Quality Report


Quality Report

Mayo Clinic Health System-Southeast Minnesota Region

DBA: Mayo Clinic Health System-Albert Lea and Austin
HCO ID: 8109
404 West Fountain Street
Albert Lea, MN, 56007
(507) 373-2384
www.mayoclinichealthsystem.org
Summary of Quality Information

Accreditation Programs

View Accreditation History
Gold Seal
Home Care
Accreditation Decision
Effective Date
9/1/2022
Last Full Survey Date
8/31/2022
Last On-Site Survey Date
8/31/2022
Gold Seal
Hospital
Accreditation Decision
Effective Date
9/3/2022
Last Full Survey Date
9/2/2022
Last On-Site Survey Date
10/13/2022

Sites

Mayo Clinic Health System-Southeast Minnesota Region
DBA: Fountain Centers-A Mayo Clinic Health System Program for Sub
404 West Fountain Street
Albert Lea, MN, 56007

Available Services

  • Chemical Dependency (Day Programs - Adult )
  • Chemical Dependency (Day Programs - Child/Youth )
  • Chemical Dependency (Non 24 Hour Care - Adult )
  • Chemical Dependency (Non 24 Hour Care - Child/Youth )
  • Chemical Dependency (Residential Care - Adult )
  • Chemical Dependency (Partial Hospitalization - Adult )
  • Chemical Dependency (Partial Hospitalization - Child/Youth )
  • Chemical Dependency (Non-detox - Adult )

Other Clinics/Practices Located at This Site:

  • Mayo Clinic Connected Care (telehealth)

Mayo Clinic Health System-Southeast Minnesota Region
DBA: Mayo Clinic Health System-Albert Lea and Austin
2708 Bridge Avenue
Albert Lea, MN, 56007

Available Services

  • Outpatient Clinics (Outpatient )

Mayo Clinic Health System-Southeast Minnesota Region
DBA: Mayo Clinic Health System-Albert Lea and Austin
1307 18th Ave NW, Austin, MN 55912
Austin, MN, 55912

Available Services

  • Outpatient Clinics (Outpatient )

Mayo Clinic Health System-Southeast Minnesota Region
DBA: Mayo Clinic Health System-Albert Lea and Austin
404 West Fountain Street
Albert Lea, MN, 56007

Available Services

  • Behavioral Health (Non 24 Hour Care - Adult )
  • Behavioral Health (Non 24 Hour Care - Child/Youth )
  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult )
  • CT Scanner (Imaging/Diagnostic Services )
  • 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 )
  • Hazardous Medication Compounding (Inpatient )
  • Inpatient Unit (Inpatient )
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services )
  • Non-Sterile Medication Compounding (Inpatient )
  • Ophthalmology (Surgical Services )
  • Orthopedic Surgery (Surgical Services )
  • Outpatient Clinics (Outpatient )
  • Plastic Surgery (Surgical Services )
  • Sterile Medication Compounding (Inpatient )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )

Other Clinics/Practices Located at This Site:

  • Anticoagulation
  • Audiology
  • Cardiology
  • Connected Care
  • Dermatology
  • DSM Health Mobile Imaging
  • Ear, Nose & Throat
  • Endocrinology
  • Family Practice
  • General Surgery
  • Internal Medicine
  • Neurology
  • Obstetrics/Gynecological
  • Oncology (Medical)
  • Ophthalmology (Eye Clinic)
  • Orthopedic
  • Pediatrics
  • Physical Medicine & Rehab
  • Podiatry, Clinic
  • Psychiatry and Psychology (AKA Behavioral Health)
  • Pulmonology
  • Radiology
  • Respiratory Therapy
  • Sleep Medicine
  • Urgent Care
  • Urology
  • Wound Care

Mayo Clinic Health System-Southeast Minnesota Region
DBA: Mayo Clinic Health System-Albert Lea and Austin
1705 Southeast Broadway
Albert Lea, MN, 56007

Available Services

  • Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

  • HealthReach

Mayo Clinic Health System-Southeast Minnesota Region
DBA: Fountain Centers-A Mayo Clinic Health System Program for Sub
2200 NW 26th St
Owatonna, MN, 55060

Available Services

  • Chemical Dependency (Day Programs - Adult )
  • Chemical Dependency (Day Programs - Child/Youth )
  • Chemical Dependency (Non 24 Hour Care - Adult )
  • Chemical Dependency (Non 24 Hour Care - Child/Youth )
  • Chemical Dependency (Partial Hospitalization - Adult )
  • Chemical Dependency (Partial Hospitalization - Child/Youth )
  • Chemical Dependency (Non-detox - Adult )

Mayo Clinic Health System-Southeast Minnesota Region
DBA: Mayo Clinic Health System-Albert Lea and Austin
1000 1st Drive Northwest
Austin, MN, 55912

Available Services

  • Behavioral Health (Non 24 Hour Care - Adult )
  • Behavioral Health (Non 24 Hour Care - Child/Youth )
  • CT Scanner (Imaging/Diagnostic Services )
  • 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 )
  • Inpatient Unit (Inpatient )
  • Labor & Delivery (Inpatient )
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services )
  • Medical /Surgical Unit (Inpatient )
  • Medical ICU (Intensive Care Unit )
  • Non-Sterile Medication Compounding (Inpatient )
  • Normal Newborn Nursery (Inpatient )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Ophthalmology (Surgical Services )
  • Orthopedic Surgery (Surgical Services )
  • Outpatient Clinics (Outpatient )
  • Sleep Laboratory (Sleep Laboratory )
  • Sterile Medication Compounding (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )

Other Clinics/Practices Located at This Site:

  • Mayo Clinic Connected Care

Mayo Clinic Health System-Southeast Minnesota Region
DBA: Mayo Clinic Health System-Albert Lea and Austin
318 1st Street Southwest
New Richland, MN, 56072

Available Services

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

Mayo Clinic Health System-Southeast Minnesota Region
DBA: Mayo Clinic Health System-Albert Lea and Austin
301 South Broadway
Wells, MN, 56097

Available Services

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

Mayo Clinic Health System-Southeast Minnesota Region
DBA: Fountain Centers-A Mayo Clinic Health System Program for Sub
300 State Ave
Faribault, MN, 55021

Available Services

  • Chemical Dependency (Day Programs - Adult )
  • Chemical Dependency (Day Programs - Child/Youth )
  • Chemical Dependency (Non 24 Hour Care - Adult )
  • Chemical Dependency (Non 24 Hour Care - Child/Youth )
  • Chemical Dependency (Partial Hospitalization - Adult )
  • Chemical Dependency (Partial Hospitalization - Child/Youth )
  • Chemical Dependency (Non-detox - Adult )

Mayo Clinic Health System-Southeast Minnesota Region
DBA: Fountain Centers-A Mayo Clinic Health System Program for Sub
4122 18th Avenue Northwest
Rochester, MN, 55901

Available Services

  • Chemical Dependency (Day Programs - Adult )
  • Chemical Dependency (Day Programs - Child/Youth )
  • Chemical Dependency (Non 24 Hour Care - Adult )
  • Chemical Dependency (Non 24 Hour Care - Child/Youth )
  • Chemical Dependency (Partial Hospitalization - Adult )
  • Chemical Dependency (Partial Hospitalization - Child/Youth )
  • Chemical Dependency (Non-detox - Adult )

Mayo Clinic Health System-Southeast Minnesota Region
DBA: Fountain Centers-A Mayo Clinic Health System Program for Sub
1000 First Drive Northwest
Austin, MN, 55912

Available Services

  • Chemical Dependency (Day Programs - Adult )
  • Chemical Dependency (Day Programs - Child/Youth )
  • Chemical Dependency (Non 24 Hour Care - Adult )
  • Chemical Dependency (Non 24 Hour Care - Child/Youth )
  • Chemical Dependency (Partial Hospitalization - Adult )
  • Chemical Dependency (Partial Hospitalization - Child/Youth )
  • Chemical Dependency (Non-detox - Adult )

Mayo Clinic Health System-Southeast Minnesota Region
DBA: Fountain Centers-A Mayo Clinic Health System Program for Sub
828 North North Avenue
Fairmont, MN, 56031

Available Services

  • Chemical Dependency (Day Programs - Adult )
  • Chemical Dependency (Day Programs - Child/Youth )
  • Chemical Dependency (Non 24 Hour Care - Adult )
  • Chemical Dependency (Non 24 Hour Care - Child/Youth )
  • Chemical Dependency (Partial Hospitalization - Adult )
  • Chemical Dependency (Partial Hospitalization - Child/Youth )
  • Chemical Dependency (Non-detox - Adult )

Mayo Clinic Health System-Southeast Minnesota Region
DBA: Fountain Centers-A Mayo Clinic Health System Program for Sub
101 Martin Luther King Jr Dr
Mankato, MN, 56001

Available Services

  • Chemical Dependency (Day Programs - Adult )
  • Chemical Dependency (Day Programs - Child/Youth )
  • Chemical Dependency (Non 24 Hour Care - Adult )
  • Chemical Dependency (Non 24 Hour Care - Child/Youth )
  • Chemical Dependency (Partial Hospitalization - Adult )
  • Chemical Dependency (Partial Hospitalization - Child/Youth )
  • Chemical Dependency (Non-detox - Adult )

Other Clinics/Practices Located at This Site:

  • Mayo Clinic Health System-Southwest Minnesota Region

Organization Commentary

Dr. Sumit Bhagra, Physician Leader MCHS-Albert Lea & Austin

We would like to take the opportunity to address the Quality Report scores for Albert Lea Medical Center for Heart Failure Care. While we do aim to improve our scores for all measures reported, each of the measures did exceed the nationwide and statewide scores for the top 50% of JCAHO accredited organizations with the exception of one measure: Discharge Instructions. This measure includes six specific indicators and our score for each of these is as follows: Activity Level 100% Diet/Fluid 82% Medications 100% Follow-up with a Physician/NP/PA 100% Weight Monitoring 0% Symptoms Worsening 55% All of these must be documented in the patient medical record for the discharge instructions measure to be scored as complete. Although we believe that our providers and support staff provide education for our patients on the importance of monitoring their weight, documentation of this was not built into our documentation system. We have have created a patient teaching tool and redesigned our discharge education chart form to include this measure. We have completed our chart reviews for the first quarter of 2004 and found significant improvement with each of the six discharge instructions indicators at 100% except for weight monitoring which was 47%, up from 0%, and symptoms worsening at 87%, up from 55%.

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.