Quality Report


Quality Report

Divine Savior Healthcare, Inc.

DBA: Aspirus Divine Savior Hospital and Clinics
HCO ID: 3742
2817 New Pinery Road
Portage, WI, 53901
(608) 742-4131
www.dshealthcare.com
Summary of Quality Information

Accreditation Programs

Gold Seal
Home Care
Accreditation Decision
Effective Date
8/29/2019
Last Full Survey Date
8/28/2019
Last On-Site Survey Date
8/28/2019
Gold Seal
Hospital
Accreditation Decision
Effective Date
8/31/2019
Last Full Survey Date
8/30/2019
Last On-Site Survey Date
10/7/2019
Gold Seal
Laboratory
Accreditation Decision
Effective Date
11/30/2018
Last Full Survey Date
11/29/2018
Last On-Site Survey Date
11/29/2018
Gold Seal
Nursing Care Center
Accreditation Decision
Effective Date
8/29/2019
Last Full Survey Date
8/28/2019
Last On-Site Survey Date
8/28/2019

Sites

Divine Savior Healthcare Crossroads Clinic
DBA: Aspirus Divine Savior Hospital and Clinics
N4390 Crossroads Clinic Road
Oxford, WI, 53952-9465

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

Divine Savior Healthcare, Inc.
DBA: Aspirus Divine Savior Hospital and Clinics
2817 New Pinery Road
Portage, WI, 53901-0387

Available Services

  • CT Scanner (Imaging/Diagnostic Services )
  • Ear/Nose/Throat Surgery (Surgical Services )
  • EEG/EKG/EMG Lab (Imaging/Diagnostic Services )
  • Gastroenterology (Surgical Services )
  • General Laboratory Tests
  • GI or Endoscopy Lab (Imaging/Diagnostic Services )
  • Gynecological Surgery (Surgical Services )
  • Gynecology (Inpatient )
  • Hazardous Medication Compounding (Inpatient )
  • Inpatient Unit (Inpatient )
  • Labor & Delivery (Inpatient )
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services )
  • Medical /Surgical Unit (Inpatient )
  • Medical ICU (Intensive Care Unit )
  • Non-Sterile Medication Compounding (Inpatient )
  • Normal Newborn Nursery (Inpatient )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Ophthalmology (Surgical Services )
  • Orthopedic Surgery (Surgical Services )
  • Outpatient Clinics (Outpatient )
  • Positron Emission Tomography (PET) (Imaging/Diagnostic Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Sleep Laboratory (Sleep Laboratory )
  • Sterile Medication Compounding (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Teleradiology (Imaging/Diagnostic Services )
  • Toxicology
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )

Divine Savior Healthcare, Inc.- Pardeeville Clinic
DBA: Aspirus Divine Savior Hospital and Clinics
102 Gillette St
Pardeeville, WI, 53954

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

Tivoli at Divine Savior Healthcare, Inc.
DBA: Tivoli at Divine Savior Healthcare, Inc.
2805 Hunters Trail
Portage, WI, 53901

Available Services

  • Dementia Care
  • General Laboratory Tests
  • Home Health Aides
  • Home Health, Non-Hospice Services
  • Medical Social Services
  • Occupational Therapy
  • Physical Therapy
  • Rehabilitation Services
  • Skilled Nursing Care
  • Skilled Nursing Services
  • Speech Language Pathology

National Patient Safety Goals and National Quality Improvement Goals

Symbol Key

  • starThis organization achieved the best possible results
  • plusThis organization's performance is above the target range/value
  • checkThis organization's performance is similar to the target range/value
  • minusThis organization's performance is below the target range/value
  • naThis measure is not applicable for this organization
  • ndNot displayed

Measures Footnote Key

  1. The measure or measure set was not reported.
  2. The measure set does not have an overall result.
  3. The number is not enough for comparison purposes.
  4. The measure meets the Privacy Disclosure Threshold rule.
  5. The organization scored above 90% but was below most other organizations.
  6. The measure results are not statistically valid.
  7. The measure results are based on a sample of patients.
  8. The number of months with measure data is below the reporting requirement.
  9. The measure results are temporarily suppressed pending resubmission of updated data.
  10. Test Measure: a measure being evaluated for reliability of the individual data elements or awaiting National Quality Forum Endorsement.
  11. There were no eligible patients that met the denominator criteria.

Symbol Key

  • starThis organization achieved the best possible results
  • plusThis organization's performance is above the target range/value
  • checkThis organization's performance is similar to the target range/value
  • minusThis organization's performance is below the target range/value
  • naThis measure is not applicable for this organization
  • ndNot displayed

Measures Footnote Key

  1. The measure or measure set was not reported.
  2. The measure set does not have an overall result.
  3. The number is not enough for comparison purposes.
  4. The measure meets the Privacy Disclosure Threshold rule.
  5. The organization scored above 90% but was below most other organizations.
  6. The measure results are not statistically valid.
  7. The measure results are based on a sample of patients.
  8. The number of months with measure data is below the reporting requirement.
  9. The measure results are temporarily suppressed pending resubmission of updated data.
  10. Test Measure: a measure being evaluated for reliability of the individual data elements or awaiting National Quality Forum Endorsement.
  11. There were no eligible patients that met the denominator criteria.

The Joint Commission only reports measures endorsed by the National Quality Forum.
* This information can also be viewed at Hospital Compare.

**      Indicates per 1000 hours of patient care.
***   The measure was not in effect for this quarter.
----   Null value or data not displayed.

Laboratory 2018 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Hospital 2019 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Nursing Care Center 2019 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Home Care 2019 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Reporting Period: January 2019 - December 2019
Emergency Department National Comparison: nd 2 Statewide Comparison: nd 2
Perinatal Care National Comparison: nd 2 Statewide Comparison: nd 2

New Changes to Quarterly Measure

Download Quarterly Measure Results

The Joint Commission only reports measures endorsed by the National Quality Forum.
* State results are not calculated for the National Patient Safety Goals.