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Spectrum Health Pennock

1009 W. Green Street
Hastings, Michigan 49058-1790

Survey Submission Date: July 30, 2021

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Preventing and Responding to Patient Harm

Measure name

Leapfrog’s Standard

Hospital’s Progress

Effective Leadership to Prevent Errors

Hospitals should take meaningful steps to raise awareness about patient safety, hold leadership accountable for reducing unsafe practices, provide resources to implement a patient safety program, and develop systems and structures to support action to improve patient safety.

ACHIEVED THE STANDARD

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Staff Work Together to Prevent Errors

Hospitals should assess their culture of safety and hold leadership accountable for implementing policies, procedures, and staff education to improve the culture of safety.

ACHIEVED THE STANDARD

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Support for Nursing Workforce

Hospitals should assess their nursing staff levels and core competencies, included nurses in leadership, and develop and implement plans to address any areas of improvement.

ACHIEVED THE STANDARD

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Handwashing

Hospitals should regularly monitor hand hygiene practices for everyone interacting with patients, and give feedback to ensure compliance. Hospitals should foster a culture of good hand hygiene, offer training and education, and provide equipment, such as paper towels, soap dispensers, and hand sanitizer.

SOME ACHIEVEMENT

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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

Medication Safety

Measure name

Leapfrog’s Standard

Hospital’s Progress

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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Safe Medication Ordering

Hospitals should enter at least 85% of inpatient medication orders through the CPOE system.

ACHIEVED THE STANDARD

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Medication Reconciliation

Hospitals should have a rate of unintentional medication discrepancies per medication that is lower than or equal to the 50th percentile (where lower performance is better) nationally.

ACHIEVED THE STANDARD

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Medication Documentation for Elective Outpatient Surgery Patients

Hospitals should document 90% or more of home medications, visit medications, and allergies/adverse reaction(s) in the patients’ clinical record.

LIMITED ACHIEVEMENT

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. more	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. more	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. more	ACHIEVED THE STANDARD
	Show more on this hospital’s performance Show less This hospital’s standardized infection ratio (SIR) is: 0.000 Note: The standardized infection ratio (SIR) includes some data collected during the COVID-19 pandemic.
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. more	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. more	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 deliver their babies through a C-section. Hospitals should have a rate of C-sections of 23.6% or less. more	ACHIEVED THE STANDARD
	Show more on this hospital’s performance Show less This hospital's rate of Cesarean sections is 13.8%
Early Elective Deliveries	This is defined as mothers being scheduled for cesarean sections or medication inductions prior to 39 weeks gestation without a medical reason. Hospitals should have a rate of early elective deliveries of 5% or less. more	ACHIEVED THE STANDARD
	Show more on this hospital’s performance Show less This hospital's rate of early elective deliveries is 0.0%
Episiotomies	This is defined as mothers having an incision made in the perineum (the birth canal) during childbirth. Hospitals should have a rate of episiotomies of 5% or less. more	ACHIEVED THE STANDARD
	Show more on this hospital’s performance Show less This hospital's rate of episiotomies is 0.5%
Screening Newborns for Jaundice Before Discharge	Hospitals should screen at least 90% of babies for jaundice. more	ACHIEVED THE STANDARD
	Show more on this hospital’s performance Show less This hospital's rate of screening newborns for jaundice before discharge is 100.0%
Preventing Blood Clots in Women Undergoing Cesarean Section	At least 90% of women undergoing a cesarean section receive treatment to prevent blood clots. more	ACHIEVED THE STANDARD
	Show more on this hospital’s performance Show less This hospital's rate of preventing blood clots in women undergoing cesarean section 94.9%
High-Risk Deliveries	Hospitals should deliver at least 50 very-low birth weight babies per year OR the hospital must maintain a lower-than-average morbidity/mortality rate for very-low birth weight babies. more	DOES NOT APPLY

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Number of Live Births

The hospital had 298 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: Communication with Parent – Communication about your child’s medicines Communication with Parent – Keeping you informed about your child’s care Communication with Child – How well nurses communicate with your child Communication with Child – How well doctors communicate with your child Attention to Safety and Comfort – Preventing mistakes and helping you report concerns. more	DOES NOT APPLY
	Show more on this hospital’s performance Show less This hospital does not admit pediatric patients or had too few pediatric admissions to administer the patient experience survey.
Radiation Dose for Abdomen/Pelvis Scans	Hospitals should use a CT radiation dose for routine CT scans of the abdomen and pelvis that falls within national benchmarks. more	CONSIDERABLE ACHIEVEMENT
Radiation Dose for Head Scans	Hospitals should have an average radiation dose for routine CT scans of the head that falls within national benchmarks. more	ACHIEVED THE STANDARD

Critical Care

Measure name	Leapfrog’s Standard	Hospital’s Progress
Specially Trained Doctors Care for Critical Care Patients	Hospitals should have 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. more	LIMITED ACHIEVEMENT

Complex Adult and Pediatric 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. more	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. In addition, hospitals should participate in a national clinical registry and achieve the same or better outcomes when compared to others who also perform this procedure. more	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. more	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. more	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. more	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. more	DOES NOT APPLY
Pancreatic Resection for Cancer	The hospital performs at least 20 procedures annually, and as part of their process for privileging surgeons, ensures that each surgeon performs at least 10 procedures annually. more	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. more	DOES NOT APPLY
Total Hip Replacement Surgery	Hospitals should perform at least 50 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 25 procedures annually. more	LIMITED ACHIEVEMENT
	Show more on this hospital’s performance Show less This hospital performed 1 total hip replacement surgeries compared to Leapfrog’s standard of 50 procedures annually. As part of their process for privileging surgeons, this hospital does not ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 25 procedures annually for total hip replacement surgeries. Additionally, this hospital does not have protocols in place to ensure that total hip replacement surgery is only performed on patients that meet defined criteria.
Total Knee Replacement Surgery	Hospitals should perform at least 50 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 25 procedures annually. more	LIMITED ACHIEVEMENT
	Show more on this hospital’s performance Show less This hospital performed 21 total knee replacement surgeries compared to Leapfrog’s standard of 50 procedures annually. As part of their process for privileging surgeons, this hospital does not ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 25 procedures annually for total knee replacement surgeries. Additionally, this hospital does not have protocols in place to ensure that total knee replacement surgery is only performed on patients that meet defined criteria.
Congenital Heart Surgery for Infants (Norwood Procedure)	Hospitals should perform at least 8 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 5 procedures annually. more	DOES NOT APPLY

Elective Outpatient Surgery - Adult

Dermatology (Skin)

Procedure		Number of Procedures Performed Annually
Complex Skin Repairs		13

Gastroenterology (Stomach and Digestive)

Procedure		Number of Procedures Performed Annually
Upper GI Endoscopies		609
Other Upper GI Procedures		6
Small Intestine and Stomal Endoscopies		2
Lower GI Endoscopies		673

General Surgery

Procedure		Number of Procedures Performed Annually
Cholecystectomies and Common Duct Explorations		122
Hemorrhoid Procedures		8
Inguinal and Femoral Hernia Repairs		65
Laparoscopies		4
Lumpectomies and Quadrantectomies of Breast		28
Mastectomies		3
Other Hernia Repairs		72

Obstetrics and Gynecology

Procedure		Number of Procedures Performed Annually
Cervix Procedures		4
Hysteroscopies		58
Uterus and Adnexa Laparoscopies		96

Ophthalmology (Eyes)

Procedure		Number of Procedures Performed Annually
Anterior Segment Eye Procedures		377
Posterior Segment Eye Procedures		3
Other Eye Procedures		5

Orthopedic (Bones and Joints)

Procedure		Number of Procedures Performed Annually
Finger, Hand, Wrist, Forearm, and Elbow Procedures		109
General Orthopedic Procedures		10
Hip Procedures		3
Knee Procedures		91
Shoulder Procedures		84
Spine Procedures		0
Toe, Foot, Ankle, and Leg Procedures		57

Otolaryngology (Ear, Nose, Mouth, and Throat)

Procedure		Number of Procedures Performed Annually
Ear Procedures		0
Mouth Procedures		0
Nasal and Sinus Procedures		1

Plastic and Reconstructive Surgery

Procedure		Number of Procedures Performed Annually
Breast Repairs or Reconstructions		0
Skin Grafts and Repairs		12

Urology (Urinary Tract, Male Reproductive)

Procedure		Number of Procedures Performed Annually
Circumcisions		2
Cystourethroscopies		66
Male Genital Procedures		3
Urethra Procedures		3
Vaginal Repair Procedures		3

Elective Outpatient Surgery - Pediatric

Orthopedic (Bones and Joints)

Procedure		Number of Procedures Performed Annually
Finger, Hand, Wrist, Forearm, and Elbow Procedures		18
General Orthopedic Procedures		0
Hip Procedures		0
Knee Procedures		2
Shoulder Procedures		7
Spine Procedures		0
Toe, Foot, Ankle, and Leg Procedures		2

Care for Elective Outpatient Surgery Patients

Measure name

Leapfrog’s Standard

Hospital’s Progress

Elective Outpatient Surgery Recovery Staffing - Adult

Hospitals should ensure that a specially certified clinician and at least one physician or nurse anesthetist are present and immediately available while an adult patient is present until discharge.

ACHIEVED THE STANDARD

Elective Outpatient Surgery Recovery Staffing - Pediatric

Hospitals should ensure that a specially certified clinician and at least one physician or nurse anesthetist are present and immediately available while a pediatric patient is present until discharge.

ACHIEVED THE STANDARD

Safe Surgery Checklist - Elective Outpatient Surgery

Hospitals should go through all the elements of a complete safe surgery checklist on all patients every time a procedure is performed.

ACHIEVED THE STANDARD

Experience of Patients Undergoing Elective Outpatient Surgery

Hospitals should perform better than most on four (4) areas including: (a) facilities and staff (b) communication about the procedure, (c) patients’ overall rating of the facility, and (d) patients willingness to recommend the facility.

SOME ACHIEVEMENT

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More Information

Patient Consent for Elective Outpatient Surgery

The hospital provides written surgical consent forms the day of their procedure.

Patient Consent to Anesthesia for Elective Outpatient Surgery

The hospital provides written anesthesia consent forms the day of their procedure.

Patient Selection

The hospital has a screening protocol to determine whether a patient’s procedure can safely be performed on an outpatient basis, and the protocol includes the following components:

History of difficult intubation	Yes
Difficult airway/aspiration risk	Yes
Body Mass Index (BMI)	Yes
American Society of Anesthesiologists (ASA) Physical Status Classification	Yes
Recent Medical History (within 30 days of scheduled procedure)	Yes
Cognitive Assessment	Yes
Sleep Apnea Assessment	Yes
Availability of transportation following discharge	Yes
Availability of a caregiver following discharge	Yes

Spectrum Health Pennock

1009 W. Green Street
Hastings, Michigan 49058-1790

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More Information

Teaching Hospital Status:	Non-Teaching
Number of acute-care beds:	20
Number of ICU beds:	11
Number of Adult Admissions	1,574
Number of Pediatric Admissions	0
Number of ICU Admissions	587
Number of NICU Admissions	0