Quality Report


Quality Report

Munson Medical Center
HCO ID: 7598
1105 Sixth Street
Traverse City, MI, 49684
(231) 935-6500
www.munsonhealthcare.org
Summary of Quality Information

Accreditation Programs

View Accreditation History
Gold Seal
Hospital
Accreditation Decision
Effective Date
11/12/2022
Last Full Survey Date
11/11/2022
Last On-Site Survey Date
12/30/2022

Advanced Certification Programs

View Certification History
Gold Seal
Advanced Comprehensive Stroke Center
Certification Decision
Effective Date
9/22/2023
Last Full Survey Date
7/19/2023
Last On-Site Survey Date
11/17/2023

Sites

1200 Sixth St.
DBA: Traverse Heart & Vascular
1200 Sixth St
Traverse City, MI, 49684

Available Services

  • Single Specialty Practitioner (Outpatient )

Other Clinics/Practices Located at This Site:

  • Laboratory-Business Occupancy
  • Traverse Heart & Vascular

5085 Anna Drive
DBA: Wound Care & Hyperbaric Services
5085 Anna Drive
Traverse City, MI, 49684

Available Services

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

Other Clinics/Practices Located at This Site:

  • Advanced Wound Care
  • HBO Services

Cowell Family Cancer Center
217 S. Madison
Traverse City, MI, 49684

Available Services

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

Other Clinics/Practices Located at This Site:

  • Bleeding Disorders Clinic
  • Infusion Clinic
  • Laboratory-Business Occupancy
  • Munson Gynecologic Oncology
  • Munson Medical Oncology
  • Radiation Oncology

Foster Family Community Health Center
550 Munson Avenue
Traverse City, MI, 49686

Available Services

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

Other Clinics/Practices Located at This Site:

  • Audiology Clinic
  • Cardiac Prevention & Rehabilitation - Business Occupancy
  • Comprehensive Pain Management Program
  • Laboratory - Business Occupancy
  • Memory & Attention Treatment Center - Business Occupancy
  • Physical Therapy - Business Occupancy
  • Pre-Procedure Services
  • Pulmonary Rehab
  • Radiology - Business Occupancy
  • Sleep Disorders Center - Business Occupancy
  • Urgent Care - Business Occupancy

Milliken Medical
224 Circle Dr.
Traverse City, MI, 49684

Available Services

  • Laboratory Draw Station (Outpatient )

Munson Behavioral Health Services
420 Brook St.
Traverse City, MI, 49684

Available Services

  • Behavioral Health (Day Programs - Adult )
  • Behavioral Health (Non 24 Hour Care - Adult )
  • Behavioral Health (Partial Hospitalization - Adult )
  • Chemical Dependency (Non 24 Hour Care - Adult )
  • Chemical Dependency (Non-detox - Adult )
  • Family Support (Non 24 Hour Care )
  • Peer Support (Non 24 Hour Care )
  • Technology-Based Addiction Services (Non 24 Hour Care - Adult )
  • Technology-Based Addiction Services (Non-detox - Adult )
  • Technology-Based Behavioral Health Srvs (Non 24 Hour Care - Adult )

Other Clinics/Practices Located at This Site:

  • Partial Hospitalization Program

Munson Family Practice Center
1400 Medical Campus Dr.
Traverse City, MI, 49684

Available Services

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

Other Clinics/Practices Located at This Site:

  • Laboratory Draw Site-Business Occupancy

Munson Healthcare West Front Medical Building
3537 West Front Street
Traverse City, MI, 49684

Available Services

  • Single Specialty Practitioner (Outpatient )

Other Clinics/Practices Located at This Site:

  • Munson Healthcare Rheumatology

Munson Laboratories at Grand Traverse Commerce Centre
3287 South Airport Road
Traverse City, MI, 49684

Available Services

  • Laboratory Draw Station (Outpatient )

Munson Medical Center
1105 Sixth Street
Traverse City, MI, 49684

Available Services

  • Allergen Extract (Inpatient )
  • 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 )
  • 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 )
  • Pediatric Unit (Inpatient )
  • Plastic Surgery (Surgical Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Rehabilitation Unit (Inpatient )
  • Rehabilitation Unit (24-hour Acute Care/Crisis Stabilization )
  • Sterile Medication Compounding (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Surgical Unit (Inpatient )
  • Thoracic Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Advanced Comprehensive Stroke Center

Munson Outpatient Services - Elk Rapids
115 Bridge St.
Elk Rapids, MI, 49629

Available Services

  • Laboratory Draw Station (Outpatient )

Munson Outpatient Services-Chums Corner
4025 Chums Village Dr, Ste. C
Traverse City, MI, 49685

Available Services

  • Laboratory Draw Station (Outpatient )

Munson Outpatient Services-Harbor Springs
8881 M-119
Harbor Springs, MI, 49740

Available Services

  • Laboratory Draw Station (Outpatient )

Munson Outpatient Services-Kingsley
2291 M-113 East
Kingsley, MI, 49649

Available Services

  • Laboratory Draw Station (Outpatient )

Munson Outpatient Services-Suttons Bay
93 B W. 4th St
Suttons Bay, MI, 49682

Available Services

  • Laboratory Draw Station (Outpatient )

Munson Professional Building
1221 Sixth Street
Traverse City, MI, 49684

Available Services

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

Other Clinics/Practices Located at This Site:

  • Bay Area Urology
  • Diabetes Education
  • Endocrinology Consultants
  • Infectious Disease
  • Laboratory Draw Site-Business Occupancy
  • Maternal Fetal Medicine
  • Neurosurgery
  • Radiology

Munson Specialty Clinics
106 S. Madison
Traverse City, MI, 49684

Available Services

  • Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

  • Craniofacial Clinic
  • Developmental Assessment Clinic
  • Synagis Clinic

Northern Pines
11293 N M-37, Suite a
Buckley, MI, 49620

Available Services

  • Laboratory Draw Station (Outpatient )

Smith Family Breast Health Center
4100 Park Forest Drive Suite 203
Traverse City, MI, 49684

Available Services

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

Thomas Judd Care Center
5041 North Royal Drive, Ste 1
Traverse City, MI, 49684

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
Reporting Period: January 2022 - December 2022
Emergency Department National Comparison: nd 2 Statewide Comparison: nd 2
Hospital-Based Inpatient Psychiatric Services National Comparison: nd 2 Statewide Comparison: nd 2
Immunization National Comparison: nd 2 Statewide Comparison: nd 2
Perinatal Care National Comparison: nd 2 Statewide Comparison: nd 2
Substance Use National Comparison: nd 2 Statewide Comparison: nd 2
Tobacco Treatment 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.