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Quality Report

Summary of Accreditation Quality Information
Mercy Health Partners
Org ID: 7565
1500 East Sherman Boulevard
Muskegon, MI  49443
(231)672-2000
www.mghp.com
Accreditation Decision: Accredited
Decision Effective Date: August 17, 2007
This organization is in full compliance with all applicable standards.  


Accredited Programs Last Full Survey Date Last On-Site Survey Date  
Hospital 8/16/2007 8/16/2007  


Other Accredited Programs / Services
Laboratory  -  Accredited by College of American Pathologists


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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
Hospital
2007 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  2009 -
Dec  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
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 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 similar to the target range/value.
This organization’s performance is similar to 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
Adult Medicine Specialists
6401 Prairie Street, Suite 2800
Muskegon, MI  49444
  • Single Specialty Group Practice (Outpatient)
Bear Creek Health Center
1877 North Getty Street
Muskegon, MI  49445
  • Multi Specialty Group Practice (Outpatient)
Brenneman & Brenneman
1715 Peck Street
Muskegon, MI  49441
  • Single Specialty Group Practice (Outpatient)
Geriatric Medical Associates
1150 E. Sherman Suites1175
Muskegon, MI  49444
  • General Laboratory Tests
  • Single Specialty Practitioner (Outpatient)
Harborwood at the Lakes
6401 Prairie Street, Suite 1600
Muskegon, MI  49444
  • Single Specialty Group Practice (Outpatient)
Harborwood Family Medicine
1675 Leahy Street, Suite 301A
Muskegon, MI  49442
  • Single Specialty Group Practice (Outpatient)
Harbour Pointe Medical Associates
3587 Henry Street, Suite 200
Muskegon, MI  49441
  • General Laboratory Tests
  • Multi Specialty Group Practice (Outpatient)
Harbour View Family Medicine
1909 Ruddiman Drive
Muskegon, MI  49445
  • Single Specialty Group Practice (Outpatient)
Hart Pavilion-Outpatient Lab/Radiology
611 E. Main St
Hart, MI  49420
  • General Laboratory Tests
  • General Outpatient Services (Outpatient)
Kinney & Parrett (KPA)
1325 Mercy Drive
Muskegon, MI  49444
  • General Laboratory Tests
  • Single Specialty Practitioner (Outpatient)
Lakes Family Medicine
6207 Harvey
Muskegon, MI  49444
  • Single Specialty Group Practice (Outpatient)
Lakes OB/Gyn
6401 Prairie Street Suite 2100
Muskegon, MI  49444
  • Single Specialty Group Practice (Outpatient)
Lakeshore Family Care
17325 VanWagoner Road
Spring Lake, MI  49456
  • General Laboratory Tests
  • Single Specialty Group Practice (Outpatient)
Mercy H.E.A.R.T. Center
1212 E. Sherman Blvd.
Muskegon, MI  49444
  • General Outpatient Services (Outpatient)
Mercy Health Partners Mercy Campus  *
1500 East Sherman Boulevard
Muskegon, MI  49444
  • Cancer Center/Oncology (Inpatient, Outpatient)
  • Cardiac Catheterization Lab (Inpatient, Outpatient)
  • Cardiac Surgery (Inpatient)
  • Cardiac Unit/Cardiology (Inpatient)
  • CT Scanner (Inpatient, Outpatient)
  • Dialysis (Inpatient)
  • EEG/EKG/EMG Lab (Inpatient, Outpatient)
  • Emergency Room (Outpatient)
  • Gastroenterology (Inpatient, Outpatient)
  • General Medical Services (Inpatient, Outpatient)
  • General Surgery (Inpatient, Outpatient)
  • GI or Endoscopy Lab (Inpatient, Outpatient)
  • Imaging/Radiology (Inpatient, Outpatient)
  • Intensive Care Unit (Inpatient)
  • Internal Medicine (Inpatient)
  • Lithotripsy/Kidney Stone Treatment (Outpatient)
  • Magnetic Resonance Imaging (Inpatient, Outpatient)
  • Nephrology (Inpatient)
  • Neurology (Inpatient, Outpatient)
  • Nuclear Medicine (Inpatient, Outpatient)
  • Operating Room (Inpatient, Outpatient)
  • Oral Maxillofacial Surgery (Inpatient)
  • Orthopedic Surgery (Inpatient, Outpatient)
  • Outpatient Surgery (Outpatient)
  • Pediatric Care (Outpatient)
  • Plastic Surgery (Inpatient, Outpatient)
  • Post Anesthesia Care Unit (PACU) (Inpatient)
  • Pulmonary Function Lab (Outpatient)
  • Radiation Oncology (Outpatient)
  • Respiratory Care (Ventilator) (Inpatient)
  • Telemetry (Inpatient)
  • Thoracic Surgery (Inpatient)
  • Ultrasound (Inpatient, Outpatient)
  • Urology (Inpatient, Outpatient)
  • Vascular Surgery (Inpatient, Outpatient)
  • Wound Care (Inpatient)
Mercy Health Partners Muskegon General Campus
1700 Oak Avenue
Muskegon, MI  49442
  • EEG/EKG/EMG Lab (Inpatient, Outpatient)
  • General Surgery (Inpatient, Outpatient)
  • Gynecology (Inpatient, Outpatient)
  • Imaging/Radiology (Inpatient, Outpatient)
  • Labor & Delivery (Inpatient)
  • Nursery (Inpatient)
  • Obstetrics (Inpatient, Outpatient)
  • Operating Room (Inpatient, Outpatient)
  • Ophthalmology/Eye Surgery (Outpatient)
  • Oral Maxillofacial Surgery (Inpatient)
  • Outpatient Surgery (Outpatient)
  • Plastic Surgery (Inpatient, Outpatient)
  • Podiatry (Outpatient)
  • Post Anesthesia Care Unit (PACU) (Inpatient)
  • Recovery/Infirmary (Outpatient)
  • Sleep Center (Outpatient)
  • Ultrasound (Inpatient, Outpatient)
  • Urgent Care/Emergency Medicine (Outpatient)
Mercy Rehab Center
1400 Mercy Drive Suite 50
Muskegon, MI  49444
  • General Outpatient Services (Outpatient)
Mercy Westshore Internal Medicine
1150 East Sherman Blvd. Suite 1100
Muskegon, MI  49442
  • Single Specialty Practitioner (Outpatient)
MHP Anticoagulation Clinic
1150 East Sherman Blvd., Suite 1400
Muskegon, MI  49444
  • General Outpatient Services (Outpatient)
Northshore Family Practice
1915 Holton Road
Muskegon, MI  49445
  • General Laboratory Tests
  • Single Specialty Practitioner (Outpatient)
Norton Family Practice
3535 Park Street, Suite 110
Muskegon, MI  49444
  • Single Specialty Group Practice (Outpatient)
OB/Gyn Associates of West Michigan
1675 Leahy, Suite 428
Muskegon, MI  49442
  • Single Specialty Group Practice (Outpatient)
Osteopathic Manipulative Medicine (OMM) Dr. Huff and Dr. Car
1150 East Sherman
Muskegon, MI  49442
  • Single Specialty Practitioner (Outpatient)
West View Family Medicine
6401 Prairie Street, Suite 2600
Muskegon, MI  49444
  • Single Specialty Group Practice (Outpatient)
Westshore Family Medicine
1223 Mercy Drive
Muskegon, MI  49444
  • Single Specialty Practitioner (Outpatient)
Women's Health Center
1787 Wagner Avneue
Muskegon, MI  49442
  • General Laboratory Tests
  • Single Specialty Group Practice (Outpatient)
Women's Health Center
1787 Wagner
Muskegon, MI  49442
  • Single Specialty Group Practice (Outpatient)

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