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Clinical Quality Metrics

Catheter-associated Urinary Tract Infections (CAUTI)

What are we measuring?

According to the CDC, a catheter-associated urinary tract infection (CAUTI) occurs when germs enter the urinary tract through a urinary catheter and cause infection. CAUTIs are one of the most common types of healthcare-associated infections (HAIs). They are preventable and treatable.

CAUTI infection rates are measured using a Standardized Infection Ratio (SIR).

  • SIR = actual # of infections/number of infections expected to occur
  • SIR of 1.0 or less is desired

For more information on CAUTI, visit the Centers for Disease Control and Prevention - Catheter-associated Urinary Tract Infections CAUTI.

How are we performing?

MyMichigan’s overall goal of top quartile performance is 0.43. The graphs below show how MyMichigan Health is performing as a whole as well as data for specific member hospital. Anything below the yellow line is good.

What are we doing to improve?

  • Standardizing urinary catheter products
  • Encouraging use of external catheters when appropriate to decrease utilization of indwelling catheters
  • Removing catheters as soon as possible
  • Ensuring proper maintenance of catheters

Use the arrows to view performance for MyMichigan Health as a whole or for a specific member hospital.

MyMichigan Health

MyMichigan Health overall saw a slight increase in CAUITs in 2023 and slightly missed the top quartile goal.

Graph showing CAUTI infections per 1000 patient days for MyMichigan Health overall. 2020 value was 0.398 (below benchmark), 2021 value was 0.364 (below benchmark), 2022 value was 0.336 (below benchmark) and 2023 value was 0.471 (slightly above benchmark.) Below benchmark values are desirable.

MyMichigan Medical Center Alma

MyMichigan Medical Center Alma saw improvement in performance from 2022 and met the goal in 2023.

Graph showing CAUTI infections per 1000 patient days for MyMichigan Medical Center Alma. 2020 value was 0.757 (above benchmark), 2021 value was 0.474 (slightly above benchmark), 2022 value was 0.734 (above benchmark) and 2023 value was 0.372 (below benchmark.) Below benchmark values are desirable

MyMichigan Medical Center Alpena

MyMichigan Medical Center Alpena has seen steady improvement since 2020 and met the goal for both 2022 and 2023.

Graph showing CAUTI infections per 1000 patient days for MyMichigan Medical Center Alpena. 2020 value was 0.960 (above benchmark), 2021 value was 0.850 (above benchmark), 2022 value was 0.355 (below benchmark) and 2023 value was 0.343 (below benchmark.) Below benchmark values are desirable.

MyMichigan Medical Center Gladwin

MyMichigan Medical Center Gladwin has had zero CAUTIs every year since 2020, meeting the goal.

Graph showing CAUTI infections per 1000 patient days for MyMichigan Medical Center Gladwin. 2020 value was 0.00 (below benchmark), 2021 value was 0.00 (below benchmark), 2022 value was 0.00 (below benchmark) and 2023 value was 0.00 (below benchmark.) Below benchmark values are desirable

MyMichigan Medical Center Midland

MyMichigan Medical Center Midland has met the top quartile goal each year since 2020.

Graph showing CAUTI infections per 1000 patient days for MyMichigan Medical Center Midland. 2020 value was 0.297 (below benchmark), 2021 value was 0.353 (below benchmark), 2022 value was 0.325 (below benchmark) and 2023 value was 0.355 (below benchmark.) Below benchmark values are desirable

MyMichigan Medical Center Sault

MyMichigan Medical Center Sault has seen an increase in CAUITs since 2022 and did not meet the top quartile goal in 2023.

Graph showing CAUTI infections per 1000 patient days for MyMichigan Medical Center Sault. 2020 value was 0.00 (below benchmark), 2021 value was 0.00 (below benchmark), 2022 value was 0.00 (below benchmark) and 2023 value was 4.287 (above benchmark.) Below benchmark values are desirable

MyMichigan Medical Center West Branch

MyMichigan Medical Center West Branch has had zero CAUTIs every year since 2020, meeting the goal.

Graph showing CAUTI infections per 1000 patient days for MyMichigan Medical Center West Branch. 2020 value was 0.00 (below benchmark), 2021 value was 0.00 (below benchmark), 2022 value was 0.00 (below benchmark) and 2023 value was 0.00 (below benchmark.) Below benchmark values are desirable.

Central Line-associated Bloodstream Infections (CLABSI)

What are we measuring?

According to the CDC, Central line-associated bloodstream infections (CLABSIs) occur when germs enter the bloodstream through a central line. CLABSIs are preventable.

CLABSI infection rates are measured using a Standardized Infection Ratio (SIR).

  • SIR = actual # of infections/number of infections expected to occur
  • SIR of 1.0 or less is desired

For more information on CLABSI, visit the Centers for Disease Control and Prevention - Central Line-associated Bloodstream Infections CLABSI Basics.

How are we performing?

MyMichigan's overall goal of top quartile performance is 0.50. The graphs below show how MyMichigan Health is performing as a whole as well as data for specific member hospital. Anything below the yellow line is good.

What are we doing to improve?

  • Implemented CHG baths
  • Remove lines when not needed

Use the arrows to view performance for MyMichigan Health as a whole or for a specific member hospital.

MyMichigan Health

MyMichigan Health saw an improvement in performance on CLABSIs from 2022 to 2023 but just missed the top quartile performance goal in 2023.

Graph showing CLABSI infections per 1000 patient days for MyMichigan Health overall. 2020 value was 0.220 (below benchmark), 2021 value was 0.569 (above benchmark), 2022 value was 0.965 (above benchmark) and 2023 value was 0.523 (slightly above benchmark.) Below benchmark values are desirable.

MyMichigan Medical Center Alma

MyMichigan Medical Center Alma has had zero CLABSIs every year since 2020 and has met the top quartile goal in 2023.

Graph showing CLABSI infections per 1000 patient days for MyMichigan Medical Center Alma. 2020 value was 0.00 (below benchmark), 2021 value was 0.00 (below benchmark), 2022 value was 0.00 (below benchmark) and 2023 value was 0.00 (below benchmark.) Below benchmark values are desirable

MyMichigan Medical Center Alpena

MyMichigan Medical Center Alpena had a slight increase in CLABSIs from 2022 and did not meet the top quartile performance for 2023.

Graph showing CLABSI infections per 1000 patient days for MyMichigan Medical Center Alpena. 2020 value was 1.501 (above benchmark), 2021 value was 1.401 (above benchmark), 2022 value was 0.00 (below benchmark) and 2023 value was 0.853 (above benchmark.) Below benchmark values are desirable.

MyMichigan Medical Center Gladwin

MyMichigan Medical Center Gladwin has had zero CLABSIs every year since 2020 and has met the top quartile goal in 2023.

Graph showing CLABSI infections per 1000 patient days for MyMichigan Medical Center Gladwin. 2020 value was 0.00 (below benchmark), 2021 value was 0.00 (below benchmark), 2022 value was 0.00 (below benchmark) and 2023 value was 0.00 (below benchmark.) Below benchmark values are desirable

MyMichigan Medical Center Midland

MyMichigan Medical Center Midland saw an improvement in performance on CLABSIs from 2022 to 2023 but just missed the top quartile performance goal in 2023.

Graph showing CLABSI infections per 1000 patient days for MyMichigan Medical Center Midland. 2020 value was 0.095 (below benchmark), 2021 value was 0.499 (below benchmark), 2022 value was 1.112 (above benchmark) and 2023 value was 0.603 (above benchmark.) Below benchmark values are desirable

MyMichigan Medical Center Sault

MyMichigan Medical Center Sault had zero CLABSIs in 2022 and has met the top quartile goal in 2023.

Graph showing CAUTI infections per 1000 patient days for MyMichigan Medical Center Sault. 2020 value was 0.00 (below benchmark), 2021 value was 0.00 (below benchmark), 2022 value was 0.00 (below benchmark) and 2023 value was 0.00 (below benchmark.) Below benchmark values are desirable

MyMichigan Medical Center West Branch

MyMichigan Medical Center West Branch had improved performance since 2022 and has met the top quartile goal in 2023 with zero CLABSIs.

Graph showing CLABSI infections per 1000 patient days for MyMichigan Medical Center West Branch. 2020 value was 0.00 (below benchmark), 2021 value was 1.965 (above benchmark), 2022 value was 4.039 (above benchmark) and 2023 value was 0.00 (below benchmark.) Below benchmark values are desirable.

Clostridium Difficile Infections (C-Diff)

What are we measuring?

Clostridium Difficile (C-Diff) is one of many types of bacteria found in feces (bowel movements). It occurs when antibiotics kill good bowel bacteria and allows the C-Diff bacteria to grow. When C-Diff grows, it produces toxins that can damage the bowel and cause diarrhea. C-Diff is the most common cause of infectious diarrhea in hospitals.

C-Diff infections have a seasonal pattern and have the highest number of infections in the winter months when more people are on antibiotics.

C-Diff infection rates are measured using a Standardized Infection Ratio (SIR).

  • SIR = actual # of infections/number of infections expected to occur
  • SIR of 1.0 or less is desired

For more information on C-Diff, visit the Centers for Disease Control and Prevention - C. diff (Clostridioides difficile).

How are we performing?

MyMichigan Health’s overall goal of top quartile performance is 0.25. The graphs below show how MyMichigan Health is performing as a whole as well as data for specific member hospitals. Anything below the yellow line is good.

What are we doing to improve?

  • Changing our lab test so that only patients with an active C difficile infection are identified and treated.
  • Having a pharmacist review the antibiotics prescribed to make sure they are the best one for the infection being treated.
  • Implementing an ordering process that allows only those patients who meet criteria to be tested.
  • Continued emphasis on the importance of hand hygiene.

Use the arrows to view performance for MyMichigan Health as a whole or for a specific member hospital.

MyMichigan Health

MyMichigan Health overall has seen over a 50% improvement in hospital acquired c-diff infections since 2021 but did not achieve top quartile performance in 2023.

Graph showing C-Diff infections per 1000 patient days for MyMichigan Health overall. Quarter 1 value was 1.09 (above benchmark), quarter 2 value was 0.82 (above benchmark), quarter 3 value was 0.15 (below benchmark) and quarter 34 value was 0.31 (slightly above benchmark.) Below benchmark values are desirable.

MyMichigan Medical Center Alma

MyMichigan Medical Center Alma has made significant improvement since 2022 and had zero hospital acquired c-diff infections in 2023 which meets the top quartile performance in 2023.

C-Diff Graph for MyMichigan Medical Center Alma showing Quarter 1 - Quarter 4 2022 data. Bechmark is 0.25 with Quarter 1 at 5.24, Quarter 2 at 1.24, Quarter 3 at 0 and Quarter 4 at 0.

MyMichigan Medical Center Alpena

MyMichigan Medical Center Alpena saw a slight increase in c-diff infections early in 2022 and 2023 and did not meet the top quartile performance goal.

C-Diff Graph for MyMichigan Medical Center Alpena showing Quarter 1 - Quarter 4 2022 data. Bechmark is 0.25 with Quarter 1 at 0.65, Quarter 2 at 1.34, Quarter 3 at 0 and Quarter 4 at 0.

MyMichigan Medical Center Clare

MyMichigan Medical Center Clare improved performance from 2022 and had zero hospital acquired c-diff infections in 2023 which meets the top quartile goal in 2023.

C-Diff Graph for MyMichigan Medical Center Clare showing Quarter 1 - Quarter 4 2022 data. Bechmark is 0.25 with Quarter 1 at4.90, Quarter 2 at 0, Quarter 3 at 0 and Quarter 4 at 0.

MyMichigan Medical Center Gladwin

MyMichigan Medical Center Gladwin saw an uptick in hospital acquired c-diff cases in 2023 and did not meet the top quartile goal in 2023.

C-Diff Graph for MyMichigan Medical Center Gladwin showing Quarter 1 - Quarter 4 2022 data. Bechmark is 0.25 with Quarter 1 at 0, Quarter 2 at 0, Quarter 3 at 0 and Quarter 4 at 0.

MyMichigan Medical Center Midland

MyMichigan Medical Center Midland’s performance has steadily improved since 2021 and just missed meeting the top quartile goal in 2023.

C-Diff Graph for MyMichigan Medical Center Midland showing Quarter 1 - Quarter 4 2022 data. Bechmark is 0.25 with Quarter 1 at 0.70, Quarter 2 at 0.76, Quarter 3 at 0.20 and Quarter 4 at 0.10.

MyMichigan Medical Center Sault

MyMichigan Medical Center Sault saw more infection in 2023 than in previous years and did not meet the top quartile goal in 2023.

C-Diff Graph for MyMichigan Medical Center Sault showing Quarter 1 - Quarter 4 2022 data. Bechmark is 0.25 with Quarter 1 no data to report, Quarter 2 at 0, Quarter 3 at 0 and Quarter 4 at 1.30.

MyMichigan Medical Center West Branch

MyMichigan Medical Center West Branch has improved performance since 2022 and had zero hospital acquired c-diff infection which met the top quartile goal in 2023.

C-Diff Graph for MyMichigan Medical Center West Branch showing Quarter 1 - Quarter 4 2022 data. Bechmark is 0.25 with Quarter 1 at 3.60, Quarter 2 at 0, Quarter 3 at 0 and Quarter 4 at 1.56.

Falls with Injury

What are we measuring?

National Database of Nursing Quality Indicators (NDNQI) is the leading nursing-sensitive quality indicators database that contains unit-level information about 600+ measures relevant to nursing performance, patient and workforce experience, and health outcomes. NDNQI counts only falls that occur on an eligible inpatient unit that reports falls.

The purpose of the Patient Falls indicator are to:

  • Determine the rates at which hospitalized patients fall
  • Determine the frequency with which patient falls result in injury
  • Explore associations between nurse staffing, nursing assessments performed, interventions used, and falls

A patient fall is a sudden, unintentional descent, with or without injury to the patient, which results in the patient coming to rest on the floor, on or against some other surface (e.g., a counter), on another person, or on an object (e.g., a trash can)

MyMichigan Health measures falls with injury using NDNQI fall indication guidelines for data collection. The falls with injury rate is a calculation using the number of falls with injury divided by the number of patient days times 1000.
For more information on Falls with Injury, visit the Agency for Healthcare Research and Quality – Preventing Falls in Hospitals.

How are we performing?

MyMichigan Health’s overall goal is the NDNQI 50th percentile NDNQI median performance which is currently 0.48. MyMichigan Health has had an intense focus on fall reduction and harm reduction for several years with overall improvements and performance trending in the right direction. The graphs below show how MyMichigan Health is performing as well as data for specific member hospitals. Anything below the yellow line is good.

What are we doing to improve?

Several evidence-based practices have been implemented over the years including:

  • Accurate patient fall risk assessment and scoring education
  • Implementation of Tailoring Interventions for Patient Safety (TIPS) program and in room posters with fall risk and preventative measures in place
  • Post fall care team huddles after fall to determine what happened and additional prevention
  • Purposeful hourly rounding on all patients
  • Staff staying with patient when toileting
  • Hardwire gait belt use while ambulating high fall risk patients
  • Bed and chair fall alarms
  • Executive Adopt a Unit program pairing an executive leader with a nursing unit to focus on fall prevention strategies

Use the arrows to view performance for MyMichigan Health as a whole or for a specific member hospital.

MyMichigan Health

MyMichigan Health’s overall falls with injuries increased slightly from 2023 and did just missed the top quartile goal.

Graph showing Falls with Injury per 1000 patient days for MyMichigan Health overall. Quarter 1 value was 0.54 (above benchmark), quarter 2 value was 0.69 (above benchmark), quarter 3 value was 0.51 (below benchmark) and quarter 4 value was 0.48 (below benchmark.) Below benchmark values are desirable.

MyMichigan Medical Center Alma

MyMichigan Medical Center Alma improved performance from 2022 and met the top quartile goal for 2023.

Graph showing Falls with Injury per 1000 patient days for MyMichigan Medical Center Alma. Quarter 1 value was 0.61 (above benchmark), quarter 2 value was 0.80 (above benchmark), quarter 3 value was 0.00 (below benchmark) and quarter 4 value was 0.30 (below benchmark.) Below benchmark values are desirable.

MyMichigan Medical Center Alpena

MyMichigan Medical Center Alpena saw an increase in falls with injury in 2023 and did not meet the top quartile goal.

Graph showing Falls with Injury per 1000 patient days for MyMichigan Medical Center Alpena. Quarter 1 value was 0.77 (above benchmark), quarter 2 value was 1.14 (above benchmark), quarter 3 value was 0.92 (above benchmark) and quarter 4 value was 0.19 (below benchmark.) Below benchmark values are desirable.

MyMichigan Medical Center Clare

MyMichigan Medical Center Clare has continued to improve performance since 2021 and met the top quartile goal in 2023.

Graph showing Falls with Injury per 1000 patient days for MyMichigan Medical Center Clare. Quarter 1 value was 0.00 (below benchmark), quarter 2 value was .00 (below benchmark), quarter 3 value was 0.00 (below benchmark) and quarter 4 value was 0.96 (above benchmark.) Below benchmark values are desirable.

MyMichigan Medical Center Gladwin

MyMichigan Medical Center Gladwin has steadily improved performance since 2021 and met the top quartile goal for 2023 with zero falls with injury.

Graph showing Falls with Injury per 1000 patient days for MyMichigan Medical Center Gladwin. Quarter 1 value was 0.00 (below benchmark), quarter 2 value was .00 (below benchmark), quarter 3 value was 0.00 (below benchmark) and quarter 4 value was 0.00 (below benchmark.) Below benchmark values are desirable.

MyMichigan Medical Center Midland

MyMichigan Medical Center Midland saw a slight increase in falls with injury in 2023 and just missed the top quartile goal for 2023.

Graph showing Falls with Injury per 1000 patient days for MyMichigan Medical Center Midland. Quarter 1 value was 0.51 (above benchmark), quarter 2 value was 0.52 (above benchmark), quarter 3 value was 0.61 (above benchmark) and quarter 4 value was 0.48 (below benchmark.) Below benchmark values are desirable.

MyMichigan Medical Center Sault

MyMichigan Medical Center Sault did not see improvement but remained consistent with performance in 2022 and did not meet the top quartile goal for 2023.

Graph showing Falls with Injury per 1000 patient days for MyMichigan Medical Center Sault. Quarter 1 value was 0.94 (above benchmark), quarter 2 value was 1.81 (above benchmark), quarter 3 value was 0.55 (above benchmark) and quarter 4 value was 1.16 (above benchmark.) Below benchmark values are desirable.

MyMichigan Medical Center West Branch

MyMichigan Medical Center West Branch has steadily improved performance since 2020 and has achieved the top quartile goal for 2023.

Graph showing Falls with Injury per 1000 patient days for MyMichigan Medical Center West Branch. Quarter 1 value was 0.00 (below benchmark), quarter 2 value was 0.00 (below benchmark), quarter 3 value was 0.54 (above benchmark) and quarter 4 value was 1.13 (above benchmark.) Below benchmark values are desirable.

Pneumonia Mortality

What are we measuring?

Pneumonia is a leading cause of inpatient hospitalizations. Pneumonia is associated with a high risk of mortality, particularly in the elderly. A goal to improving quality of care for these patients is to eliminate unnecessary deaths. We are measuring the number of pneumonia deaths within 30-days of hospital discharge.

How are we performing?

MyMichigan Health’s overall goal of top quartile performance is below 15.9% The graphs below show how MyMichigan Health is performing as a whole as well as data for specific member hospitals. Anything below the yellow line is good.

What are we doing to improve?

  • Implemented a standard orders set across the health system that incorporates best practices for pneumonia patient treatment.
  • Provider education in collaboration with Michigan Medicine.
  • Added Continuing Care Clinics in Alma and Midland to ensure timely hospital follow-up after discharge for patients without a Primary Care Provider (PCP), or whose PCP does not have an appointment opening in the requested time frame.

Use the arrows to view performance for MyMichigan Health as a whole or for a specific member hospital.

MyMichigan Health

MyMichigan Health overall continues to improve performance since 2020 and just missed top quartile performance in 2023.

Graph showing Pneumonia deaths within 30-days of hospital discharge for MyMichigan Health overall. Quarter 1 value was 24.1% (above benchmark), quarter 2 value was 14.5% (below benchmark), quarter 3 value was 12.8% (below benchmark) and quarter 4 value was 12.7% (below benchmark.) Below benchmark values are desirable.

MyMichigan Medical Center Alma

MyMichigan Medical Center Alma continues to reduce pneumonia mortality rates and achieved the top quartile goal in 2023.

Graph showing Pneumonia deaths within 30-days of hospital discharge for MyMichigan Medical Center Alma. Quarter 1 value was 21.2% (above benchmark), quarter 2 value was 12.5% (below benchmark), quarter 3 value was 20.0% (above benchmark) and quarter 4 value was 18.8% (above benchmark.) Below benchmark values are desirable.

MyMichigan Medical Center Alpena

MyMichigan Medical Center Alpena has steadily reduced pneumonia mortality rates every year since 2020 and achieved top quartile performance in 2023.

Graph showing Pneumonia deaths within 30-days of hospital discharge for MyMichigan Medical Center Alpena. Quarter 1 value was 10.7% (below benchmark), quarter 2 value was 14.7% (below benchmark), quarter 3 value was 14.3% (below benchmark) and quarter 4 value was 8.8% (below benchmark.) Below benchmark values are desirable.

MyMichigan Medical Center Clare

MyMichigan Medical Center Clare has steadily reduced pneumonia mortality rates every year since 2020 and achieved top quartile performance in 2023.

Graph showing Pneumonia deaths within 30-days of hospital discharge for MyMichigan Medical Center Clare. Quarter 1 value was 20.0% (above benchmark), quarter 2 value was 14.3% (below benchmark), quarter 3 value was 0% (below benchmark) and quarter 4 value was 0% (below benchmark.) Below benchmark values are desirable.

MyMichigan Medical Center Gladwin

MyMichigan Medical Center Gladwin saw an increase in pneumonia mortality rates since in 2023 from 2022 rates and did not meet the top quartile goal for 2023.

Graph showing Pneumonia deaths within 30-days of hospital discharge for MyMichigan Medical Center Gladwin. Quarter 1 value was 40.0% (above benchmark), quarter 2 value was 33.3% (above benchmark), quarter 3 value was 0% (below benchmark) and quarter 4 value was 0% (below benchmark.) Below benchmark values are desirable.

MyMichigan Medical Center Midland

MyMichigan Medical Center Midland’s performance has stayed consistent with 2022 rates and did not meet the top quartile goal for 2023.

Graph showing Pneumonia deaths within 30-days of hospital discharge for MyMichigan Medical Center Midland. Quarter 1 value was 38.3% (above benchmark), quarter 2 value was 21.3% (above benchmark), quarter 3 value was 24.2% (above benchmark) and quarter 4 value was 20.5% (below benchmark.) Below benchmark values are desirable.

MyMichigan Medical Center Sault

MyMichigan Medical Center Sault joined MyMichigan Health in 2022 and has met the top quartile goal in 2022 and 2023.

Graph showing Pneumonia deaths within 30-days of hospital discharge for MyMichigan Medical Center Sault. Quarter 1 value was 14.3% (below benchmark), quarter 2 value was 4.5% (below benchmark), quarter 3 value was 7.7% (below benchmark) and quarter 4 value was 7.4% (below benchmark.) Below benchmark values are desirable.

MyMichigan Medical Center West Branch

MyMichigan Medical Center West Branch has seen improved performance in pneumonia mortality since 2020 and met the top quartile goal for 2023.

Graph showing Pneumonia deaths within 30-days of hospital discharge for MyMichigan Medical Center West Branch. Quarter 1 value was 26.3% (above benchmark), quarter 2 value was 11.8% (below benchmark), quarter 3 value was 0% (below benchmark) and quarter 4 value was 9.1% (below benchmark.) Below benchmark values are desirable.