Quality Report


Quality Report

Mayo Clinic Health System - Franciscan Medical Center, Inc.

DBA: Mayo Clinic Health System - Franciscan Healthcare
HCO ID: 7650
700 West Avenue South
La Crosse, WI, 54601
(608) 785-0940
mayoclinichealthsystem.org
Summary of Quality Information

Accreditation Programs

View Accreditation History
Gold Seal
Behavioral Health Care and Human Services
Accreditation Decision
Effective Date
3/15/2018
Last Full Survey Date
3/14/2018
Last On-Site Survey Date
3/14/2018
Gold Seal
Critical Access Hospital
Accreditation Decision
Effective Date
9/25/2021
Last Full Survey Date
9/24/2021
Last On-Site Survey Date
9/24/2021
Gold Seal
Home Care
Accreditation Decision
Effective Date
9/25/2021
Last Full Survey Date
9/24/2021
Last On-Site Survey Date
9/24/2021
Gold Seal
Hospital
Accreditation Decision
Effective Date
9/25/2021
Last Full Survey Date
9/24/2021
Last On-Site Survey Date
9/24/2021

Advanced Certification Programs

View Certification History
Gold Seal
Primary Stroke Center
Certification Decision
Effective Date
4/16/2022
Last Full Survey Date
4/15/2022
Last On-Site Survey Date
4/15/2022

Sites

Mayo Clinic Health System - Franciscan Healthcare
DBA: Franciscan Healthcare-Sparta
310 West Main Street
Sparta, WI, 54656

Available Services

  • Acute Care
  • CT Scanner (Imaging/Diagnostic Services )
  • Gastroenterology (Surgical Services )
  • GI or Endoscopy Lab (Imaging/Diagnostic Services )
  • Mammography (Imaging/Diagnostic Services )
  • Medical /Surgical Unit (Inpatient )
  • Ophthalmology (Surgical Services )
  • Orthopedic Surgery (Surgical Services )
  • Swing Beds
  • Teleradiology (Imaging/Diagnostic Services )
  • Trauma Center (Trauma Center )
  • Ultrasound (Imaging/Diagnostic Services )

Mayo Clinic Health System - Franciscan Medical Center, Inc
DBA: Franciscan Healthcare - Arcadia
895 Dettloff Drive
Arcadia, WI, 54612

Available Services

  • Behavioral Health (Non 24 Hour Care - Adult )
  • Chemical Dependency (Non 24 Hour Care - Adult )
  • Chemical Dependency (Non-detox - Adult )
  • Community Integration (Non 24 Hour Care )
  • Outpatient Clinics (Outpatient )

Mayo Clinic Health System - Franciscan Medical Center, Inc.
DBA: Franciscan Healthcare - Caledonia
701 North Sprague Street
Caledonia, MN, 55921-1066

Available Services

  • Outpatient Clinics (Outpatient )

Mayo Clinic Health System - Franciscan Medical Center, Inc.
DBA: Franciscan Healthcare - Tomah
325 Butts Avenue
Tomah, WI, 54660-1412

Available Services

  • Behavioral Health (Non 24 Hour Care - Adult )
  • Behavioral Health (Non 24 Hour Care - Child/Youth )
  • Outpatient Clinics (Outpatient )
  • Peer Support (Non 24 Hour Care )

Mayo Clinic Health System - Franciscan Medical Center, Inc.
DBA: Franciscan Healthcare - Hospice
700 West Avenue South
La Crosse, WI, 54601

Available Services

  • Hospice Care

Mayo Clinic Health System - Franciscan Medical Center, Inc.
DBA: Franciscan Healthcare - Onalaska
191 Theatre Road
Onalaska, WI, 54650-8679

Available Services

  • Behavioral Health (Non 24 Hour Care - Adult )
  • Behavioral Health (Non 24 Hour Care - Child/Youth )
  • Chemical Dependency (Non 24 Hour Care - Adult )
  • Chemical Dependency (Non-detox - Adult )
  • Community Integration (Non 24 Hour Care )
  • Outpatient Clinics (Outpatient )

Mayo Clinic Health System - Franciscan Medical Center, Inc.
DBA: Franciscan Healthcare - Holmen
1303 Main Street South
Holmen, WI, 54636-8927

Available Services

  • Outpatient Clinics (Outpatient )

Mayo Clinic Health System - Franciscan Medical Center, Inc.
DBA: Franciscan Healthcare - Sparta Clinic
310 West Main Street
Sparta, WI, 54656

Available Services

  • Addiction Services
  • Addiction Services (Non-detox - Adult )
  • Behavioral Health (Non 24 Hour Care - Adult )
  • Behavioral Health (Non 24 Hour Care - Child/Youth )
  • 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 )
  • Community Integration (Non 24 Hour Care )
  • Outpatient Clinics (Outpatient )

Mayo Clinic Health System - Franciscan Medical Center, Inc.
DBA: Franciscan Healthcare at Belle Square
232 3rd Street North Suite 100
La Crosse, WI, 54601

Available Services

  • Outpatient Clinics (Outpatient )

Mayo Clinic Health System - Franciscan Medical Center, Inc.
DBA: Franciscan Healthcare - Sparta Eye Clinic
400 Jefferson Ave.
Sparta, WI, 54656

Available Services

  • Outpatient Clinics (Outpatient )

Mayo Clinic Health System - Franciscan Medical Center, Inc.
DBA: Franciscan Healthcare - La Crosse
700 West Avenue, South
La Crosse, WI, 54601-4783

Available Services

  • Brachytherapy (Imaging/Diagnostic Services )
  • Cardiac Catheterization Lab (Surgical Services )
  • CT Scanner (Imaging/Diagnostic Services )
  • Dialysis Unit (Inpatient )
  • Ear/Nose/Throat Surgery (Surgical Services )
  • 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 )
  • 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 )
  • Nuclear Pharmacy (Inpatient )
  • Ophthalmology (Surgical Services )
  • Orthopedic Surgery (Surgical Services )
  • 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 )
  • Sleep Laboratory (Sleep Laboratory )
  • Sterile Medication Compounding (Inpatient )
  • Surgical Unit (Inpatient )
  • Teleradiology (Imaging/Diagnostic Services )
  • Thoracic Surgery (Surgical Services )
  • Trauma Center (Trauma Center )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Primary Stroke Center

Mayo Clinic Health System - Franciscan Medical Center, Inc.
DBA: Franciscan Healthcare - Prairie Du Chien
800 East Blackhawk Avenue
Prairie Du Chien, WI, 53821-1698

Available Services

  • Behavioral Health (Non 24 Hour Care - Adult )
  • Behavioral Health (Non 24 Hour Care - Child/Youth )
  • Chemical Dependency (Non 24 Hour Care - Adult )
  • Chemical Dependency (Non 24 Hour Care - Child/Youth )
  • Chemical Dependency (Non-detox - Adult )
  • Community Integration (Non 24 Hour Care )
  • Outpatient Clinics (Outpatient )

Mayo Clinic Health System - Franciscan Medical Center, Inc.
DBA: Franciscan Healthcare - La Crosse
615 South 10th Street
La Crosse, WI, 54601-4783

Available Services

  • Addiction Services
  • Addiction Services (Non-detox - Adult )
  • Behavioral Health (Non 24 Hour Care - Adult )
  • Behavioral Health (Non 24 Hour Care - Child/Youth )
  • 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 )
  • Peer Support (Non 24 Hour Care )

Mayo Clinic Health System - Franciscan Medical Center, Inc.
DBA: Franciscan Healthcare - La Crosse
800 West Avenue South
La Crosse, WI, 54601-4783

Available Services

  • Behavioral Health (Non 24 Hour Care - Adult )
  • Behavioral Health (Non 24 Hour Care - Child/Youth )
  • Community Integration (Non 24 Hour Care )
  • Outpatient Clinics (Outpatient )

Special Quality Awards

   Due to our commitment to accurate data reporting, The Joint Commission is suspending the practice of updating Special Quality Awards until
  further notice
  • 2014 ACS National Surgical Quality Improvement Program

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 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.

Behavioral Health Care and Human Services 2018 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Hospital 2021 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Home Care 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
Reporting Period: April 2020 - March 2021
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

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