Quality Report


Quality Report

Ascension Macomb-Oakland Hospital
HCO ID: 7481
11800 East Twelve Mile Road
Warren, MI, 48093
(586) 573-5000
www.ascension.org
Summary of Quality Information

Accreditation Programs

View Accreditation History
Gold Seal
Behavioral Health Care and Human Services
Accreditation Decision
Effective Date
12/7/2022
Last Full Survey Date
12/6/2022
Last On-Site Survey Date
12/6/2022
Gold Seal
Hospital
Accreditation Decision
Effective Date
12/10/2022
Last Full Survey Date
12/9/2022
Last On-Site Survey Date
1/31/2023

Advanced Certification Programs

View Certification History
Gold Seal
Primary Stroke Center
Certification Decision
Effective Date
10/25/2023
Last Full Survey Date
10/24/2023
Last On-Site Survey Date
10/24/2023

Core Certification Programs

Gold Seal
Joint Replacement - Hip
Certification Decision
Effective Date
8/15/2023
Last Full Survey Date
8/14/2023
Last On-Site Survey Date
8/14/2023
Gold Seal
Joint Replacement - Knee
Certification Decision
Effective Date
8/15/2023
Last Full Survey Date
8/14/2023
Last On-Site Survey Date
8/14/2023
Gold Seal
Medication Compounding
Certification Decision
Effective Date
3/16/2023
Last Full Survey Date
3/15/2023
Last On-Site Survey Date
3/15/2023

Sites

Advance Wound Healing and Hyperbaric Center
11900 E. 12 Mile Road, Suite 208
Warren, MI, 48093

Available Services

  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

AMOH Breast Center
27472 Schoenherr, Suite 120
Warren, MI, 48088

Available Services

  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

AMOH Motor City Orthopedics and Sports Medicine Institute
11900 E Twelve Mile Road Suite 300
Warren, MI, 48093

Available Services

  • Single Specialty Practitioner (Outpatient )

AMOH Physical Therapy, Warren
27450 Schoenherr Road, Suite 100A
Warren, MI, 48088

Available Services

  • Outpatient Clinics (Outpatient )

AMOH St. John Oral Surgery and Dental Clinic
7633 East Jefferson Avenue, Suite 70
Detroit, MI, 48214

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Anesthesia (Outpatient )
  • General Laboratory Tests
  • Hazardous Medication Compounding (Inpatient )
  • Non-Sterile Medication Compounding (Inpatient )
  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )
  • Sterile Medication Compounding (Inpatient )

Ascension Macomb-Oakland Hospital, Madison Heights
27351 Dequindre Road
Madison Heights, MI, 48071

Available Services

  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult )
  • Community Integration (Non 24 Hour Care )
  • CT Scanner (Imaging/Diagnostic Services )
  • Ear/Nose/Throat Surgery (Surgical Services )
  • Eating Disorders
  • Eating Disorders (Outpatient )
  • EEG/EKG/EMG Lab (Imaging/Diagnostic Services )
  • Family Support (Non 24 Hour Care )
  • Gastroenterology (Surgical Services )
  • General Laboratory Tests
  • GI or Endoscopy Lab (Imaging/Diagnostic Services )
  • Gynecological Surgery (Surgical Services )
  • Hazardous Medication Compounding (Inpatient )
  • Hematology/Oncology Unit (Inpatient )
  • Inpatient Unit (Inpatient )
  • Interventional Radiology (Inpatient )
  • Interventional Radiology (Outpatient )
  • Interventional Radiology (Imaging/Diagnostic Services )
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services )
  • Medical /Surgical Unit (Inpatient )
  • Medical ICU (Intensive Care Unit )
  • Non-Sterile Medication Compounding (Inpatient )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Ophthalmology (Surgical Services )
  • Orthopedic Surgery (Surgical Services )
  • Outpatient Clinics (Outpatient )
  • Peer Support (Non 24 Hour Care )
  • Plastic Surgery (Surgical Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Sleep Laboratory (Sleep Laboratory )
  • Sterile Medication Compounding (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Surgical Unit (Inpatient )
  • Teleradiology (Imaging/Diagnostic Services )
  • Thoracic Surgery (Surgical Services )
  • Toxicology
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Medication Compounding
  • Primary Stroke Center

Ascension Macomb-Oakland Hospital, Warren
11800 E. 12 Mile Road
Warren, MI, 48093

Available Services

  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult )
  • Brachytherapy (Imaging/Diagnostic Services )
  • Cardiac Catheterization Lab (Surgical Services )
  • Cardiac Surgery (Surgical Services )
  • Cardiothoracic Surgery (Surgical Services )
  • Cardiovascular Unit (Inpatient )
  • Community Integration (Non 24 Hour Care )
  • CT Scanner (Imaging/Diagnostic Services )
  • Ear/Nose/Throat Surgery (Surgical Services )
  • EEG/EKG/EMG Lab (Imaging/Diagnostic Services )
  • Family Support (Non 24 Hour Care )
  • Gastroenterology (Surgical Services )
  • General Laboratory Tests
  • GI or Endoscopy Lab (Imaging/Diagnostic Services )
  • Gynecological Surgery (Surgical Services )
  • Gynecology (Inpatient )
  • Hazardous Medication Compounding (Inpatient )
  • Hematology/Oncology Unit (Inpatient )
  • Inpatient Unit (Inpatient )
  • Interventional Radiology (Inpatient )
  • Interventional Radiology (Outpatient )
  • Interventional Radiology (Imaging/Diagnostic Services )
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services )
  • Medical /Surgical Unit (Inpatient )
  • Medical ICU (Intensive Care Unit )
  • Neurosurgery (Surgical Services )
  • Non-Sterile Medication Compounding (Inpatient )
  • Normal Newborn Nursery (Inpatient )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Ophthalmology (Surgical Services )
  • Orthopedic Surgery (Surgical Services )
  • Orthopedic/Spine Unit (Inpatient )
  • Peer Support (Non 24 Hour Care )
  • 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 )
  • Rehabilitation Unit (24-hour Acute Care/Crisis Stabilization )
  • Sterile Medication Compounding (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Surgical Unit (Inpatient )
  • Teleradiology (Imaging/Diagnostic Services )
  • Thoracic Surgery (Surgical Services )
  • Toxicology
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Joint Replacement - Hip
  • Joint Replacement - Knee
  • Medication Compounding
  • Primary Stroke Center

Ascension Michigan MRI
27379 Dequindre Road
Madison Heights, MI, 48071

Available Services

  • Outpatient Clinics (Outpatient )

Cardiac & Pulmonary Rehabilitation
12000 E. 12 Mile Road
Warren, MI, 48093

Available Services

  • Outpatient Clinics (Outpatient )

Macomb Oakland Urology Clinic
27450 Schoenherr Road, Suite 400
Warren, MI, 48088

Available Services

  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Motor City Internists
11885 East 12 Mile Road, Suite 200B
Warren, MI, 48093

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Neurological Recovery Systems
27450 Schoenherr Road, Suite 100A
Warren, MI, 48088

Available Services

  • Outpatient Clinics (Outpatient )

Oakland Primary Care
27450 Schoenherr Road, Suite 400
Warren, MI, 48088

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Oakland Sleep Center
27351 Dequindre Road
Madison Heights, MI, 48071

Available Services

  • Outpatient Clinics (Outpatient )

Cooperative Agreements

Hospital - Accredited by American College of Surgeons-Commission on Cancer (ACoS-COC)

National Patient Safety Goals and National Quality Improvement Goals

Symbol Key

  • starThis organization achieved the best possible results
  • plusThis organization's performance is better than the target range/value
  • checkThis organization's performance is similar to the target range/value
  • minusThis organization's performance is worse than the target range /value
  • naThis measure is not applicable for this organization
  • ndNot displayed

Measures 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.
  12. The measure rate is within optimal range.

Symbol Key

  • starThis organization achieved the best possible results
  • plusThis organization's performance is better than the target range/value
  • checkThis organization's performance is similar to the target range/value
  • minusThis organization's performance is worse than the target range/value
  • naThis measure is not applicable for this organization
  • ndNot displayed

Measures 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.
  12. The measure rate is within optimal range.

* This information can also be viewed at Hospital Compare.

**      Indicates per 1000 hours of patient care.
***   The measure was not in effect for this quarter.
----   Null value or data not displayed.

Hospital 2022 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Behavioral Health Care and Human Services 2022 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Reporting Period: January 2022 - December 2022
Perinatal Care National Comparison: nd 2 Statewide Comparison: nd 2

New Changes to Quarterly Measure

Download Quarterly Measure Results

* State results are not calculated for the National Patient Safety Goals.