Quality Report


Quality Report

Ascension St. John Hospital
HCO ID: 7498
22101 Moross Road
Detroit, MI, 48236-2172
(313) 343-4000
https://healthcare.ascension.org/Locations/Michigan/MIDET/De
Summary of Quality Information

Accreditation Programs

View Accreditation History
Gold Seal
Hospital
Accreditation Decision
Effective Date
12/6/2023
Last Full Survey Date
7/29/2022
Last On-Site Survey Date
12/5/2023

Advanced Certification Programs

View Certification History
Gold Seal
Advanced Comprehensive Stroke Center
Certification Decision
Effective Date
4/28/2022
Last Full Survey Date
4/27/2022
Last On-Site Survey Date
4/27/2022

Sites

Ascension Michigan Lab Services
19251 Mack Avenue, Suite 80
Grosse Pointe, MI, 48236

Available Services

  • General Laboratory Tests

Ascension St John Newland Medical Associates Rochester Hills
1901 Star Batt Drive, Suite 100C
Rochester, MI, 48309

Available Services

  • Single Specialty Practitioner (Outpatient )

Ascension St. John Chesterfield Health Center at 26 Mile
36750 26 Mile Road Suite 130
Chesterfield, MI, 48047

Available Services

  • General Laboratory Tests
  • Single Specialty Practitioner (Outpatient )
  • Toxicology

Ascension St. John Hospital
22101 Moross
Detroit, MI, 48236

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 )
  • Coronary Care Unit (Inpatient )
  • CT Scanner (Imaging/Diagnostic Services )
  • Dialysis Unit (Inpatient )
  • Ear/Nose/Throat Surgery (Surgical Services )
  • EEG/EKG/EMG Lab (Imaging/Diagnostic Services )
  • 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 (Imaging/Diagnostic Services )
  • Labor & Delivery (Inpatient )
  • 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 )
  • 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 )
  • 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
  • Transplant Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Advanced Comprehensive Stroke Center

Ascension St. John Hospital 26 Mile - Emergency Room
36750 26 Mile Road Suite 110
Chesterfield, MI, 48047

Available Services

  • Administration of Blood Product (Outpatient )
  • Administration of High Risk Medications (Outpatient )
  • Anesthesia (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Ascension St. John Hospital at 12 Mile
21000 Twelve Mile Road, Suite 120
Saint Clair Shores, MI, 48081

Available Services

  • General Laboratory Tests
  • Toxicology

Ascension St. John Hospital at 23 Mile
1700 23 Mile Road, Suite 125
Macomb, MI, 48044

Available Services

  • General Laboratory Tests
  • Toxicology

Ascension St. John Hospital at 23 Mile - Emergency Room
17700 23 Mile Road, Suite 150
Macomb, MI, 48044

Available Services

  • Administration of Blood Product (Outpatient )
  • Administration of High Risk Medications (Outpatient )
  • Anesthesia (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Ascension St. John Hospital Health Center at 12 Mile
21000 12 Mile Road, Suite 116 & 120
Saint Clair Shores, MI, 48081

Available Services

  • Outpatient Clinics (Outpatient )

Ascension St. John Hospital Health Center at 23 Mile
17700 23 Mile Road, Suite 175
Macomb, MI, 48044

Available Services

  • Perform Invasive Procedure (Outpatient )
  • Single Specialty Practitioner (Outpatient )

Ascension St. John Hospital Health Center at Kercheval
17141 Kercheval
Grosse Pointe, MI, 48230

Available Services

  • Single Specialty Practitioner (Outpatient )

Ascension St. John Hospital Mammography - Liggett Breast Cen
19229 Mack, Suite 31
Grosse Pointe Woods, MI, 48236

Available Services

  • Single Specialty Practitioner (Outpatient )

Ascension St. John Hospital Neurodiagnostics (EEG)
22201 Moross, Suite 360
Detroit, MI, 48236

Available Services

  • Single Specialty Practitioner (Outpatient )

Ascension St. John Hospital Neurodiagnostics (EEG)
17900 23 Mile Road, Suite 303
Macomb, MI, 48044

Available Services

  • Single Specialty Practitioner (Outpatient )

Ascension St. John Pharmacotherapy
22101 Moross Avenue
Grosse Pointe, MI, 48236

Available Services

  • Single Specialty Practitioner (Outpatient )

ASJH Neuroendovascular and Neurocritical Care
22201 Moross Road, Suite 380
Detroit, MI, 48236

Available Services

  • Single Specialty Practitioner (Outpatient )

ASJH Orthopedic Surgery and Sports Medicine
11270 E. 13 Mile Road, Suite 4
Warren, MI, 48093

Available Services

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

ASJH Orthopedics and Sports Medicine
22201 Moross Road Suite 150
Grosse Pointe, MI, 48236

Available Services

  • Single Specialty Practitioner (Outpatient )

Blue Pain Water Specialists
46591 Romeo Plank Road, Suite 137
Macomb, MI, 48044

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Perform Invasive Procedure (Outpatient )
  • Single Specialty Practitioner (Outpatient )

Blue Water Pain Specialists
21000 12 Mile Road, Suite 100
Saint Clair Shores, MI, 48081

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Perform Invasive Procedure (Outpatient )
  • Single Specialty Practitioner (Outpatient )

Cancer Center Genetics
19229 Mack Avenue, Suite 18
Grosse Pointe Woods, MI, 48236

Available Services

  • Single Specialty Practitioner (Outpatient )

Cardiac Rehabilitation Services
22151 Moross, Suite 123
Detroit, MI, 48236

Available Services

  • Single Specialty Practitioner (Outpatient )

Center for Palliative and Supportive Care
19229 Mack Avenue, Suite 24
Grosse Pointe, MI, 48236

Available Services

  • Single Specialty Practitioner (Outpatient )

Eastside Cardiovascular Medicine
25195 Kelly Road, Suite A
Roseville, MI, 48066

Available Services

  • Administration of High Risk Medications (Outpatient )
  • General Laboratory Tests
  • Perform Invasive Procedure (Outpatient )
  • Single Specialty Practitioner (Outpatient )

Eastside Cardiovascular Medicine
17900 23 Mile Road, Suite 303
Macomb, MI, 48044

Available Services

  • Single Specialty Practitioner (Outpatient )

Eastside Neurosurgery
22201 Moross, Suite 380
Detroit, MI, 48236

Available Services

  • Single Specialty Practitioner (Outpatient )

Eastside Neurosurgery
17900 23 Mile Road, Suite 303
Macomb, MI, 48044

Available Services

  • Single Specialty Practitioner (Outpatient )

Endoscopy Services
22151 Moross, Ground Floor
Detroit, MI, 48236

Available Services

  • Administration of Blood Product (Outpatient )
  • Administration of High Risk Medications (Outpatient )
  • Anesthesia (Outpatient )
  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Great Lakes Cancer Infusion Center
17900 23 Mile Road, Suite 403
Macomb, MI, 48044

Available Services

  • Administration of Blood Product (Outpatient )
  • Administration of High Risk Medications (Outpatient )
  • Hazardous Medication Compounding (Outpatient )
  • High Risk Sterile Medication Compounding (Outpatient )
  • Single Specialty Practitioner (Outpatient )

Great Lakes Cancer Management Specialists
19229 Mack Avenue, Suite 34
Grosse Pointe Woods, MI, 48236

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Perform Invasive Procedure (Outpatient )
  • Single Specialty Practitioner (Outpatient )

Great Lakes Cancer Management Specialists
17900 23 Mile Road, Suite 402
Macomb, MI, 48044

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Perform Invasive Procedure (Outpatient )
  • Single Specialty Practitioner (Outpatient )

Great Lakes Cancer Management Specialists
4014 River Road. Bldg.1
East China, MI, 48054

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Hazardous Medication Compounding (Outpatient )
  • High Risk Sterile Medication Compounding (Outpatient )
  • Single Specialty Practitioner (Outpatient )

Great Lakes Cancer Management Specialists
19229 Mack, Suite 24
Grosse Pointe Woods, MI, 48236

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Perform Invasive Procedure (Outpatient )
  • Single Specialty Practitioner (Outpatient )

Great Lakes Cancer Management Specialists
11800 12 Mile Road, Webber Cancer Center
Warren, MI, 48093

Available Services

  • Administration of High Risk Medications (Outpatient )
  • General Laboratory Tests
  • Perform Invasive Procedure (Outpatient )
  • Single Specialty Practitioner (Outpatient )

Great Lakes Cancer Management Specialists
19229 Mack Avenue, Suite 27
Grosse Pointe, MI, 48236

Available Services

  • General Laboratory Tests

Gynecology/Oncology
22301 Foster Winter Drive, 3rd Floor
Southfield, MI, 48075

Available Services

  • Single Specialty Practitioner (Outpatient )

Gynecology/Oncology
19229 Mack Ave, Suite 39
Grosse Pointe Woods, MI, 48236

Available Services

  • Single Specialty Practitioner (Outpatient )

Harper Family Practice
19901 East Ten Mile Road
St Clair Shrs, MI, 48080

Available Services

  • General Laboratory Tests
  • Perform Invasive Procedure (Outpatient )
  • Single Specialty Practitioner (Outpatient )

Heart Rhythm Institute
25195 Kelly Road, Suite A
Roseville, MI, 48066

Available Services

  • Single Specialty Practitioner (Outpatient )

Infusion Services
19229 Mack, Suite 22
Grosse Pointe Woods, MI, 48236

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Hazardous Medication Compounding (Outpatient )
  • High Risk Sterile Medication Compounding (Outpatient )
  • Single Specialty Practitioner (Outpatient )

Internal Medicine Specialty Center
22201 Moross, Suite 50
Detroit, MI, 48236

Available Services

  • Administration of High Risk Medications (Outpatient )
  • General Laboratory Tests
  • Perform Invasive Procedure (Outpatient )
  • Single Specialty Practitioner (Outpatient )

Lakeshore Ear, Nose & Throat
21000 Twelve Mile Road, Suite 111
Saint Clair Shores, MI, 48081

Available Services

  • Perform Invasive Procedure (Outpatient )
  • Single Specialty Practitioner (Outpatient )

Lakeshore Ear, Nose & Throat
17900 23 Mile Road, Suite 203
Macomb, MI, 48044

Available Services

  • Perform Invasive Procedure (Outpatient )
  • Single Specialty Practitioner (Outpatient )

Masonic Medical Center
21099 Masonic
Saint Clair Shores, MI, 48082

Available Services

  • Administration of High Risk Medications (Outpatient )
  • General Laboratory Tests
  • Perform Invasive Procedure (Outpatient )
  • Single Specialty Practitioner (Outpatient )

Michigan Breast Specialists
17900 23 Mile Road, Suite 203
Macomb, MI, 48044

Available Services

  • Single Specialty Practitioner (Outpatient )

Newland Medical Associates
46701 Grand River, Suite 2 South
Novi, MI, 48374

Available Services

  • General Laboratory Tests
  • Perform Invasive Procedure (Outpatient )
  • Single Specialty Practitioner (Outpatient )

Newland Medical Associates
22301 Foster Winter Drive, 2nd Floor
Southfield, MI, 48075

Available Services

  • General Laboratory Tests
  • Perform Invasive Procedure (Outpatient )
  • Single Specialty Practitioner (Outpatient )

Newland Medical Associates
1901 Star Batt Drive, Suite 100D
Rochester, MI, 48309

Available Services

  • Administration of High Risk Medications (Outpatient )
  • General Laboratory Tests
  • Hazardous Medication Compounding (Outpatient )
  • Single Specialty Practitioner (Outpatient )

Newland Medical Associates
22301 Foster Winter Drive, 3rd Floor
Southfield, MI, 48075

Available Services

  • Single Specialty Practitioner (Outpatient )

Newland Medical Associates
31500 Telegraph, Suite 225
Bingham Farms, MI, 48025

Available Services

  • Administration of High Risk Medications (Outpatient )
  • General Laboratory Tests
  • High Risk Sterile Medication Compounding (Outpatient )
  • Single Specialty Practitioner (Outpatient )

Newland Medical Associates
46701 Grand River, Suite 1 South
Novi, MI, 48374

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Hazardous Medication Compounding (Outpatient )
  • Single Specialty Practitioner (Outpatient )

Newland Rheumatology
22290 Providence Drive, Suite 200
Southfield, MI, 48075

Available Services

  • Perform Invasive Procedure (Outpatient )
  • Single Specialty Practitioner (Outpatient )

Physical Therapy
20952 Twelve Mile Road, Suite 110
St Clair Shrs, MI, 48081

Available Services

  • Single Specialty Practitioner (Outpatient )

Physical Therapy
17141 Kercheval
Grosse Pointe, MI, 48230

Available Services

  • Single Specialty Practitioner (Outpatient )

Physical Therapy
36750 26 Mile Road
Chesterfield, MI, 48047

Available Services

  • Single Specialty Practitioner (Outpatient )

Podiatric Surgery Clinic
22201 Moross, Suite 250
Detroit, MI, 48236

Available Services

  • Perform Invasive Procedure (Outpatient )
  • Single Specialty Practitioner (Outpatient )

Premier Family Physicians
24100 Little Mack
St Clair Shrs, MI, 48080

Available Services

  • General Laboratory Tests
  • Perform Invasive Procedure (Outpatient )
  • Single Specialty Practitioner (Outpatient )

Radiation Therapy
19229 Mack, Suite 10
Grosse Pointe Woods, MI, 48236

Available Services

  • Single Specialty Practitioner (Outpatient )

Rheumatology
17900 23 Mile Rd., Suite 402
Macomb, MI, 48044

Available Services

  • Perform Invasive Procedure (Outpatient )
  • Single Specialty Practitioner (Outpatient )

Romeo Planck MRI
46591 Romeo Planck Suite 133
Macomb, MI, 48044

Available Services

  • Single Specialty Practitioner (Outpatient )

Romeo Plank Diag Ctr/Noninvasive Cardiology
17900 23 Mile Road, Suite 303
Macomb, MI, 48044

Available Services

  • Single Specialty Practitioner (Outpatient )

St. Clair Adult Medicine Specialists
17141 Kercheval
Grosse Pointe, MI, 48230

Available Services

  • General Laboratory Tests
  • Single Specialty Practitioner (Outpatient )

St. John Center for Wellness
18303 Ten Mile Road, Suite 500
Roseville, MI, 48066

Available Services

  • Administration of High Risk Medications (Outpatient )
  • General Laboratory Tests
  • Perform Invasive Procedure (Outpatient )
  • Single Specialty Practitioner (Outpatient )

St. John Children's Center
22201 Moross, Suite 270
Detroit, MI, 48236

Available Services

  • General Laboratory Tests
  • Single Specialty Practitioner (Outpatient )

St. John Children's Center
22201 Moross, Suite 70
Detroit, MI, 48236

Available Services

  • General Laboratory Tests
  • Single Specialty Practitioner (Outpatient )

St. John Children's Center - Rochester
1135 W. University Drive, Suite 355
Rochester, MI, 48307

Available Services

  • General Laboratory Tests
  • Single Specialty Practitioner (Outpatient )

St. John Family Medical Center
24911 Little Mack, Suite C
St Clair Shrs, MI, 48080

Available Services

  • Administration of High Risk Medications (Outpatient )
  • General Laboratory Tests
  • Perform Invasive Procedure (Outpatient )
  • Single Specialty Practitioner (Outpatient )

St. John Internal Medicine
19251 Mack, Suite 333
Grosse Pointe Woods, MI, 48236

Available Services

  • Administration of High Risk Medications (Outpatient )
  • General Laboratory Tests
  • Perform Invasive Procedure (Outpatient )
  • Single Specialty Practitioner (Outpatient )

St. John OB/GYN Clinic
22201 Moross, Suite 370
Detroit, MI, 48236

Available Services

  • Administration of High Risk Medications (Outpatient )
  • General Laboratory Tests
  • Perform Invasive Procedure (Outpatient )
  • Single Specialty Practitioner (Outpatient )

St. John OB/GYN Professionals
22151 Moross, Suite 313
Detroit, MI, 48236

Available Services

  • Administration of High Risk Medications (Outpatient )
  • General Laboratory Tests
  • Perform Invasive Procedure (Outpatient )
  • Single Specialty Practitioner (Outpatient )

St. John Rheumatology
22151 Moross, PBI, Suite 203
Detroit, MI, 48236

Available Services

  • Single Specialty Practitioner (Outpatient )

St. John Ultrasound/NST
22151 Moross, PB1 Suite 320
Detroit, MI, 48236

Available Services

  • General Laboratory Tests
  • Perform Invasive Procedure (Outpatient )
  • Single Specialty Practitioner (Outpatient )

Surgery Center
17700 23 Mile Road, Suite 200
Macomb, MI, 48044

Available Services

  • Administration of Blood Product (Outpatient )
  • Administration of High Risk Medications (Outpatient )
  • Ambulatory Surgery Center (Outpatient )
  • Anesthesia (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Surgery Center
21000 Twelve Mile Road, Ste. 130
St Clair Shrs, MI, 48081

Available Services

  • Administration of Blood Product (Outpatient )
  • Administration of High Risk Medications (Outpatient )
  • Ambulatory Surgery Center (Outpatient )
  • Anesthesia (Outpatient )
  • Perform Invasive Procedure (Outpatient )

The Holley Institute
22151 Moross, Suite 223
Detroit, MI, 48236

Available Services

  • Single Specialty Practitioner (Outpatient )

Transplant Center
22201 Moross, Suite 480
Detroit, MI, 48236

Available Services

  • Single Specialty Practitioner (Outpatient )

Warren Family Physicians
11270 East Thirteen Mile Road, Suite 4
Warren, MI, 48093

Available Services

  • Administration of High Risk Medications (Outpatient )
  • General Laboratory Tests
  • Perform Invasive Procedure (Outpatient )
  • Single Specialty Practitioner (Outpatient )

Webber Cancer Center Infusion
11800 12 Mile Road
Warren, MI, 48093

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Hazardous Medication Compounding (Outpatient )
  • High Risk Sterile Medication Compounding (Outpatient )
  • Single Specialty Practitioner (Outpatient )

Wound and Hyperbaric Center
22151 Moross, Suite B145
Detroit, MI, 48236

Available Services

  • Perform Invasive Procedure (Outpatient )
  • Single Specialty Practitioner (Outpatient )

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 2023 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

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