Joint Commission

An independent, not-for-profit organization, The Joint Commission accredits and certifies nearly 21,000 healthcare organizations and programs in the United States. Joint Commission accreditation and certification are recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards. Learn more about The Joint Commission.

Hospital Compare | CMS 3-Star Rating

The Centers for Medicare & Medicaid Services (CMS) and the nation’s hospitals work collaboratively to publicly report hospital quality performance information on the Care Compare website. View the Hospital Compare score for UP Health System – Marquette. 

HealthGrades

After leaving the hospital, patients are randomly selected to answer the standardized, multiple-question survey developed by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). Healthgrades obtains this survey data from the Centers for Medicare and Medicaid Services (CMS). UP Health System – Marquette received the HealthGrades Patient Safety Excellence Award in 2014, 2016, and 2020. Read more about HealthGrades.

Hospital Safety Grade | LeapFrog Group

Leapfrog Hospital Safety Grades (formerly known as Hospital Safety Scores) are assigned to nearly 3,000 general acute-care hospitals across the nation twice annually. The Safety Grade is the gold standard measure of patient safety, cited in MSNBC, The New York Times, and AARP The Magazine. 

The Leapfrog Hospital Safety Grade uses more than 30 national performance measures from CMS, the Leapfrog Hospital Survey, and information from other supplemental data sources. Taken together, those performance measures produce a single letter grade representing a hospital’s overall performance in keeping patients safe from preventable harm and medical errors. The Leapfrog Hospital Safety Grade methodology has been peer-reviewed and published in the Journal of Patient Safety. Read more about the LeapFrog Group and UP Health System – Marquette's LeapFrog Group rating. 

ACC Chest Pain Center with Primary PCI Accreditation

Hospitals that have earned the American College of Cardiology Chest Pain Center with Primary PCI Accreditation have proven exceptional competency in treating patients with heart attack symptoms and have primary PCI available 24/7 every day of the year. As required to meet the criteria of the accreditation designation, they have streamlined their systems from admission to evaluation to diagnosis and treatment through to appropriate post-discharge care and recommendations and assistance in patient lifestyle changes. In addition, they have formal agreements with other facilities that regularly refer heart attack patients to their facility for primary PCI. Learn more about ACC Accreditation.

Level 2 Trauma Center

UP Health System – Marquette is verified by the American College of Surgeons Committee on Trauma (ACS-COT) as a Level II Trauma Center. As a Level II Trauma Center, our facility can initiate definitive care for all injured patients. Elements of a Level II Trauma center include 24-hour immediate coverage by trauma/general surgeons, orthopedic surgeons, neurosurgical, anesthesiology, emergency medicine, radiology, and critical care. We also provide staff trauma prevention and continuing education programs, and our trauma team incorporates a comprehensive quality assessment program. Additionally, we assist with rural trauma development outreach to transferring facilities throughout the Upper Peninsula.

Nationally Accredited Breast Center

To achieve voluntary Nationally Accredited Breast Cancer (NAPBC) accreditation, a breast center complies with the NAPBC standards that address a center’s leadership, clinical services, research, community outreach, professional education, and patient quality improvement. Breast centers seeking NAPBC accreditation undergo a site visit every three years. As an NAPBC-accredited center, we are committed to maintaining levels of excellence in the delivery of comprehensive, patient-centered, multidisciplinary care resulting in high-quality care for patients with breast disease. Patients can be confident that their breast care team includes healthcare professionals from a variety of disciplines who are committed to working together to provide the best care available through their entire course of treatment. Patients receiving care at an NAPBC-accredited center also have access to information on clinical trials and new treatment options, genetic counseling, and patient-centered services including psychosocial support, rehabilitation services, and survivorship care. Find more information here.

Commission on Cancer Accreditation

To earn voluntary Commission on Cancer (CoC) accreditation, a cancer program must meet 34 CoC quality care standards, be evaluated every three years through a survey process, and maintain levels of excellence in the delivery of comprehensive patient-centered care. Because we are a CoC-accredited cancer center, we take a multidisciplinary approach to treating cancer as a complex disease group requiring consultation among surgeons, medical and radiation oncologists, diagnostic radiologists, pathologists, and other cancer specialists. This multidisciplinary partnership results in improved patient care.

The CoC Accreditation Program provides the framework for UP Health System – Marquette to improve its quality of patient care through various cancer-related programs that focus on the full spectrum of cancer care including prevention, early diagnosis, cancer staging, optimal treatment, rehabilitation, life-long follow-up for recurrent disease, and end-of-life care. When patients receive care at a CoC facility, they also have access to information on clinical trials and new treatments, genetic counseling, and patient-centered services including psycho-social support, a patient navigation process, and a survivorship care plan that documents the care each patient receives and seeks to improve cancer survivors’ quality of life. Find more information here.

National Patient Safety Goals

As Joint Commission-accredited facilities, UP Health System strives to continually improve patient care by adhering to the National Patient Safety Goals (NPSGs). The NPSGs were established in 2002 to help accredited organizations address specific areas of concern regarding patient safety—the first set of safety goals were effective on January 1, 2003. The Joint Commission determines the highest priority patient safety issues, including NPSGs, from input from practitioners, provider organizations, purchasers, consumer groups, and other stakeholders. Learn more about the current year’s safety goals here.

Duke Quality Network

UP Health System – Marquette is aligned with the Duke Quality Network. The Duke Quality Network connects community hospitals to the quality and patient safety resources of Duke Health through a proven model focused on leadership, performance improvement, and a culture of safety. Read more about the Duke Quality Network.

Blue Distinction

Blue Distinction Center and Blue Distinction Center+ designations are awarded to healthcare facilities based on a thorough, objective evaluation of their performance in the areas that matter the most — like quality care, treatment expertise and overall patient results, to name a few. The criteria are established with the help of expert physicians and medical organizations. UP Health System – Marquette is a Blue Distinction Center+ for: Bariatric Surgery (Gastric Stapling, Gastric Banding), Knee and Hip Replacement, and Spine Surgery. Read more about Blue Distinction Center+ Designation.

BCBSM State Collaborative Quality Initiatives & Value Partnerships

For the past 25 years in Michigan, the Collaborative Quality Initiatives (CQIs) have taken a cooperative bottom-up approach to healthcare quality improvement. Made up of physician organizations and hospitals around the state and led by local clinicians who set the quality improvement plan, the CQIs rely on an approach that uses granular data collection, analysis, and transparency to develop and implement practice improvements to support a learning health system. The quality improvement work of the CQIs is administered directly by clinician leaders who direct statewide consortiums of their peers. Each CQI is financially supported by Blue Cross Blue Shield of Michigan (BCBSM). (Howard et. al, 2022) ¹

UP Health System participates in numerous Michigan CQIs to ensure the best quality of care for our patients.

– BMC2 Cardiovascular Consortium

The BMC2 Cardiovascular Consortium is a collaborative consortium of healthcare providers dedicated to improving the quality of care and outcomes for cardiovascular patients across the State of Michigan. UPHS participates in the BMC2 Percutaneous Coronary Intervention (PCI), Vascular Surgery, and TAVR registries. Learn more about BMC2. 

– Michigan Arthroplasty Registry Collaborative Quality Initiative 

The Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) is a group of orthopedic surgeons and medical professionals dedicated to improving the quality of care for patients undergoing hip and knee replacement procedures in Michigan.

MARCQI has created a statewide quality improvement infrastructure by developing a consortium of hospitals and ambulatory surgery centers in Michigan to engage in quality improvement activities for hip and knee joint replacement surgery procedures. Improved quality improves patient safety, reduces complications, and reduces the cost of this care in the State of Michigan. The consortium improves the quality of care by addressing variations in patient outcomes related to hip and knee joint replacement surgery. Learn more about MARCQI. 

– Michigan Spine Surgery Improvement Collaborative

The Michigan Spine Surgery Improvement Collaborative (MSSIC) is a statewide quality improvement collaborative involving orthopedic surgeons and neurosurgeons to improve the quality of care of spine surgery. The objective of this collaboration is to heighten patient care outcomes while consequently increasing the efficiency of treatment. Learn more about MSSIC. 

– Michigan Bariatric Surgery Collaborative

The Michigan Bariatric Surgery Collaborative (MBSC) is a regional, voluntary consortium of hospitals and surgeons that perform bariatric (weight loss) surgery in Michigan. The goal of the project is to improve the quality of care for patients undergoing bariatric surgery. The project is funded by Blue Cross and Blue Shield of Michigan/Blue Care Network (BCBSM/BCN) and coordinated at the University of Michigan. Learn more about MBSC. 

– Michigan Hospital Medicine Safety Consortium

The Michigan Hospital Medicine Safety Consortium (HMS) is a data-driven collaborative designed to provide the infrastructure needed to facilitate information sharing to support Michigan hospitals in improving patient safety and the quality of care for hospitalized medical patients. Learn more about HMS.

– Michigan Obstetrics Initiative

The Obstetrics Initiative (OBI) is a data-driven quality improvement project working to support vaginal delivery and safely reduce the use of cesarean delivery among low-risk births, with improved or stable maternal and neonatal morbidity rates. Learn more about OBI.

– Michigan Trauma Quality Improvement Program

The Michigan Trauma Quality Improvement Program (MTQIP) aims to measure and improve the quality of care administered to trauma patients through a statewide collaboration of participating trauma centers in Michigan. Learn more about MTQIP.

– Michigan Surgical Quality Collaborative

The Michigan Surgical Quality Collaborative (MSQC) is a group of Michigan hospitals dedicated to overall surgical quality improvement, including better patient care and lower costs. They are multidisciplinary and inclusive and work together to transform surgical quality and deliver cost-effective care. Members of MSQC contribute data and share their ideas. MSQC hosts a robust regional registry to analyze any issues, identify best practices, and disseminate them widely. Their independence and regional focus give them the flexibility to respond quickly to cost and quality issues as they arise. Learn more about MSQC.

– The Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative

The Michigan Society of Thoracic and Cardiovascular Surgeons (MSTCVS) Quality Collaborative is a multidisciplinary group of medical professionals dedicated to improving the care of adult cardiac and general thoracic surgery patients in Michigan.

The Collaborative promotes and shares optimal care processes of cardiac and general thoracic surgery outcomes and implements quality improvement initiatives based on regional and national data as well as clinical research and evidence-based cardiac and thoracic surgery practice and guidelines. Learn more about MSTCVS. 

– Michigan Value Collaborative

The goal of the Michigan Value Collaborative (MVC) is to improve the health of Michigan through sustainable, high-value healthcare. It is a partnership between Michigan hospitals, physician organizations, and BCBSM/BCN. Working in conjunction with the many specialty-specific CQI programs in BCBSM's Value Partnership Program, MVC aims to understand variation in healthcare use, identify best practices, and lead interventions for improving care before, during, and after hospitalization. The program improves healthcare quality across Michigan through rigorous performance feedback, empirical identification of best practices, and collaborative learning. Learn more about MVC.