St. Joseph Mercy Hospital-Ann Arbor


About the Facility

CMS Certification Number (CCN)
23T156
Ownership Type
Non-profit
CMS Region
Chicago
Certification Date
Address
5301 East Huron River Drive
Phone Number
(734) 712-5358

Facility Medical Condition Statistics

All other conditions
98
Brain disease or condition (non-traumatic)
21
Brain injury (traumatic)
45
Hip or femur fracture
Data not available for this reporting period.
Hip or knee replacement, amputation or other bone or joint condition
47
Nervous system disorder (excluding stroke)
17
Spinal cord disease or condition (non-traumatic)
32
Spinal cord injury (traumatic)
14
Stroke
136

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
2.926
Comparative performance category
No Different than the National Benchmark
Catheter days
376
Predicted number of infections (B)
1.024
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
415
Denominator
418
Facility rate
99.3
Change in patients ability to care for themselves
Average risk-adjusted change score
10.4
Denominator
365
Average observed change score
11.1
Change in patients ability to move around
Average risk-adjusted change score
21.2
Denominator
365
Average observed change score
22.2
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
156
Denominator
365
Facility rate
42.7
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
92
Denominator
365
Facility rate
25.2
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
2
Denominator
418
Facility rate
0.5
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.102
SIR 95% confidence interval - upper limit
2.006
Comparative performance category
No Different than the National Benchmark
Patient days
8,549
Predicted number of infections (B)
3.294
Number of infections reported (A)
2
SIR (A/B)
0.607
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
300
Number of health care workers
334
Rate of flu vaccination
89.8
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
18
Number of eligible stays
283
Unadjusted potentially preventable readmission rate
6.36
Risk-standardized potentially preventable readmission rate (RSRR)
7.90
Lower limit of the 95% confidence interval on the RSRR
6.24
Upper limit of the 95% confidence interval on the RSRR
9.85
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
12
Number of eligible stays
300
Unadjusted potentially preventable readmission rate
4.00
Risk-standardized potentially preventable readmission rate (RSRR)
4.59
Lower limit of the 95% confidence interval on the RSRR
3.20
Upper limit of the 95% confidence interval on the RSRR
6.21
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)
168
Number of eligible stays
247
Observed discharge to community rate
68.02
Risk-standardized discharge to community rate
68.09
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
63.03
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
72.69
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
0.86
Number of eligible episodes
255
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
418
Denominator
418
Facility rate
100.0
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
2
Denominator
418
Facility observed rate
0.5
Facility risk-adjusted rate
0.6
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
298
Number of health care workers
351
Rate of COVID-19 vaccination
84.9