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Spectrum Health Pennock
Hastings, Michigan 49058-1790
Preventing and Responding to Patient Harm
| Measure name | Leapfrog’s Standard | Hospital’s Progress | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Steps to Avoid Harm |
Hospitals have all of the following processes and protocols in place: effective leadership to prevent patient harm, regular surveys of staff to ensure they feel safe to speak up if they see a mistake, effective nursing plans to prevent patient harm, and handwashing protocols to reduce healthcare associated infections. |
 ACHIEVED THE STANDARD |
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| Appropriate Use of Antibiotics |
Hospitals should have a program to combat antibiotic over-prescribing that includes all seven (7) core elements developed by the Centers for Disease Control and Prevention (CDC). |
ACHIEVED THE STANDARD |
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| Responding to Never Events |
Hospitals should have a never events policy that includes all nine (9) actions that should occur following a “never event,” which includes apologizing to the patient and not charging for costs associated with the never event. |
ACHIEVED THE STANDARD |
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Medication Safety
| Measure name | Leapfrog’s Standard | Hospital’s Progress | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Safe Medication Ordering |
Hospitals should have doctors and other licensed prescribers enter at least 85% of inpatient medication orders through the CPOE system, and via a test, have demonstrated that prescribers are alerted to at least 60% of serious medication ordering errors. |
 CONSIDERABLE ACHIEVEMENT |
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This Hospital's Percentage of Inpatient Medication Orders Entered Electronically: 50-74% This Hospital’s CPOE Test Score: Full Demonstration of National Safety Standard for Decision Support |
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| Medication Reconciliation |
Hospitals should use a nationally endorsed protocol to track how well they are collecting and maintaining inpatient medication lists. |
ACHIEVED THE STANDARD |
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| Safe Medication Administration |
Hospitals should have nurses and other clinicians use BCMA in all medical/surgical units, intensive care units, and labor and delivery units to scan the patient and medication prior to administration at least 95% of the time. The BCMA system includes decision support to prevent errors and the hospital has processes to prevent workarounds. |
ACHIEVED THE STANDARD |
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Healthcare Associated Infections
| Measure name | Leapfrog’s Standard | Hospital’s Progress |
|---|---|---|
| Infection in the Blood |
Hospitals should have fewer than expected central-line associated blood stream infections. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC’s National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given various factors. A number lower than one means fewer infections than expected; a number more than one means more infections than expected. |
UNABLE TO CALCULATE Sample size too small to calculate score |
| Infection in the Urinary Tract |
Hospitals should have fewer than expected catheter-associated urinary tract infections. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC’s National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given various factors. A number lower than one means fewer infections than expected; a number more than one means more infections than expected. |
UNABLE TO CALCULATE Sample size too small to calculate score |
| C. difficile Infection |
Hospitals should have fewer than expected colon infections from C. diff bacteria. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC’s National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given various factors. A number lower than one means fewer infections than expected; a number more than one means more infections than expected. |
ACHIEVED THE STANDARD |
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This hospital’s standardized infection ratio (SIR) is: 0.430 |
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| MRSA Infection |
Hospitals should have fewer than expected antibiotic resistant bacterial infections. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC’s National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given various factors. A number lower than one means fewer infections than expected; a number more than one means more infections than expected. |
UNABLE TO CALCULATE Sample size too small to calculate score |
| Surgical Site Infection After Colon Surgery |
Hospitals should have fewer than expected surgical site infections after major colon surgery. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC’s National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given various factors. A number lower than one means fewer infections than expected; a number more than one means more infections than expected. |
UNABLE TO CALCULATE Sample size too small to calculate score |
Maternity Care
| Measure name | Leapfrog’s Standard | Hospital’s Progress | ||||||
|---|---|---|---|---|---|---|---|---|
| Cesarean Sections |
This is defined as first-time mothers giving birth to a single baby, at full-term, in the head-down position delivering their babies through a C-section. Hospitals should have a C-section rate of 23.9% or less. |
ACHIEVED THE STANDARD |
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This hospital's rate of Cesarean sections is: 20.9% |
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| Early Elective Deliveries |
This is defined as mothers scheduling cesarean sections or medication inductions prior to 39 weeks gestation without a medical reason. Hospitals should have an early elective delivery rate of 5% or less. |
ACHIEVED THE STANDARD |
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This hospital's rate of early elective deliveries is: 0.0% |
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| Episiotomies |
This is defined as mothers having an incision made in the perineum (the birth canal) during childbirth. Hospitals should have an episiotomy rate of is 5% or less. |
ACHIEVED THE STANDARD |
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This hospital's rate of episiotomies is: 0.0% |
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| Maternity Care Processes |
Hospitals should screen at least 90% of babies for jaundice and at least 90% of women undergoing a cesarean section receive treatment to prevent blood clots. |
ACHIEVED THE STANDARD |
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| High-Risk Deliveries |
To achieve Leapfrog's standard, hospitals must deliver at least 50 very-low birth weight babies per year and ensure that at least 90% of mothers receive antenatal steroids prior to delivery OR the hospital must maintain a lower-than-average morbidity/mortality rate for very-low birth weight babies and ensure that at least 90% of mothers receive antenatal steroids prior to delivery. |
DOES NOT APPLY | ||||||
More Information
| Number of Live Births |
The hospital had 321 live births (i.e., liveborn infants) at this hospital location for the reporting time period. |
Pediatric Care
| Measure name | Leapfrog’s Standard | Hospital’s Progress |
|---|---|---|
| Experience of Children and their Parents |
Hospitals should perform better than most hospitals in five (5) areas:
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DOES NOT APPLY |
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This hospital does not admit pediatric patients or had too few pediatric admissions to administer the patient experience survey. |
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| Radiation Dose for Abdomen/Pelvis Scans |
Hospitals should ensure their average CT radiation dose for routine CT scans of the abdomen and pelvis falls within national benchmarks. |
ACHIEVED THE STANDARD |
| Radiation Dose for Head Scans |
Hospitals should ensure that their average radiation dose for routine CT scans of the head falls within national benchmarks. |
ACHIEVED THE STANDARD |
Critical Care
| Measure name | Leapfrog’s Standard | Hospital’s Progress |
|---|---|---|
| Specially Trained Doctors Care for Critical Care Patients |
The hospital has intensivists present on-site at least eight hours a day, seven days per week or has intensivists present via 24/7 telemedicine with some on-site intensivist presence. When not in the ICU, the intensivist immediately responds to calls and has another physician or trained clinician who can immediately reach the patient. |
 LIMITED ACHIEVEMENT |
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This hospital achieved the standard using on-site intensivist coverage. |
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Complex Adult Surgery
| Measure name | Leapfrog’s Standard | Hospital’s Progress |
|---|---|---|
| Carotid Artery Surgery |
Hospitals should perform at least 20 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 10 procedures annually. |
DOES NOT APPLY |
| Mitral Valve Repair and Replacement |
Hospitals should perform at least 40 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 20 procedures annually. |
DOES NOT APPLY |
| Open Aortic Procedures |
Hospitals should perform at least 10 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 7 procedures annually. |
DOES NOT APPLY |
| Bariatric Surgery for Weight Loss |
Hospitals should perform at least 50 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 20 procedures annually. |
DOES NOT APPLY |
| Esophageal Resection for Cancer |
Hospitals should perform at least 20 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 7 procedures annually. |
DOES NOT APPLY |
| Lung Resection for Cancer |
Hospitals should perform at least 40 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 15 procedures annually. |
DOES NOT APPLY |
| Pancreatic Resection for Cancer |
Hospitals should perform at least 20 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 10 procedures annually. |
DOES NOT APPLY |
| Rectal Cancer Surgery |
Hospitals should perform at least 16 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 6 procedures annually. |
DOES NOT APPLY |
Spectrum Health Pennock
1009 W. Green Street
Hastings, Michigan 49058-1790
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