Quality Report


Quality Report

Mercy Health System Corporation
HCO ID: 7644
1000 Mineral Point Avenue
Janesville, WI, 53548
(608) 756-6625
mercyhealthsystem.org
Summary of Quality Information

Accreditation Programs

View Accreditation History
Gold Seal
Behavioral Health Care and Human Services
Accreditation Decision
Effective Date
7/21/2021
Last Full Survey Date
7/20/2021
Last On-Site Survey Date
7/20/2021
Gold Seal
Critical Access Hospital
Accreditation Decision
Effective Date
7/23/2021
Last Full Survey Date
7/22/2021
Last On-Site Survey Date
7/22/2021
Gold Seal
Hospital
Accreditation Decision
Effective Date
7/24/2021
Last Full Survey Date
7/23/2021
Last On-Site Survey Date
9/8/2021
Gold Seal
Laboratory
Accreditation Decision
Effective Date
10/14/2023
Last Full Survey Date
4/28/2023
Last On-Site Survey Date
3/12/2024

Advanced Certification Programs

View Certification History
Gold Seal
Acute Stroke Ready Hospital
Certification Decision
Effective Date
12/7/2022
Last Full Survey Date
12/6/2022
Last On-Site Survey Date
12/6/2022
Gold Seal
Primary Stroke Center
Certification Decision
Effective Date
12/8/2022
Last Full Survey Date
12/7/2022
Last On-Site Survey Date
12/7/2022

Sites

Mercy Health System Corporation
1000 Mineral Point Avenue
Janesville, WI, 53548-5003

Available Services

  • Allergen Extract (Inpatient )
  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult )
  • Brachytherapy (Imaging/Diagnostic Services )
  • Cardiac Catheterization Lab (Surgical Services )
  • Cardiac Surgery (Surgical Services )
  • Cardiothoracic Surgery (Surgical Services )
  • Chemical Dependency (24-hour Acute Care/Crisis Stabilization - Adult )
  • Chemical Dependency (Detox - Adult )
  • Community Integration (Non 24 Hour Care )
  • 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 )
  • Interventional Radiology (Imaging/Diagnostic Services )
  • Labor & Delivery (Inpatient )
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services )
  • Mammography (Imaging/Diagnostic Services )
  • Medical /Surgical Unit (Inpatient )
  • Medical ICU (Intensive Care Unit )
  • Neurosurgery (Surgical Services )
  • Non-Sterile Medication Compounding (Inpatient )
  • Normal Newborn Nursery (Inpatient )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • On Site Pharmacy
  • Ophthalmology (Surgical Services )
  • Orthopedic Surgery (Surgical Services )
  • Orthopedic/Spine Unit (Inpatient )
  • Pediatric Unit (Inpatient )
  • Plastic Surgery (Surgical Services )
  • Positron Emission Tomography (PET) (Imaging/Diagnostic Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Radiation Oncology (Imaging/Diagnostic Services )
  • Rehabilitation Services
  • Skilled Nursing Care
  • Sleep Laboratory (Sleep Laboratory )
  • Sterile Medication Compounding (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Surgical Unit (Inpatient )
  • Teleradiology (Imaging/Diagnostic Services )
  • Thoracic Surgery (Surgical Services )
  • Toxicology
  • Trauma Center (Trauma Center )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Primary Stroke Center

Mercyhealh Child and Adolescent Treatment Program
2600 Humes Road
Janesville, WI, 53545

Available Services

  • Behavioral Health (Day Programs - Child/Youth )
  • Behavioral Health (Partial Hospitalization - Child/Youth )

Mercyhealth Algonquin Medical Center
2401 Harnish Dr., Suite 101
Algonquin, IL, 60102

Available Services

  • General Laboratory Tests
  • Single Specialty Practitioner (Outpatient )

Mercyhealth Barrington Medical Center
500 West Highway 22
Barrington, IL, 60010

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

Mercyhealth Behavioral Health Clinic-Walworth
N2846 State Road 67
Williams Bay, WI, 53191

Available Services

  • Behavioral Health (Non 24 Hour Care - Adult )
  • Behavioral Health (Non 24 Hour Care - Child/Youth )

Mercyhealth Beloit
2825 Prairie Avenue
Beloit, WI, 53511

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

Mercyhealth Brodhead Medical Center
2310 First Center Avenue
Brodhead, WI, 53520

Available Services

  • General Laboratory Tests
  • Urgent Care (Outpatient )

Mercyhealth Crystal Lake Physician Clinic
875 S. Route 31
Crystal Lake, IL, 60014

Available Services

  • Perform Invasive Procedure (Outpatient )
  • Urgent Care (Outpatient )

Mercyhealth Delavan
1038 East Geneva Street
Delavan, WI, 53115

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

Mercyhealth East
3524 East Milwaukee
Janesville, WI, 53545

Available Services

  • General Laboratory Tests
  • Perform Invasive Procedure (Outpatient )
  • Toxicology
  • Urgent Care (Outpatient )

Mercyhealth Edgerton
217 North Main Street
Edgerton, WI, 53534

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

Mercyhealth Elkhorn
839 N. Wisconsin Street
Elkhorn, WI, 53121

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

Mercyhealth Evansville
300 Union Street
Evansville, WI, 53536

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

Mercyhealth Harvard Hospital Clinic
1001 Grant Street
Harvard, IL, 60033

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

Mercyhealth Harvard South
348 S. Division St
Harvard, IL, 60033

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

Mercyhealth Henry Palmer Building
903 Mineral Point Avenue
Janesville, WI, 53548

Available Services

  • Addiction Services
  • Addiction Services (Non-detox - Adult )
  • Behavioral Health (Day Programs - Adult )
  • Behavioral Health (Non 24 Hour Care - Adult )
  • Behavioral Health (Non 24 Hour Care - Child/Youth )
  • Behavioral Health (Partial Hospitalization - Adult )
  • Chemical Dependency (Day Programs - Adult )
  • Chemical Dependency (Partial Hospitalization - Adult )
  • Chemical Dependency (Non-detox - Adult )
  • Community Integration (Non 24 Hour Care )
  • Developmental Disabilities - Programs / Services (Non 24 Hour Care - Child/Youth )
  • Outpatient Clinics (Outpatient )
  • Persons with Intellectual/Developmental Disabilities (In-Home Behavioral Health Care Services - Child/Youth )

Other Clinics/Practices Located at This Site:

  • Mercyhealth Autism Program
  • Mercyhealth Behavioral Health Clinic
  • Mercyhealth Lung Center
  • Mercyhealth Sleep Center

Mercyhealth Hospital & Medical Center-Walworth
N2950 State Road 67
Lake Geneva, WI, 53147

Available Services

  • Acute Care
  • 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 )
  • Labor & Delivery (Inpatient )
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services )
  • Mammography (Imaging/Diagnostic Services )
  • Medical /Surgical Unit (Inpatient )
  • Medical ICU (Intensive Care Unit )
  • 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 )
  • Surgical ICU (Intensive Care Unit )
  • Teleradiology (Imaging/Diagnostic Services )
  • Toxicology
  • Ultrasound (Imaging/Diagnostic Services )

Certification Programs

  • Acute Stroke Ready Hospital

Mercyhealth Hospital and Trauma Center Emergency North
3400 Deerfield Drive
Janesville, WI, 53546

Available Services

  • Administration of Blood Product (Outpatient )
  • Administration of High Risk Medications (Outpatient )
  • Anesthesia (Outpatient )
  • Emergency Care (Outpatient )
  • General Laboratory Tests
  • Perform Invasive Procedure (Outpatient )
  • Toxicology

Mercyhealth Lake Geneva
350 Peller Rd
Lake Geneva, WI, 53147

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

Mercyhealth Mall
1010 North Washington St
Janesville, WI, 53547

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

Mercyhealth McHenry
3922 Mercy Drive
McHenry, IL, 60050

Available Services

  • General Laboratory Tests
  • Urgent Care (Outpatient )

Mercyhealth Michael Berry Building
1000 Mineral Point Avenue
Janesville, WI, 53548

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Anesthesia (Outpatient )
  • Dialysis (Outpatient )
  • Hazardous Medication Compounding (Outpatient )
  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Other Clinics/Practices Located at This Site:

  • Mercyhealth Kidney Care and Dialysis Center

Mercyhealth Milton
725 Janesville St
Milton, WI, 53563

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

Mercyhealth Richmond
9715 Prairie Ridge
Richmond, IL, 60071

Available Services

  • General Laboratory Tests
  • Single Specialty Practitioner (Outpatient )

Mercyhealth South
849 Kellogg
Janesville, WI, 53546

Available Services

  • General Laboratory Tests
  • Urgent Care (Outpatient )

Mercyhealth Sports Medicine and Rehabilitation Center
557 North Washington St.
Janesville, WI, 53545

Available Services

  • Outpatient Clinics (Outpatient )

Mercyhealth Terrace
510 N. Terrace Street
Janesville, WI, 53548

Available Services

  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Mercyhealth Transitional Care Center
1000 Mineral Point Ave.
Janesville, WI, 53545

Available Services

  • On Site Pharmacy
  • Rehabilitation Services
  • Skilled Nursing Care

Mercyhealth West
1000 Mineral Point Avenue
Janesville, WI, 53545

Available Services

  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Mercyhealth Whitewater
507 West Main
Whitewater, WI, 53190

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )

Mercyhealth Woodstock
2000 Lake Avenue
Woodstock, IL, 60098

Available Services

  • General Laboratory Tests
  • Perform Invasive Procedure (Outpatient )
  • Urgent Care (Outpatient )

Cooperative Agreements

Hospital - Accredited by American College of Surgeons-Commission on Cancer (ACoS-COC)

National Patient Safety Goals and National Quality Improvement Goals

Symbol Key

  • starThis organization achieved the best possible results
  • plusThis organization's performance is better than the target range/value
  • checkThis organization's performance is similar to the target range/value
  • minusThis organization's performance is worse than 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.
  12. The measure rate is within optimal range.

Symbol Key

  • starThis organization achieved the best possible results
  • plusThis organization's performance is better than the target range/value
  • checkThis organization's performance is similar to the target range/value
  • minusThis organization's performance is worse than 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.
  12. The measure rate is within optimal range.

* 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.

Hospital 2021 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Behavioral Health Care and Human Services 2021 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Critical Access Hospital 2021 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Laboratory 2023 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Reporting Period: January 2022 - December 2022
Perinatal Care National Comparison: nd 2 Statewide Comparison: nd 2
Perinatal Care National Comparison: nd 2 Statewide Comparison: nd 2
Perinatal Care 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

* State results are not calculated for the National Patient Safety Goals.