Quality Report


Quality Report

Stoughton Hospital
HCO ID: 7707
900 Ridge Street
Stoughton, WI, 53589
(608) 873-6611
stoughtonhospital.com
Summary of Quality Information

Accreditation Programs

Gold Seal
Critical Access Hospital
Accreditation Decision
Effective Date
2/10/2021
Last Full Survey Date
12/13/2019
Last On-Site Survey Date
2/9/2021

Sites

Oregon Rehabilitation & Sports Medicine/Urgent Care
990 Janesville Street
Oregon, WI, 53575

Available Services

  • Outpatient Clinics (Outpatient )

Stoughton Hospital Association
900 Ridge Street
Stoughton, WI, 53589

Available Services

  • Acute Care
  • CT Scanner (Imaging/Diagnostic Services )
  • Ear/Nose/Throat Surgery (Surgical Services )
  • Gastroenterology (Surgical Services )
  • Gynecological Surgery (Surgical Services )
  • Interventional Radiology (Outpatient )
  • Interventional Radiology (Imaging/Diagnostic Services )
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services )
  • Mammography (Imaging/Diagnostic Services )
  • Medical /Surgical Unit (Inpatient )
  • Medical ICU (Intensive Care Unit )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Ophthalmology (Surgical Services )
  • Orthopedic Surgery (Surgical Services )
  • Plastic Surgery (Surgical Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Psychiatric Unit
  • Sleep Laboratory (Sleep Laboratory )
  • Swing Beds
  • Teleradiology (Imaging/Diagnostic Services )
  • Trauma Center (Trauma Center )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )

Stoughton Wellness and Athletic Center
2300 Highway 51
Stoughton, WI, 53589

Available Services

  • Outpatient Clinics (Outpatient )

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.

Critical Access Hospital 2021 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na

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.