Quality Report


Quality Report

Gundersen Lutheran Medical Center, Inc.
HCO ID: 7649
1910 South Avenue
La Crosse, WI, 54601
(608) 782-7300
www.gundersenhealth.org
Summary of Quality Information

Accreditation Programs

View Accreditation History
Gold Seal
Home Care
Accreditation Decision
Effective Date
12/3/2022
Last Full Survey Date
12/2/2022
Last On-Site Survey Date
12/2/2022
Gold Seal
Hospital
Accreditation Decision
Effective Date
12/3/2022
Last Full Survey Date
12/2/2022
Last On-Site Survey Date
1/18/2023

Advanced Certification Programs

View Certification History
Gold Seal
Primary Stroke Center
Certification Decision
Effective Date
5/13/2023
Last Full Survey Date
5/12/2023
Last On-Site Survey Date
5/12/2023

Sites

Gundersen Lutheran Medical Center, Inc.
DBA: Gundersen Lutheran Medical Center Founders Building
710 Denton Street
La Crosse, WI, 54601

Available Services

  • Outpatient Clinics (Outpatient )

Gundersen Lutheran Medical Center, Inc.
DBA: Gundersen Lutheran Medical Center East Building
724 Denton
La Crosse, WI, 54601

Available Services

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

Gundersen Lutheran Medical Center, Inc.
DBA: Gundersen Lutheran Medical Center La Crosse Clinic
1836 South Avenue
La Crosse, WI, 54601

Available Services

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

Gundersen Lutheran Medical Center, Inc.
DBA: Gundersen Lutheran Medical Center Onalaska Clinic
3111 Gundersen Drive
Onalaska, WI, 54650

Available Services

  • Administration of Blood Product (Outpatient )
  • Administration of High Risk Medications (Outpatient )
  • Anesthesia (Outpatient )
  • Behavioral Health (Non 24 Hour Care - Adult )
  • Behavioral Health (Non 24 Hour Care - Child/Youth )
  • Hazardous Medication Compounding (Outpatient )
  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Gundersen Lutheran Medical Center, Inc.
1910 South Avenue
La Crosse, WI, 54601

Available Services

  • Addiction Services
  • Addiction Services (Non-detox - Adult )
  • Behavioral Health (Non 24 Hour Care - Adult )
  • Behavioral Health (Non 24 Hour Care - Child/Youth )
  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult )
  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Child/Youth )
  • Cardiac Catheterization Lab (Surgical Services )
  • Cardiac Surgery (Surgical Services )
  • Cardiothoracic Surgery (Surgical Services )
  • Cardiovascular Unit (Inpatient )
  • Chemical Dependency (Day Programs - Adult )
  • Chemical Dependency (Non 24 Hour Care - Adult )
  • Chemical Dependency (Non 24 Hour Care - Child/Youth )
  • Chemical Dependency (Partial Hospitalization - Adult )
  • Chemical Dependency (Non-detox - Adult )
  • CT Scanner (Imaging/Diagnostic Services )
  • Ear/Nose/Throat Surgery (Surgical Services )
  • Eating Disorders
  • Eating Disorders
  • Eating Disorders (Outpatient - Adult )
  • Eating Disorders (Outpatient - Child/Youth )
  • Eating Disorders (Non 24 Hour Care - Adult )
  • Eating Disorders (Non 24 Hour Care - Child/Youth )
  • EEG/EKG/EMG Lab (Imaging/Diagnostic Services )
  • Gastroenterology (Surgical Services )
  • GI or Endoscopy Lab (Imaging/Diagnostic Services )
  • Gynecological Surgery (Surgical Services )
  • Gynecology (Inpatient )
  • Hazardous Medication Compounding (Inpatient )
  • Hematology/Oncology Unit (Inpatient )
  • Inpatient Unit (Inpatient )
  • Interventional Radiology (Imaging/Diagnostic Services )
  • Labor & Delivery (Inpatient )
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services )
  • Medical /Surgical Unit (Inpatient )
  • Medical ICU (Intensive Care Unit )
  • Neuro/Spine Unit (Inpatient )
  • Neurosurgery (Surgical Services )
  • Non-Sterile Medication Compounding (Inpatient )
  • Normal Newborn Nursery (Inpatient )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Ophthalmology (Surgical Services )
  • Orthopedic Surgery (Surgical Services )
  • Orthopedic/Spine Unit (Inpatient )
  • Outpatient Clinics (Outpatient )
  • Pediatric Unit (Inpatient )
  • Plastic Surgery (Surgical Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Rehabilitation Unit (Inpatient )
  • Rehabilitation Unit (24-hour Acute Care/Crisis Stabilization )
  • Sterile Medication Compounding (Inpatient )
  • Surgical Unit (Inpatient )
  • Technology-Based Addiction Services (Non 24 Hour Care - Adult )
  • Technology-Based Addiction Services (Non 24 Hour Care - Child/Youth )
  • Technology-Based Addiction Services (Non-detox - Adult )
  • Technology-Based Behavioral Health Srvs (Non 24 Hour Care - Adult )
  • Technology-Based Behavioral Health Srvs (Non 24 Hour Care - Child/Youth )
  • Thoracic Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Primary Stroke Center

Gundersen Lutheran Medical Center, Inc.
DBA: Gundersen Hospice
333 Front St. N
La Crosse, WI, 54601

Available Services

  • Hospice Care

Gundersen Lutheran Medical Center, Inc.
DBA: Gundersen Lutheran Medical Center Winona Campus
1122 West Highway 61
Winona, MN, 55987

Available Services

  • Administration of Blood Product (Outpatient )
  • Administration of High Risk Medications (Outpatient )
  • Anesthesia (Outpatient )
  • Behavioral Health (Non 24 Hour Care - Adult )
  • Behavioral Health (Non 24 Hour Care - Child/Youth )
  • Hazardous Medication Compounding (Outpatient )
  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Gundersen Lutheran Medical Center, Inc.
DBA: Gundersen Lutheran Medical Center Onalaska Annex
123 16th Avenue South
Onalaska, WI, 54650

Available Services

  • 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 (Non 24 Hour Care - Adult )
  • Chemical Dependency (Non 24 Hour Care - Child/Youth )
  • Chemical Dependency (Partial Hospitalization - Adult )
  • Chemical Dependency (Non-detox - Adult )
  • Technology-Based Addiction Services (Non 24 Hour Care - Adult )
  • Technology-Based Addiction Services (Non 24 Hour Care - Child/Youth )
  • Technology-Based Addiction Services (Non-detox - Adult )
  • Technology-Based Behavioral Health Srvs (Non 24 Hour Care - Adult )
  • Technology-Based Behavioral Health Srvs (Non 24 Hour Care - Child/Youth )

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 2022 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Home Care 2022 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

New Changes to Quarterly Measure

Download Quarterly Measure Results

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