Quality Report


Quality Report

University of Wisconsin Hospitals and Clinics Authority
HCO ID: 7656
600 Highland Avenue
Madison, WI, 53792
(608) 262-0098
www.uwhealth.org
Summary of Quality Information

Accreditation Programs

Gold Seal
Home Care
Accreditation Decision
Effective Date
10/7/2017
Last Full Survey Date
10/6/2017
Last On-Site Survey Date
11/17/2017
Gold Seal
Hospital
Accreditation Decision
Effective Date
12/21/2017
Last Full Survey Date
10/6/2017
Last On-Site Survey Date
12/21/2017
Gold Seal
Laboratory
Accreditation Decision
Effective Date
10/25/2019
Last Full Survey Date
10/24/2019
Last On-Site Survey Date
10/24/2019

Advanced Certification Programs

Gold Seal
Certification Decision
Effective Date
9/26/2018
Last Full Survey Date
5/12/2021
Last On-Site Survey Date
5/12/2021
Gold Seal
Certification Decision
Effective Date
4/7/2018
Last Full Survey Date
4/6/2018
Last On-Site Survey Date
4/6/2018
Gold Seal
Certification Decision
Effective Date
7/25/2018
Last Full Survey Date
7/24/2018
Last On-Site Survey Date
7/24/2018

Sites

University of Wisconsin Hospitals and Clinics Authority
DBA: UW Health University Station Clinics
2880 University Avenue
Madison, WI, 53705

Available Services

  • Administration of High Risk Medications (Outpatient )
  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

University of Wisconsin Hospitals and Clinics Authority
DBA: UW Health East Clinic
5249 East Terrace Drive
Madison, WI, 53718

Available Services

  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

University of Wisconsin Hospitals and Clinics Authority
DBA: UW Health Research Park
621 Science Drive
Madison, WI, 53711

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Canes and Crutches
  • Custom Orthoses Fabricated
  • Durable Medical Equipment
  • General Laboratory Tests
  • Heat/Cold Applications
  • Neuromuscular Electrical Stimulators
  • Off The Shelf Orthoses
  • Orthoses Prefabricated - Custom fitted
  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )
  • Supplies
  • Surgical Dressings
  • Tens Units

University of Wisconsin Hospitals and Clinics Authority
DBA: UW Health Oakwood Clinic
6209 Mineral Point Road
Madison, WI, 53705

Available Services

  • Single Specialty Practitioner (Outpatient )

University of Wisconsin Hospitals and Clinics Authority
DBA: UW Health Waisman Center
1500 Highland Avenue
Madison, WI, 53705

Available Services

  • Outpatient Clinics (Outpatient )

University of Wisconsin Hospitals and Clinics Authority
DBA: University of Wisconsin Hospital and Clinics
600 Highland Avenue
Madison, WI, 53792-8350

Available Services

  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult )
  • Brachytherapy (Imaging/Diagnostic Services )
  • Burn Unit (Inpatient )
  • Cardiac Catheterization Lab (Surgical Services )
  • Cardiac Surgery (Surgical Services )
  • Cardiothoracic Surgery (Surgical Services )
  • Cardiovascular Unit (Inpatient )
  • Coronary Care Unit (Inpatient )
  • CT Scanner (Imaging/Diagnostic Services )
  • Dialysis Unit (Inpatient )
  • 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 )
  • Hematology/Oncology Unit (Inpatient )
  • Inpatient Unit (Inpatient )
  • Interventional Radiology (Imaging/Diagnostic Services )
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services )
  • Medical /Surgical Unit (Inpatient )
  • Medical ICU (Intensive Care Unit )
  • Neuro/Spine ICU (Intensive Care Unit )
  • Neuro/Spine Unit (Inpatient )
  • Neurosurgery (Surgical Services )
  • Non-Sterile Medication Compounding (Inpatient )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Nuclear Pharmacy (Inpatient )
  • Ophthalmology (Surgical Services )
  • Orthopedic Surgery (Surgical Services )
  • Orthopedic/Spine Unit (Inpatient )
  • Outpatient Clinics (Outpatient )
  • 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 )
  • Sterile Medication Compounding (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Surgical Unit (Inpatient )
  • Teleradiology (Imaging/Diagnostic Services )
  • Thoracic Surgery (Surgical Services )
  • Toxicology
  • Transplant Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Advanced Comprehensive Stroke Center
  • Inpatient Diabetes
  • Ventricular Assist Device

University of Wisconsin Hospitals and Clinics Authority
DBA: UW Health West Clinic
451 Junction Road
Madison, WI, 53717

Available Services

  • Administration of High Risk Medications (Outpatient )
  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

University of Wisconsin Hospitals and Clinics Authority
DBA: UW Health Rehabilitation Clinics
6630 University Ave.
Middleton, WI, 53562

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Canes and Crutches
  • Custom Orthoses Fabricated
  • Diabetic Footwear and Inserts
  • Diabetic Shoes and Inserts-custom
  • Durable Medical Equipment
  • General Laboratory Tests
  • Off The Shelf Orthoses
  • Orthoses Prefabricated - Custom fitted
  • Perform Invasive Procedure (Outpatient )
  • Single Specialty Practitioner (Outpatient )
  • Supplies
  • Surgical Dressings
  • Tens Units
  • Walkers, Canes and Crutches

University of Wisconsin Hospitals and Clinics Authority
DBA: UW Health Kidney Clinic
3034 Fish Hatchery Rd.
Madison, WI, 53713

Available Services

  • General Laboratory Tests
  • Single Specialty Practitioner (Outpatient )

University of Wisconsin Hospitals and Clinics Authority
DBA: UW Health Adolescent Alcohol/Drug Assessment Intervention
122 E. Olin Ave., Suite 275
Madison, WI, 53713

Available Services

  • Single Specialty Practitioner (Outpatient )

University of Wisconsin Hospitals and Clinics Authority
DBA: UW Health Orthotics and Prosthetics
6220 University Avenue
Madison, WI, 53705

Available Services

  • Custom Orthoses Fabricated
  • Diabetic Footwear and Inserts
  • Diabetic Shoes and Inserts-custom
  • Durable Medical Equipment
  • Limb Prostheses
  • Neuromuscular Electrical Stimulators
  • Off The Shelf Orthoses
  • Orthoses Prefabricated - Custom fitted
  • Prosthetics (Home Medical Equipment)
  • Supplies

University of Wisconsin Hospitals and Clinics Authority
DBA: UW Health Pharmacy Services
600 Highland Avenue, Room E5/230
Madison, WI, 53792-8350

Available Services

  • Blood Glucose Monitors (non-mail order)
  • Durable Medical Equipment
  • Nebulizers Equipment
  • Respiratory Equipment

University of Wisconsin Hospitals and Clinics Authority
DBA: UW Health Pharmacy Services
600 Highland Ave, Room 1338, Mail C-150
Madison, WI, 53792-8350

Available Services

  • Blood Glucose Monitors (non-mail order)
  • Durable Medical Equipment
  • Nebulizers Equipment
  • Respiratory Equipment

University of Wisconsin Hospitals and Clinics Authority
DBA: UW Health UH Rehab DME
600 Highland Avenue
Madison, WI, 53792

Available Services

  • Canes and Crutches
  • Custom Orthoses Fabricated
  • Durable Medical Equipment
  • Heat/Cold Applications
  • Neuromuscular Electrical Stimulators
  • Off The Shelf Orthoses
  • Orthoses Prefabricated - Custom fitted
  • Supplies
  • Surgical Dressings
  • Tens Units

University of Wisconsin Hospitals and Clinics Authority
DBA: UW Health Hand and Upper Extremity Rehabilitation Clinic
1 S. Park Street, Suite H1012
Madison, WI, 53715

Available Services

  • Custom Orthoses Fabricated
  • Durable Medical Equipment
  • Neuromuscular Electrical Stimulators
  • Off The Shelf Orthoses
  • Orthoses Prefabricated - Custom fitted
  • Single Specialty Practitioner (Outpatient )
  • Supplies
  • Surgical Dressings

University of Wisconsin Hospitals and Clinics Authority
DBA: UW Health Yahara Rehab Clinic
1050 East Broadway
Monona, WI, 53716

Available Services

  • Canes and Crutches
  • Custom Orthoses Fabricated
  • Durable Medical Equipment
  • Neuromuscular Electrical Stimulators
  • Off The Shelf Orthoses
  • Orthoses Prefabricated - Custom fitted
  • Single Specialty Practitioner (Outpatient )
  • Supplies
  • Surgical Dressings
  • Tens Units
  • Walkers, Canes and Crutches

University of Wisconsin Hospitals and Clinics Authority
DBA: UW Health Pharmacy Services
5249 E Terrace Dr
Madison, WI, 53718

Available Services

  • Blood Glucose Monitors (non-mail order)
  • Durable Medical Equipment
  • Nebulizers Equipment
  • Respiratory Equipment

University of Wisconsin Hospitals and Clinics Authority
DBA: UW Health Pharmacy Services
451 Junction Rd Ste 9901 Rm 1191
Madison, WI, 53717

Available Services

  • Blood Glucose Monitors (non-mail order)
  • Durable Medical Equipment
  • Nebulizers Equipment
  • Pharmacy/Dispensary,General Services
  • Respiratory Equipment
  • Specialty Pharmacy

University of Wisconsin Hospitals and Clinics Authority
DBA: UW Health Digestive Health Center
750 University Row
Madison, WI, 53705

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Anesthesia (Outpatient )
  • General Laboratory Tests
  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

University of Wisconsin Hospitals and Clinics Authority
DBA: UW Health at The American Center
4602 Eastpark Boulevard
Madison, WI, 53718

Available Services

  • CT Scanner (Imaging/Diagnostic Services )
  • Dialysis Unit (Inpatient )
  • EEG/EKG/EMG Lab (Imaging/Diagnostic Services )
  • Gastroenterology (Surgical Services )
  • General Laboratory Tests
  • GI or Endoscopy Lab (Imaging/Diagnostic Services )
  • Hazardous Medication Compounding (Inpatient )
  • Inpatient Unit (Inpatient )
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services )
  • Medical /Surgical Unit (Inpatient )
  • Neuro/Spine Unit (Inpatient )
  • Neurosurgery (Surgical Services )
  • Non-Sterile Medication Compounding (Inpatient )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Orthopedic Surgery (Surgical Services )
  • Orthopedic/Spine Unit (Inpatient )
  • Outpatient Clinics (Outpatient )
  • Plastic Surgery (Surgical Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Sterile Medication Compounding (Inpatient )
  • Teleradiology (Imaging/Diagnostic Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )

University of Wisconsin Hospitals and Clinics Authority
DBA: UW Health at The American Center
4602 Eastpark Blvd, Room 1301
Madison, WI, 53718

Available Services

  • Blood Glucose Monitors (non-mail order)
  • Durable Medical Equipment
  • Nebulizers Equipment
  • Respiratory Equipment

University of Wisconsin Hospitals and Clinics Authority
DBA: UW Health at The American Center
4602 Eastpark Blvd, Room 2520
Madison, WI, 53718

Available Services

  • Canes and Crutches
  • Custom Orthoses Fabricated
  • Diabetic Footwear and Inserts
  • Diabetic Shoes and Inserts-custom
  • Durable Medical Equipment
  • Heat/Cold Applications
  • Neuromuscular Electrical Stimulators
  • Off The Shelf Orthoses
  • Orthoses Prefabricated - Custom fitted
  • Supplies
  • Surgical Dressings
  • Tens Units
  • Walkers, Canes and Crutches

University of Wisconsin Hospitals and Clinics Authority
DBA: UW Health Union Corners Physical Therapy
2502 Winnebago Street
Madison, WI, 53705

Available Services

  • Single Specialty Practitioner (Outpatient )

University of Wisconsin Hospitals and Clinics Authority
DBA: UW Health Pain Management Clinic
1102 S. Park Street, 3rd Floor
Madison, WI, 53715

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Perform Invasive Procedure (Outpatient )
  • Single Specialty Practitioner (Outpatient )

University of Wisconsin Hospitals and Clinics Authority
DBA: UW Health Pharmacy Services
3185 Deming Way
Middleton, WI, 53562-1435

Available Services

  • Blood Glucose Monitors (non-mail order)
  • Durable Medical Equipment
  • Nebulizers Equipment
  • Pharmacy/Dispensary,General Services
  • Respiratory Equipment
  • Specialty Pharmacy

University of Wisconsin Hospitals and Clinics Authority
DBA: UW Health Advanced Pelvic Surgery Clinic
202 South Park Street
Madison, WI, 53715

Available Services

  • General Laboratory Tests
  • Perform Invasive Procedure (Outpatient )
  • Single Specialty Practitioner (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
  • 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program
  • 2014 Magnet Award
  • 2012 Silver - The Medal of Honor for Organ Donation
  • 2010 Silver - The Medal of Honor for Organ Donation

Organization Commentary

Mr. Ric Ransom, VP/President, UW Hospitals, Madison Region

The University of Wisconsin Hospitals and Clinics reviews our National Quality Improvement Goal data. We identify opportunities for improvement and implement initiatives to address these areas.

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.

Home Care 2016 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Hospital 2018 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Laboratory 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

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.