St Joseph Mercy - Oakland


About the Facility

CMS Certification Number (CCN)
23T029
Ownership Type
Non-profit
CMS Region
Chicago
Certification Date
Address
44405 Woodward Ave.
Phone Number
(248) 858-6311

Facility Medical Condition Statistics

All other conditions
109
Brain disease or condition (non-traumatic)
41
Brain injury (traumatic)
19
Hip or femur fracture
-
Hip or knee replacement, amputation or other bone or joint condition
Data not available for this reporting period.
Nervous system disorder (excluding stroke)
36
Spinal cord disease or condition (non-traumatic)
27
Spinal cord injury (traumatic)
Data not available for this reporting period.
Stroke
71

Facility Quality of Patient Care Measures

Catheter-associated urinary tract infections (CAUTI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
Not Available
SIR 95% confidence interval - upper limit
2.892
Comparative performance category
No Different than the National Benchmark
Catheter days
456
Predicted number of infections (B)
1.036
Number of infections reported (A)
0
SIR (A/B)
0.000
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
312
Denominator
313
Facility rate
99.7
Change in patients ability to care for themselves
Average risk-adjusted change score
8.9
Denominator
268
Average observed change score
10.0
Change in patients ability to move around
Average risk-adjusted change score
22.8
Denominator
268
Average observed change score
24.9
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
95
Denominator
268
Facility rate
35.4
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
73
Denominator
268
Facility rate
27.2
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
313
Facility rate
0.0
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.013
SIR 95% confidence interval - upper limit
1.306
Comparative performance category
No Different than the National Benchmark
Patient days
6,570
Predicted number of infections (B)
3.775
Number of infections reported (A)
1
SIR (A/B)
0.265
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
18
Number of health care workers
156
Rate of flu vaccination
11.5
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
41
Number of eligible stays
399
Unadjusted potentially preventable readmission rate
10.28
Risk-standardized potentially preventable readmission rate (RSRR)
8.74
Lower limit of the 95% confidence interval on the RSRR
7.09
Upper limit of the 95% confidence interval on the RSRR
10.56
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
19
Number of eligible stays
436
Unadjusted potentially preventable readmission rate
4.36
Risk-standardized potentially preventable readmission rate (RSRR)
4.49
Lower limit of the 95% confidence interval on the RSRR
3.42
Upper limit of the 95% confidence interval on the RSRR
6.08
Comparative performance category
No Different than the National Rate
Rate of successful return to home or community from an IRF
Observed number of discharges to community (DTC)
243
Number of eligible stays
356
Observed discharge to community rate
68.26
Risk-standardized discharge to community rate
68.46
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
64.21
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
72.65
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
0.93
Number of eligible episodes
354
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
93
Denominator
313
Facility rate
29.7
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
1
Denominator
309
Facility observed rate
0.3
Facility risk-adjusted rate
0.4
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
73
Number of health care workers
83
Rate of COVID-19 vaccination
88.0