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Gundersen St. Joseph's Hospital and Clinics

PO Box 527, 400 Water Avenue
Hillsboro, Wisconsin, 54634
608-489-8000
http://www.gundersenhealth.org/st-josephs/

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Generated: Friday, August 29, 2025
This hospital does not provide Birth Services
Measure Hospital Result State Average State Benchmark National Average Report Period
Hip and Knee Surgery Complications 3.294 2.66 3.6 7/1/2021-6/30/2024
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Measure Hospital Result State Average State Benchmark National Average Report Period
Catheter-Associated Urinary Tract Infections 0.61 0 1 1/1/2024-12/31/2024
Central Line Associated Blood Stream Infections IP 0.53 0 1 1/1/2024-12/31/2024
Clostridioides difficile Infections 0.57 0 1 1/1/2024-12/31/2024
Methicillin-Resistant Staph. aureus Infections 0.44 0 1 1/1/2024-12/31/2024
Surgical Site Infection - Abdominal Hysterectomy NA 1.66 0 1 1/1/2024-12/31/2024
Surgical Site Infection - Colon Surgery NA 0.91 0 1 1/1/2024-12/31/2024
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Measure Hospital Result State Average State Benchmark National Average Report Period
Acute Stroke 5.197 0 6.83 4/1/2024-3/31/2025
Chronic Obstructive Pulmonary Disease 8.882 7.3 8.8 7/1/2021-6/30/2024
GastrointestinaI Hemorrhage 1.31 0 2.54 4/1/2024-3/31/2025
Heart Attack 11.898 10.64 12.2 7/1/2021-6/30/2024
Heart Failure 12.329 9.7 11.6 7/1/2021-6/30/2024
Hip Fracture 1.559 0 1.95 4/1/2024-3/31/2025
Pneumonia 15.989 13.03 16.2 7/1/2021-6/30/2024
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This hospital does not provide Mortality - Procedures Services
Measure Hospital Result State Average State Benchmark National Average Report Period
Always Quiet at Night 66 78 62 10/1/2023-9/30/2024
Definitely Recommend Hospital 74 87 70 10/1/2023-9/30/2024
Doctors Always Communicated Well 82 89 80 10/1/2023-9/30/2024
Nurses Always Communicated Well 83 91 80 10/1/2023-9/30/2024
Patient Rated Hospital High 76 87 72 10/1/2023-9/30/2024
Patients Always Received Requested Help 71 83 66 10/1/2023-9/30/2024
Patients Understood Their Care When They Left 55 64 52 10/1/2023-9/30/2024
Room Always Clean 77 87 74 10/1/2023-9/30/2024
Staff Always Explained Medications 65 74 62 10/1/2023-9/30/2024
Staff Provided Discharge Instructions 90 93 86 10/1/2023-9/30/2024
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Measure Hospital Result State Average State Benchmark National Average Report Period
Healthcare Personnel Influenza Immunization 84.566 79.62 94.09 --- 10/1/2024-5/15/2025
In Hospital Fall Associated Fracture Rate 0 0.041 0 0.03 4/1/2024-3/31/2025
Pneumothorax 0 0.011 0 0.02 4/1/2024-3/31/2025
Pressure Ulcers 0 0.027 0 0.07 4/1/2024-3/31/2025
Sepsis-1 70 71 63 10/1/2023-9/30/2024
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Measure Hospital Result State Average State Benchmark National Average Report Period
Perioperative Blood Clot 0.163 0 0.31 4/1/2024-3/31/2025
Perioperative Hemorrhage 0.165 0 0.23 4/1/2024-3/31/2025
Postoperative Respiratory Failure 0.299 0 0.73 4/1/2024-3/31/2025
Postoperative Sepsis 0.178 0 0.42 4/1/2024-3/31/2025
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This hospital does not provide Perinatal Services
Measure Hospital Result State Average State Benchmark National Average Report Period
All Cause Unplanned Readmissions 4.1 9.65 7 --- 1/1/2024-12/31/2024
Chronic Obstructive Pulmonary Disease 17.911 17.3 18.2 7/1/2021-6/30/2024
Coronary Artery Bypass Graft DNR 10.483 9.22 10.6 7/1/2021-6/30/2024
Heart Attack 13.484 12.52 13.6 7/1/2021-6/30/2024
Heart Failure 19.339 18.01 19.7 7/1/2021-6/30/2024
Hip and Knee Surgery 4.722 3.9 4.8 7/1/2021-6/30/2024
Pneumonia 15.778 14.62 16 7/1/2021-6/30/2024
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