The Joint Commission
Quality Check
Quality Report

Summary of Accreditation Quality Information
Mercy Health Partners-Mercy Campus
DBA: Mercy Health Muskegon-Mercy Campus
Org ID: 7565
1500 East Sherman Boulevard
Muskegon, MI  49443
(231)672-2000
www.mercyhealthmuskegon.com


Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full Survey Date Last On-Site Survey Date
Hospital
Accredited 8/24/2013 8/23/2013   1/3/2014  


Accreditation programs recognized by the Centers for Medicare and Medicaid Services (CMS)
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.
National Patient Safety Goals and National Quality Improvement Goals
    Compared to other Joint Commission Accredited Organizations
    Nationwide Statewide
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:
Oct  2012 -
Sep  2013
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 above 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 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.
  • 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
Not displayed.
3
Not displayed.
3
  • 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
   
 
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
DBA:  Mercy Health Physician Partners-Adult Medicine Specialists
6401 Prairie Street, Suite 2800
Muskegon, MI  49444
    Services:
    • Outpatient Clinics (Outpatient)
    Bear Creek Health Center
    DBA:  Mercy Health Physician Partners-Bear Creek Health Center
    1877 North Getty Street
    Muskegon, MI  49445
      Services:
      • Outpatient Clinics (Outpatient)
      • Perform Invasive Procedure (Outpatient)
      Fruitport Family Medicine
      DBA:  Mercy Health Physician Partners-Fruitport Family Medicine
      3443 Farr Road
      Fruitport, MI  49415
        Services:
        • Outpatient Clinics (Outpatient)
        • Perform Invasive Procedure (Outpatient)
        Geriatric Medical Associates
        DBA:  Mercy Health Physician Partners-Geriatric Medical Associates
        1150 E. Sherman Suites1125
        Muskegon, MI  49444
          Services:
          • General Laboratory Tests
          • Perform Invasive Procedure (Outpatient)
          • Single Specialty Practitioner (Outpatient)
          Great Lakes OB/GYN
          DBA:  Mercy Health Physician Partners-Great Lakes OB/GYN
          1775 Wells Avenue
          Muskegon, MI  49444
            Services:
            • Outpatient Clinics (Outpatient)
            • Perform Invasive Procedure (Outpatient)
            Harborwood at the Lakes
            DBA:  Mercy Health Physician Partners-Harborwood at the Lakes
            6401 Prairie Street, Suite 1600
            Muskegon, MI  49444
              Services:
              • Outpatient Clinics (Outpatient)
              • Perform Invasive Procedure (Outpatient)
              Harborwood Family Medicine
              DBA:  Mercy Health Physician Partners-Harborwood Family Medicine
              1675 Leahy Street, Suite 301A
              Muskegon, MI  49442
                Services:
                • Outpatient Clinics (Outpatient)
                • Perform Invasive Procedure (Outpatient)
                Harbour Pointe Medical Associates
                DBA:  Mercy Health Physician Partners-Harbour Pointe Medical Assoc
                3587 Henry Street, Suite 200
                Muskegon, MI  49441
                  Services:
                  • Administration of High Risk Medications (Outpatient)
                  • General Laboratory Tests
                  • Outpatient Clinics (Outpatient)
                  • Perform Invasive Procedure (Outpatient)
                  Harbour View Family Medicine
                  DBA:  Mercy Health Physician Partners-Harbour View Family Medicine
                  1909 Ruddiman Drive
                  Muskegon, MI  49445
                    Services:
                    • Outpatient Clinics (Outpatient)
                    Johnson Family Center for Cancer Care
                    1440 East Sherman Boulevard
                    Muskegon, MI  49444
                      Services:
                      • Administration of High Risk Medications (Outpatient)
                      • Anesthesia (Outpatient)
                      • Outpatient Clinics (Outpatient)
                      • Perform Invasive Procedure (Outpatient)
                      Kinney & Parrett (KPA)
                      DBA:  Mercy Health Physician Partners-Kinney & Parrett (KPA)
                      1325 Mercy Drive
                      Muskegon, MI  49444
                        Services:
                        • General Laboratory Tests
                        • Perform Invasive Procedure (Outpatient)
                        • Single Specialty Practitioner (Outpatient)
                        Lakes Family Medicine
                        DBA:  Mercy Health Physician Partners-Lakes Family Medicine
                        6207 Harvey
                        Muskegon, MI  49444
                          Services:
                          • Outpatient Clinics (Outpatient)
                          Lakes OB/Gyn
                          DBA:  Mercy Health Physician Partners-Lakes OB/GYN
                          6401 Prairie Street Suite 2100
                          Muskegon, MI  49444
                            Services:
                            • Outpatient Clinics (Outpatient)
                            • Perform Invasive Procedure (Outpatient)
                            Lakes OB/GYN Satellite
                            DBA:  Mercy Health Physician Partners-Lakes OB/GYN
                            1675 Leahy Suite 215A
                            Muskegon, MI  49442
                              Services:
                              • Outpatient Clinics (Outpatient)
                              • Perform Invasive Procedure (Outpatient)
                              Lakeshore Family Care
                              DBA:  Mercy Health Physician Partners-Lakeshore Family Care
                              601 W. Savidge Street
                              Spring Lake, MI  49456
                                Services:
                                • General Laboratory Tests
                                • Outpatient Clinics (Outpatient)
                                • Perform Invasive Procedure (Outpatient)
                                Mercy H.E.A.R.T. Center
                                DBA:  Mercy Health Physician Partners-Mercy H.E.A.R.T. Center
                                1212 E. Sherman Blvd.
                                Muskegon, MI  49444
                                  Services:
                                  • Outpatient Clinics (Outpatient)
                                  Mercy Health Partners Mercy Campus  *
                                  DBA:  Mercy Health Muskegon Mercy Campus
                                  1500 East Sherman Boulevard
                                  Muskegon, MI  49444
                                    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)
                                    • Dialysis Unit (Inpatient)
                                    • EEG/EKG/EMG Lab (Imaging/Diagnostic Services)
                                    • Gastroenterology (Surgical Services)
                                    • GI or Endoscopy Lab (Imaging/Diagnostic Services)
                                    • Hematology/Oncology Unit (Inpatient)
                                    • Interventional Radiology (Imaging/Diagnostic Services)
                                    • Magnetic Resonance Imaging (Imaging/Diagnostic Services)
                                    • Medical /Surgical Unit (Inpatient)
                                    • Medical ICU (Intensive Care Unit)
                                    • Nuclear Medicine (Imaging/Diagnostic Services)
                                    • Orthopedic Surgery (Surgical Services)
                                    • Orthopedic/Spine Unit (Inpatient)
                                    • Plastic Surgery (Surgical Services)
                                    • Positron Emission Tomography (PET) (Imaging/Diagnostic Services)
                                    • Post Anesthesia Care Unit (PACU) (Inpatient)
                                    • Surgical ICU (Intensive Care Unit)
                                    • Surgical Unit (Inpatient)
                                    • Thoracic Surgery (Surgical Services)
                                    • Ultrasound (Imaging/Diagnostic Services)
                                    • Urology (Surgical Services)
                                    • Vascular Surgery (Surgical Services)
                                    Mercy Health Partners Muskegon General Campus
                                    DBA:  Mercy Health Muskegon General Campus
                                    1700 Oak Avenue
                                    Muskegon, MI  49442
                                      Services:
                                      • Administration of High Risk Medications (Outpatient)
                                      • Urgent Care (Outpatient)
                                      Mercy Health Partners Sleep Disorder Center
                                      DBA:  Mercy Health Muskegon Sleep Disorder Center
                                      1700 Oak Avenue
                                      Muskegon, MI  49444
                                        Services:
                                        • Outpatient Clinics (Outpatient)
                                        Mercy Rehab Center
                                        1400 Mercy Drive Suite 50
                                        Muskegon, MI  49444
                                          Services:
                                          • Outpatient Clinics (Outpatient)
                                          Mercy Westshore Internal Medicine
                                          DBA:  Mercy Health Physician Partners-Mercy Westshore Internal Med
                                          1150 East Sherman Blvd. Suite 1100
                                          Muskegon, MI  49442
                                            Services:
                                            • Single Specialty Practitioner (Outpatient)
                                            MHP Anticoagulation Clinic
                                            DBA:  Mercy Health Muskegon Anticoagulation Clinic
                                            1150 East Sherman Blvd., Suite 1400
                                            Muskegon, MI  49444
                                              Services:
                                              • Outpatient Clinics (Outpatient)
                                              Northshore Family Practice
                                              DBA:  Mercy Health Physician Partners-Northshore Family Practice
                                              1915 Holton Road
                                              Muskegon, MI  49445
                                                Services:
                                                • General Laboratory Tests
                                                • Single Specialty Practitioner (Outpatient)
                                                Norton Family Practice
                                                DBA:  Mercy Health Physician Partners-Norton Family Practice
                                                3535 Park Street, Suite 110
                                                Muskegon, MI  49444
                                                  Services:
                                                  • Administration of High Risk Medications (Outpatient)
                                                  • Outpatient Clinics (Outpatient)
                                                  • Perform Invasive Procedure (Outpatient)
                                                  OB/Gyn Associates of West Michigan
                                                  DBA:  Mercy Health Physician Partners-OB/Gyn Associates of West Mi
                                                  1675 Leahy, Suite 428
                                                  Muskegon, MI  49442
                                                    Services:
                                                    • Outpatient Clinics (Outpatient)
                                                    • Perform Invasive Procedure (Outpatient)
                                                    Osteopathic Manipulative Medicine (OMM) Dr. Huff and Dr. Car
                                                    DBA:  Mercy Health Physician Partners-Osteopathic Manipulative Med
                                                    1150 East Sherman
                                                    Muskegon, MI  49442
                                                      Services:
                                                      • Single Specialty Practitioner (Outpatient)
                                                      Shoreline Neurological Consultants
                                                      DBA:  Mercy Health Physician Partners-Shoreline Neurological Consu
                                                      1675 Leahy Suite 401
                                                      Muskegon, MI  49442
                                                        Services:
                                                        • Outpatient Clinics (Outpatient)
                                                        West Michigan Gastroenterology
                                                        DBA:  Mercy Health Physician Partners-West Michigan Gastroenterolo
                                                        1675 Leahy Street Suite 324B
                                                        Muskegon, MI  49442
                                                          Services:
                                                          • Single Specialty Practitioner (Outpatient)
                                                          West View Family Medicine
                                                          DBA:  Mercy Health Physician Partners-West View Family Medicine
                                                          6401 Prairie Street, Suite 2600
                                                          Muskegon, MI  49444
                                                            Services:
                                                            • Outpatient Clinics (Outpatient)
                                                            Westshore Cardiology
                                                            DBA:  Mercy Health Physician Partners-Westshore Cardiology
                                                            1212 East Sherman Boulevard
                                                            Muskegon, MI  49444
                                                              Services:
                                                              • Outpatient Clinics (Outpatient)
                                                              Westshore Family Medicine
                                                              DBA:  Mercy Health Physician Partners-Westshore Family Medicine
                                                              1223 Mercy Drive
                                                              Muskegon, MI  49444
                                                                Services:
                                                                • Perform Invasive Procedure (Outpatient)
                                                                • Single Specialty Practitioner (Outpatient)
                                                                Women's Health Center
                                                                DBA:  Mercy Health Physician Partners-Women's Health Center
                                                                1675 Leahy Street Suite 311A
                                                                Muskegon, MI  49442
                                                                  Services:
                                                                  • Outpatient Clinics (Outpatient)
                                                                  • Perform Invasive Procedure (Outpatient)

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