Quality Report


Quality Report

W.A. Foote Memorial Hospital, Inc.

DBA: Henry Ford Jackson Hospital
HCO ID: 7536
205 N. East Ave
Jackson, MI, 49201
(517) 205-4800
www.henryford.com
Summary of Quality Information

Accreditation Programs

Gold Seal
Behavioral Health Care and Human Services
Accreditation Decision
Effective Date
3/28/2023
Last Full Survey Date
3/27/2023
Last On-Site Survey Date
3/27/2023
Gold Seal
Home Care
Accreditation Decision
Effective Date
4/1/2023
Last Full Survey Date
3/31/2023
Last On-Site Survey Date
6/2/2023
Gold Seal
Hospital
Accreditation Decision
Effective Date
4/5/2024
Last Full Survey Date
3/31/2023
Last On-Site Survey Date
4/4/2024

Advanced Certification Programs

Gold Seal
Certification Decision
Effective Date
8/24/2022
Last Full Survey Date
8/23/2022
Last On-Site Survey Date
8/23/2022

Core Certification Programs

Gold Seal
Certification Decision
Effective Date
8/30/2023
Last Full Survey Date
8/29/2023
Last On-Site Survey Date
8/29/2023
Gold Seal
Certification Decision
Effective Date
8/30/2023
Last Full Survey Date
8/29/2023
Last On-Site Survey Date
8/29/2023
Gold Seal
Certification Decision
Effective Date
8/17/2023
Last Full Survey Date
8/16/2023
Last On-Site Survey Date
8/16/2023

Sites

Henry Ford Addiction Recovery Center - Jackson
2424 W. Washington Ave, Suite 200
Jackson, MI, 49203

Available Services

  • Addiction Services
  • Addiction Services (Non-detox - Adult )
  • Behavioral Health (Day Programs - Adult )
  • Behavioral Health (Partial Hospitalization - Adult )
  • Chemical Dependency (Day Programs - Adult )
  • Chemical Dependency (Non 24 Hour Care - Adult )
  • Chemical Dependency (Residential Care - Adult )
  • Chemical Dependency (Partial Hospitalization - Adult )
  • Chemical Dependency (Detox - Adult )
  • Chemical Dependency (Non-detox - Adult )
  • Community Integration (Non 24 Hour Care )

Other Clinics/Practices Located at This Site:

  • Suite 100 - Henry Ford Substance Abuse Services - Jackson

Henry Ford Cardiology - Jackson
309 Page Ave
Jackson, MI, 49201

Available Services

  • Outpatient Clinics (Outpatient )

Henry Ford Cardiology - Jonesville
216 Olds Street
Jonesville, MI, 49250

Available Services

  • Outpatient Clinics (Outpatient )

Henry Ford Diagnostic Center - North Jackson Street
505 N. Jackson St
Jackson, MI, 49201

Available Services

  • Outpatient Clinics (Outpatient )

Henry Ford Digestive Health - East Avenue
205 S. East Ave
Jackson, MI, 49201

Available Services

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

Henry Ford Ear, Nose & Throat - Jackson
1111 Teneyck Street, Suite 100
Jackson, MI, 49201

Available Services

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

Other Clinics/Practices Located at This Site:

  • Suite 200 - Henry Ford Hearing Center - Jackson

Henry Ford Family Medicine - Brooklyn
153 Wamplers Lake Rd
Brooklyn, MI, 49230

Available Services

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

Other Clinics/Practices Located at This Site:

  • Henry Ford Diagnostic Center - Brooklyn

Henry Ford Family Medicine - Grass Lake
12369 E Michigan Ave
Grass Lake, MI, 49240

Available Services

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

Other Clinics/Practices Located at This Site:

  • Henry Ford Diagnostic Center - Grass Lake

Henry Ford Family Medicine - Summit Woods
2585 Spring Arbor Rd
Jackson, MI, 49203

Available Services

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

Henry Ford Hand Therapy - Hillsdale
61 W. Carleton Rd
Hillsdale, MI, 49242

Available Services

  • Outpatient Clinics (Outpatient )

Henry Ford Home Medical Equipment - Jackson
700 E. Michigan Ave
Jackson, MI, 49201

Available Services

  • Blood Glucose Monitors (non-mail order)
  • Breast Prostheses and Accessories
  • Canes and Crutches
  • Commodes
  • Continuous Positive Airway Pressure
  • Custom Orthoses Fabricated
  • Durable Medical Equipment
  • Enteral Equipment and/or Supplies
  • Enteral Nutrients
  • Gastric Suction Pumps
  • Hospital Beds - Electric
  • Hospital Beds - Manual
  • Insulin Infusion Pump Supplies
  • Nebulizers Equipment
  • Off The Shelf Orthoses
  • Ostomy Supplies
  • Oxygen
  • Patient Lifts and Accessories
  • Prosthetics (Home Medical Equipment)
  • Respiratory Assist Devices
  • Respiratory Equipment
  • Seat Lift Mechanisms
  • Suction Pump
  • Supplies
  • Support Surfaces for Beds (New)
  • Surgical Dressings
  • Tens Units
  • Tracheostomy Supplies
  • Traction Equipment
  • Urological Supplies
  • Walkers, Canes and Crutches
  • Wheelchair Seating / Cushions
  • Wheelchairs - Manual Non-Custom
  • Wheelchairs-Standard Manual Related Accessories and Repairs

Henry Ford Hospice Home - Jackson
2150 Kingsbrooke Dr
Jackson, MI, 49202

Available Services

  • Hospice Care

Henry Ford Medical Center - Albion
27931 C Dr North
Albion, MI, 49224

Available Services

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

Other Clinics/Practices Located at This Site:

  • Henry Ford Diagnostic Center - Albion
  • Henry Ford Family Medicine - Albion

Henry Ford Medical Center - Cascade Ridge
3305 Spring Arbor Rd, Suite 500
Jackson, MI, 49203

Available Services

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

Other Clinics/Practices Located at This Site:

  • Suite 100 - Henry Ford Diagnostic Center - Cascade Ridge
  • Suite 200 - Henry Ford Pediatrics - Cascade Ridge
  • Suite 500 - Henry Ford Women's Health - Jackson

Henry Ford Medical Center - Chelsea
1145 S. Main Street
Chelsea, MI, 48118

Available Services

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

Henry Ford Medical Center - East Michigan Avenue
3235 E. Michigan Ave, Suite 100
Jackson, MI, 49202

Available Services

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

Other Clinics/Practices Located at This Site:

  • Henry Ford Diagnostic Center - East Michigan Avenue
  • Henry Ford Family Medicine - East Michigan Avenue

Henry Ford Medical Center - Jackson
1201 E. Michigan Ave
Jackson, MI, 49201

Available Services

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

Other Clinics/Practices Located at This Site:

  • Henry Ford Bone Densitometry
  • Suite 100 - Henry Ford Sports Medicine - Jackson
  • Suite 101 Henry Ford Orthopedic Specialty Group/Sports Medic
  • Suite 115 - Henry Ford Diagnostic Center - Jackson
  • Suite 120 - Henry Ford Physical Medicine & Rehabilitation -
  • Suite 200 - Henry Ford Pain Management - Jackson
  • Suite 240 - Henry Ford Neurology - Jackson
  • Suite 240 - Henry Ford Neurosurgery - Jackson
  • Suite 240 Henry Ford Podiatry - Jackson
  • Suite 300 - Henry Ford Orthopedics - Jackson
  • Suite 300 - Henry Ford Physical Rehabilitation - Jackson

Henry Ford Medical Center - Leslie
130 N. Sherman St
Leslie, MI, 49251

Available Services

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

Other Clinics/Practices Located at This Site:

  • Henry Ford Diagnostic Center - Leslie
  • Henry Ford Family Medicine - Leslie

Henry Ford Medical Center - Mason
810 Hogsback Rd, Ste A
Mason, MI, 48854

Available Services

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

Other Clinics/Practices Located at This Site:

  • Suite A - Henry Ford Family Medicine - Mason
  • Suite A - Henry Ford Vascular - Mason
  • Suite B - Henry Ford Diagnostic Center - Mason
  • Suite B - Henry Ford Physical Rehabilitation - Mason

Henry Ford Medical Center - North St.
1401 W. North St
Jackson, MI, 49202

Available Services

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

Other Clinics/Practices Located at This Site:

  • Henry Ford Diagnostic Center - North St.
  • Henry Ford Family Medicine - North St.
  • Henry Ford Same Day Care - North St.

Henry Ford Medical Center - Spring Arbor
7845 Spring Arbor Rd
Spring Arbor, MI, 49283

Available Services

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

Other Clinics/Practices Located at This Site:

  • Henry Ford Diagnostic Center - Spring Arbor
  • Henry Ford Family Medicine - Spring Arbor

Henry Ford Medical Center - Springport Road
2200 Springport Rd
Jackson, MI, 49202

Available Services

  • Behavioral Health (Non 24 Hour Care - Adult )
  • Behavioral Health (Non 24 Hour Care - Child/Youth )
  • Community Integration (Non 24 Hour Care )
  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Other Clinics/Practices Located at This Site:

  • Suite 100 - Henry Ford Pharmacy #7369
  • Suite 210 - Henry Ford Diabetes Education Center - Jackson
  • Suite 210 - Henry Ford Nutrition Counseling Services - Jacks
  • Suite 230 - Henry Ford Medication Management Clinic - Jackso
  • Suite 500a - Henry Ford Wound Care and Hyperbaric Center Jac
  • Suite 500b - Henry Ford Infectious Disease - Jackson
  • Suite 800 - Henry Ford Diagnostic Center - Springport Road

Henry Ford Medical Center - Townsend
400 Hinckley Blvd, Suite 100
Jackson, MI, 49203

Available Services

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

Other Clinics/Practices Located at This Site:

  • Suite 100 - Henry Ford Family Medicine - Townsend
  • Suite 100 - Henry Ford Same Day Care - Townsend
  • Suite 200 - Henry Ford Diagnostic Center - Townsend

Henry Ford Medical Center - W. Michigan Avenue
744 W. Michigan Ave, Suite 201
Jackson, MI, 49201

Available Services

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

Other Clinics/Practices Located at This Site:

  • Suite 101 - Henry Ford Bariatric Center - Jackson
  • Suite 200 - Henry Ford Jackson - Outpatient Behavioral Health
  • Suite 201 - Henry Ford Gastroenterology - Jackson
  • Suite 300 - Henry Ford Urology - W. Michigan Avenue

Henry Ford Osteoporosis Center - Jackson
3333 Spring Arbor Road, Suite 100
Jackson, MI, 49203

Available Services

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

Other Clinics/Practices Located at This Site:

  • Suite 200 - Henry Ford Endocrinology - Jackson
  • Suite 500 - Henry Ford Plastic Surgery - Jackson

Henry Ford Pediatrics - Franklin Street
760 W. Franklin St
Jackson, MI, 49201

Available Services

  • Outpatient Clinics (Outpatient )

Henry Ford Professional Building
1100 E. Michigan Ave
Jackson, MI, 49201

Available Services

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

Certification Programs

  • Medication Compounding

Other Clinics/Practices Located at This Site:

  • Suite 100 - Henry Ford Heart Failure Clinic - Jackson
  • Suite 102 - Henry Ford Cardiac Rehabilitation - Jackson
  • Suite 104 - Henry Ford Diagnostic Center - Professional Buil
  • Suite 201 - Henry Ford Cardiac Surgery - Jackson
  • Suite 201 - Henry Ford Cardiovascular Medicine - Jackson
  • Suite 201 - Henry Ford Thoracic Surgery - Jackson
  • Suite 203 Henry Ford General Surgery - Jackson
  • Suite 204 - Henry Ford Electrophysiology - Jackson
  • Suite 204 Henry Ford Electrophysiology - Jackson
  • Suite 209 - Henry Ford Outpatient Procedure Center - Jackson
  • Suite 300 - Henry Ford Acute Care Clinic - Jackson
  • Suite 300 - Henry Ford General Surgery - Professional Buildi
  • Suite 300 - Henry Ford Outpatient Trauma - Jackson
  • Suite 307 - Henry Ford Hematology & Oncology - Jackson

Henry Ford Radiation Oncology - Jackson (Paul Tejada Center)
1102 E. Michigan Ave
Jackson, MI, 49201

Available Services

  • Outpatient Clinics (Outpatient )

Henry Ford Rheumatology - Jackson
4304 Page Ave Ste 200
Michigan Center, MI, 49254

Available Services

  • Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

  • Suite 100 - Henry Ford Diagnostic Center - Michigan Center
  • Suite 100 - Henry Ford Physical Rehabilitation - Michigan Ce

Henry Ford Surgery Center - Jackson
1125 E. Michigan Ave
Jackson, MI, 49201

Available Services

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

Henry Ford Thoracic Surgery - Hillsdale
3271 Carleton Road
Hillsdale, MI, 49242

Available Services

  • Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

  • Henry Ford Cardiology - Hillsdale

Henry Ford Urology - Spring Arbor Road
2800 Spring Arbor Road, Suite 101
Jackson, MI, 49203

Available Services

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

Henry Ford Vascular - Jackson
300 W. Washington Ave, Suite 300
Jackson, MI, 49201

Available Services

  • Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

  • Suite 350 - Henry Ford Vascular Lab - Jackson

One Jackson Square
100 E. Michigan Ave
Jackson, MI, 49201

Available Services

  • Home Health Aides
  • Home Health, Non-Hospice Services
  • Hospice Care
  • Medical Social Services
  • Occupational Therapy
  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )
  • Physical Therapy
  • Skilled Nursing Services
  • Speech Language Pathology

Other Clinics/Practices Located at This Site:

  • Suite 101 - Henry Ford Occupational Health - Jackson
  • Suite 102 - Henry Ford Internal Medicine - Jackson
  • Suite 103 - Henry Ford Physical Rehabilitation - Jackson
  • Suite 400 - Henry Ford Home Care - South Central Michigan
  • Suite 400 - Henry Ford Hospice - South Central Michigan
  • Suite 400 - Henry Ford Jackson - Advanced Illness Management

W.A. Foote Memorial Hospital, Inc.
DBA: Henry Ford Jackson Hospital
205 N East Ave
Jackson, MI, 49201

Available Services

  • Behavioral Health (Day Programs - Adult )
  • Behavioral Health (Non 24 Hour Care - Adult )
  • Behavioral Health (Non 24 Hour Care - Child/Youth )
  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult )
  • Behavioral Health (Partial Hospitalization - Adult )
  • Cardiac Catheterization Lab (Surgical Services )
  • Cardiac Surgery (Surgical Services )
  • Cardiothoracic Surgery (Surgical Services )
  • Cardiovascular Unit (Inpatient )
  • Chemical Dependency (Non 24 Hour Care - Adult )
  • Chemical Dependency (Non-detox - Adult )
  • Community Integration (Non 24 Hour Care )
  • 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 )
  • 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 )
  • Neuro/Spine Unit (Inpatient )
  • Neurosurgery (Surgical Services )
  • Non-Sterile Medication Compounding (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 )
  • Sleep Laboratory (Sleep Laboratory )
  • Sterile Medication Compounding (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Surgical Unit (Inpatient )
  • Teleradiology (Imaging/Diagnostic Services )
  • Thoracic Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

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

Other Clinics/Practices Located at This Site:

  • Henry Ford Behavioral Health Access Center - Jackson
  • Henry Ford Behavioral Health Outpatient Services - Jackson
  • Henry Ford Infusion Therapy - Jackson
  • Henry Ford Partial Hospitalization Program - Jackson
  • Henry Ford Sleep Center - Jackson

Cooperative Agreements

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.

Behavioral Health Care and Human Services 2023 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Home Care 2023 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Hospital 2024 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

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