary Care
                        • Neighbors Caring for Neighbors Outreach Center
                        Services:
                        • Outpatient Clinics (Outpatient)
                        Henry Ford Macomb Sleep Center
                        15945 Nineteen Mile Road
                        Clinton Township, MI  48038
                          Services:
                          • Single Specialty Practitioner (Outpatient)
                          Henry Ford Macomb Speciality Hospital (East Campus)
                          215 North Avenue
                          Mount Clemens, MI  48043
                            Services:
                            • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult)
                            • Family Support (Non 24 Hour Care)
                            Henry Ford Macomb Women's Health Center
                            14049 13 Mile Ste 6
                            Warren, MI  48088
                              Services:
                              • Outpatient Clinics (Outpatient)
                              • Perform Invasive Procedure (Outpatient)
                              Henry Ford Macomb-Warren Internal Medicine
                              13801 15 Mile Rd,
                              Sterling Heights, MI  48312
                                Services:
                                • Outpatient Clinics (Outpatient)
                                HF Macomb Family Medicine and Village Health Center
                                31505 32 Mile Road
                                Richmond, MI  48062
                                Other Clinics/Practices located at this site:
                                • Henry Ford Macomb Village Health Center Physical Therapy
                                • Henry Ford Macomb Village Health Obstetrics
                                Services:
                                • Outpatient Clinics (Outpatient)
                                • Perform Invasive Procedure (Outpatient)
                                Josephine Ford Cancer Institute
                                15855 19 Mile Road,
                                Clinton Township, MI  48038
                                Other Clinics/Practices located at this site:
                                • Henry Ford Macomb Hematology/Oncology, Ste 400
                                • Henry Ford Macomb Oncology
                                Services:
                                • Administration of High Risk Medications (Outpatient)
                                • Outpatient Clinics (Outpatient)
                                Lakeside OB/GYN ,
                                16151 19 Mile Road, Suite 300
                                Clinton Township, MI  48038
                                  Services:
                                  • Perform Invasive Procedure (Outpatient)
                                  • Single Specialty Practitioner (Outpatient)
                                  Shelby Family Medicine
                                  49310 Van Dyke Avenue
                                  Shelby Township, MI  48315
                                  Other Clinics/Practices located at this site:
                                  • Shelby OB/GYN
                                  • Shelby Township Health Center-Rehab Services
                                  Services:
                                  • Outpatient Clinics (Outpatient)
                                  • Perform Invasive Procedure (Outpatient)
                                  Shelby Medical Mall and Urgent Care
                                  50505 Schoenherr
                                  Utica, MI  48315
                                  Other Clinics/Practices located at this site:
                                  • Henry Ford Macomb Center for Health Managment
                                  • Henry Ford Macomb Family Medicine(Cardellio)
                                  • Henry Ford Macomb Hospital Oncology
                                  • Henry Ford Macomb Rheumatology
                                  • Shelby Urgent Care
                                  Services:
                                  • Outpatient Clinics (Outpatient)

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