Mercy Health System Corporation

Doing business as Mercy Health System Corp

Hospital in Janesville, WI, Medicare certification number 520066. CMS publishes 63 quality measures for it.

Medicare certification

Provider of Services

CCN: 520066The number CMS certifies the facility under, not a provider identifier
Status: Active
Provider type: Hospital – Short-term
Listed by Care Compare as: Acute Care Hospitals
Ownership: Voluntary non-profit - Private
Control type: Private (not for profit)
Participating since: Jul 1, 1966
Last certification: Jul 24, 2021
Beds: 240
Overall star rating: 3 of 5Care Compare
Address: 1000 Mineral Point Ave
Janesville, WI 53548
(608) 756-6080

NPI records for this facility (CCN to NPI Mapping) 1

Mercy Health System Corporation

dba Mercy Hospital Janesville
- General Acute Care Hospital
- Janesville, WI
- NPI 1093768962
Medicare enrollment

Patient survey (HCAHPS) 9

Medicare Care Compare

Cleanliness - star rating Better4 of 5
- State average 4.01 (computed here)
- National average 3.44 (computed here)
- Period from 10/01/2024
Communication about medicines - star rating Better3 of 5
- State average 3.58 (computed here)
- National average 2.71 (computed here)
- Period from 10/01/2024
Discharge information - star rating Worse3 of 5
- State average 4.14 (computed here)
- National average 3.31 (computed here)
- Period from 10/01/2024
Doctor communication - star rating Better4 of 5
- State average 3.68 (computed here)
- National average 3.12 (computed here)
- Period from 10/01/2024
Nurse communication - star rating Better4 of 5
- State average 4.22 (computed here)
- National average 3.43 (computed here)
- Period from 10/01/2024
Overall hospital rating - star rating Worse3 of 5
- State average 3.88 (computed here)
- National average 3.29 (computed here)
- Period from 10/01/2024
Quietness - star rating Worse3 of 5
- State average 3.95 (computed here)
- National average 3.27 (computed here)
- Period from 10/01/2024
Recommend hospital - star rating Worse3 of 5
- State average 4.14 (computed here)
- National average 3.64 (computed here)
- Period from 10/01/2024
Summary star rating Worse3 of 5
- State average 4.04 (computed here)
- National average 3.27 (computed here)
- Period from 10/01/2024

Affiliated providers 475

Page 1 of 19Medicare Care Compare

Clinicians who list this facility as a hospital or facility affiliation in Care Compare.

Marwan M. Abdulsattar, MD
- Anesthesiology Physician
- Janesville, WI
- NPI 1265790695
Anju Agarwal, DO
- Hospitalist Physician
- Winfield, IL
- NPI 1952335671
Anil Aggarwal, M.D.
- Anesthesiology Physician
- Menomonee Falls, WI
- NPI 1164405288
Umber Ahmad, DO
- Rheumatology Physician
- McHenry, IL
- NPI 1083957153
Ammar Ahmed, M.D.
- Emergency Medicine Physician
- Peoria, IL
- NPI 1336526524
Imdad Ahmed, MD
- Cardiovascular Disease Physician
- Janesville, WI
- NPI 1053536219
Yousuf A Ahmed, MD
- Infectious Disease Physician
- Kansas City, KS
- NPI 1609286590
Muhammad Javaid Akbar, MD
- Hospitalist Physician
- Madison, WI
- NPI 1720096753
Qusai Taher Alitter, M.D.
- Pulmonary Disease Physician
- Peru, IL
- NPI 1093169419
Muhammad B Alkhan, MD
- Internal Medicine Physician
- Janesville, WI
- NPI 1114950813
Giuseppe A Altamore, DO
- Emergency Medicine Physician
- Janesville, WI
- NPI 1477828564
Michael M Altaweel, MD
- Ophthalmology Physician
- Madison, WI
- NPI 1700853876
Arthur Mark Altbuch, M.D.
- Geriatric Medicine (Family Medicine) Physician
- Janesville, WI
- NPI 1821021429
Nelly Y Amador, M.D., PMD
- Emergency Medicine Physician
- Boscobel, WI
- NPI 1336119064
Hiba Anaqrah, MD
- Emergency Medicine Physician
- Iowa City, IA
- NPI 1417516428
Jane E Anderson, MD
- Family Medicine Physician
- Janesville, WI
- NPI 1942220140
Sarah Anderson
- Physician Assistant
- Janesville, WI
- NPI 1194411751
Janine Elizabeth Andriusis, D.O.
- Emergency Medicine Physician
- Joliet, IL
- NPI 1356581037
Ehteshamul Haque Anjum, M.D.
- Nephrology Physician
- Janesville, WI
- NPI 1932229390
Scott B Armstrong, MD
- Obstetrics & Gynecology Physician
- Meridian, ID
- NPI 1205806965
Kristine K. Arndt, MD
- Internal Medicine Physician
- Janesville, WI
- NPI 1720442809
Mohammad B Ashraf, M.D.
- Pulmonary Disease Physician
- Auburn, NY
- NPI 1922238120
Alexandra Halleen Atkins, MD
- Emergency Medicine Physician
- Minneapolis, MN
- NPI 1942876792
David E Augustine, M.D.
- Family Medicine Physician
- Manitowoc, WI
- NPI 1619083185
Katherine Kristjanson Aulis, MD
- Emergency Medicine Physician
- Chicago, IL
- NPI 1558985861

Complications and deaths 18

Medicare Care Compare

Abdominopelvic accidental puncture or laceration rate As expected1.22
- State average 1.12 (computed here)
- National average 1.06
- No different than the national rate
- 382 patients
- Period from 07/01/2022
CMS Medicare PSI 90: Patient safety and adverse events composite As expected1.16
- State average 1.02 (computed here)
- National average 1
- No different than the national value
- Period from 07/01/2022
Death rate for CABG surgery patients As expected4.6
- State average 2.37 (computed here)
- National average 2.4
- No different than the national rate
- 42 patients
- Period from 07/01/2022
Death rate for COPD patients As expected8.9
- State average 8.59 (computed here)
- National average 8.6
- No different than the national rate
- 104 patients
- Period from 07/01/2022
Death rate for heart attack patients As expected13.3
- State average 11.65 (computed here)
- National average 11.9
- No different than the national rate
- 122 patients
- Period from 07/01/2022
Death rate for heart failure patients As expected9.2
- State average 12.02 (computed here)
- National average 11.1
- No different than the national rate
- 196 patients
- Period from 07/01/2022
Death rate for pneumonia patients As expected13.9
- State average 15.15 (computed here)
- National average 15.2
- No different than the national rate
- 146 patients
- Period from 07/01/2022
Death rate for stroke patients As expected12.7
- State average 11.76 (computed here)
- National average 11.9
- No different than the national rate
- 123 patients
- Period from 07/01/2023
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate As expected4.2
- State average 3.88 (computed here)
- National average 3.9
- No different than the national rate
- 1,482 patients
- Period from 07/01/2024
Iatrogenic pneumothorax rate As expected0.24
- State average 0.21 (computed here)
- National average 0.21
- No different than the national rate
- 2,826 patients
- Period from 07/01/2022
In-hospital fall-associated fracture rate As expected0.29
- State average 0.27 (computed here)
- National average 0.27
- No different than the national rate
- 2,935 patients
- Period from 07/01/2022
Perioperative pulmonary embolism or deep vein thrombosis rate As expected4.13
- State average 3.5 (computed here)
- National average 3.52
- No different than the national rate
- 651 patients
- Period from 07/01/2022
Postoperative acute kidney injury requiring dialysis rate As expected1.54
- State average 1.73 (computed here)
- National average 1.67
- No different than the national rate
- 239 patients
- Period from 07/01/2022
Postoperative hemorrhage or hematoma rate As expected3.63
- State average 2.45 (computed here)
- National average 2.34
- No different than the national rate
- 629 patients
- Period from 07/01/2022
Postoperative respiratory failure rate As expected10.95
- State average 8.39 (computed here)
- National average 9.42
- No different than the national rate
- 242 patients
- Period from 07/01/2022
Postoperative sepsis rate As expected7.04
- State average 4.94 (computed here)
- National average 5.27
- No different than the national rate
- 239 patients
- Period from 07/01/2022
Postoperative wound dehiscence rate As expected2.02
- State average 1.81 (computed here)
- National average 1.77
- No different than the national rate
- 94 patients
- Period from 07/01/2022
Pressure ulcer rate As expected0.63
- State average 0.76 (computed here)
- National average 0.63
- No different than the national rate
- 2,525 patients
- Period from 07/01/2022

Measures CMS does not publish for this facility (2)

Death rate among surgical inpatients with serious treatable complications — 1
Rate of complications for hip/knee replacement patients — 1

Infections 5

Medicare Care Compare

Catheter Associated Urinary Tract Infections (ICU + select Wards) As expected0.22
- State average 0.54
- National average 1
- No different than national benchmark
- Period from 10/01/2024
Central Line Associated Bloodstream Infection (ICU + select Wards) Better0.17
- State average 0.54
- National average 1
- Better than the national benchmark
- Period from 10/01/2024
Clostridium Difficile (C.Diff) Better0.21
- State average 0.53
- National average 1
- Better than the national benchmark
- Period from 10/01/2024
MRSA Bacteremia As expected0.58
- State average 0.58
- National average 1
- No different than national benchmark
- Period from 10/01/2024
SSI - Colon Surgery As expected0.54
- State average 0.98
- National average 1
- No different than national benchmark
- Period from 10/01/2024

Measures CMS does not publish for this facility (1)

SSI - Abdominal Hysterectomy — 13

Outpatient imaging 2

Medicare Care Compare

Abdomen CT Use of Contrast Material 0.9
- State average 4.55 (computed here)
- National average 5.83 (computed here)
- Period from 07/01/2024
Breast Cancer Screening Recall Rates 3.6
- State average 5.62 (computed here)
- National average 8.08 (computed here)
- Period from 07/01/2024

Spending per patient 1

Medicare Care Compare

Medicare hospital spending per patient (Medicare Spending per Beneficiary) 0.92
- State average 0.9
- National average 0.99 (computed here)
- Period from 01/01/2024

Timely and effective care 16

Medicare Care Compare

Antithrombotic Therapy by End of Hospital Day 2 93
- State average 96.09 (computed here)
- National average 92.79 (computed here)
- 85 patients
- Period from 01/01/2024
Appropriate care for severe sepsis and septic shock 61
- State average 72
- National average 65
- 255 patients
- Period from 10/01/2024
Average (median) time all patients spent in the emergency department before leaving from the visit, including psychiatric/mental health patients and patients who were transferred to another facility. A lower number of minutes is better 167
- State average 144
- National average 168
- 390 patients
- Period from 10/01/2024
Average (median) time patients spent in the emergency department before leaving from the visit, excluding patients transferred to another facility or psychiatric care/mental health patients. A lower number of minutes is better 161
- State average 137
- National average 162
- 361 patients
- Period from 10/01/2024
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better 305
- State average 203
- National average 257
- 23 patients
- Period from 10/01/2024
Discharged on Antithrombotic Therapy 96
- State average 98.07 (computed here)
- National average 96.1 (computed here)
- 104 patients
- Period from 01/01/2024
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients 100
- State average 97
- National average 93
- 84 patients
- Period from 01/01/2024
Head CT results 52
- State average 74
- National average 69
- 21 patients
- Period from 10/01/2024
Healthcare workers given influenza vaccination 66
- State average 85
- National average 78
- 2,256 patients
- Period from 10/01/2024
Left before being seen 3
- State average 2
- National average 2
- 31,924 patients
- Period from 01/01/2024
Safe Use of Opioids - Concurrent Prescribing 16
- State average 14
- National average 15
- 1,438 patients
- Period from 01/01/2024
Septic Shock 3-Hour Bundle 72
- State average 77
- National average 73
- 113 patients
- Period from 10/01/2024
Septic Shock 6-Hour Bundle 73
- State average 88
- National average 87
- 67 patients
- Period from 10/01/2024
Severe Sepsis 3-Hour Bundle 86
- State average 85
- National average 81
- 256 patients
- Period from 10/01/2024
Severe Sepsis 6-Hour Bundle 93
- State average 94
- National average 93
- 153 patients
- Period from 10/01/2024
ST-Segment Elevation Myocardial Infarction (STEMI) 65
- State average 37.33 (computed here)
- National average 46.51 (computed here)
- 46 patients
- Period from 01/01/2024

Measures CMS does not publish for this facility (14)

Anticoagulation Therapy for Atrial Fibrillation/Flutter — 1
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better — 1
Emergency department volume — medium
Global Malnutrition Composite Score — 5
Global Malnutrition Composite Score: Malnutrition Diagnosis Documented — 5
Global Malnutrition Composite Score: Malnutrition Risk Screening — 5
Global Malnutrition Composite Score: Nutrition Assessment — 5
Global Malnutrition Composite Score: Nutritional Care Plan — 5
Hospital Harm - Opioid Related Adverse Events — 5
Hospital Harm - Severe Hyperglycemia — 5
Hospital Harm - Severe Hypoglycemia — 5
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery — 5
Intensive Care Unit Venous Thromboembolism Prophylaxis — 5
Venous Thromboembolism Prophylaxis — 5

Unplanned visits 12

Medicare Care Compare

Acute Myocardial Infarction (AMI) 30-Day Readmission Rate As expected14.5
- State average 14.09 (computed here)
- National average 14.4
- No different than the national rate
- 167 patients
- Period from 07/01/2023
Heart failure (HF) 30-Day Readmission Rate As expected20.3
- State average 21.16 (computed here)
- National average 21.3
- No different than the national rate
- 280 patients
- Period from 07/01/2023
Hospital return days for heart attack patients 86.9
- State average 9.95 (computed here)
- National average 6.71 (computed here)
- More days than average per 100 discharges
- 119 patients
- Period from 07/01/2022
Hospital return days for heart failure patients 27.4
- State average -5.03 (computed here)
- National average 4.02 (computed here)
- Average days per 100 discharges
- 216 patients
- Period from 07/01/2022
Hospital return days for pneumonia patients 2.4
- State average -3.39 (computed here)
- National average 5.65 (computed here)
- Average days per 100 discharges
- 150 patients
- Period from 07/01/2022
Pneumonia (PN) 30-Day Readmission Rate As expected17.2
- State average 17.04 (computed here)
- National average 17.3
- No different than the national rate
- 250 patients
- Period from 07/01/2023
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy As expected6.1
- State average 5.66 (computed here)
- National average 5.4
- No different than the national rate
- 181 patients
- Period from 01/01/2024
Rate of inpatient admissions for patients receiving outpatient chemotherapy As expected10.6
- State average 10.67 (computed here)
- National average 10.7
- No different than the national rate
- 181 patients
- Period from 01/01/2024
Rate of readmission for CABG As expected10
- State average 10.61 (computed here)
- National average 11
- No different than the national rate
- 60 patients
- Period from 07/01/2023
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients As expected20.6
- State average 19.79 (computed here)
- National average 20
- No different than the national rate
- 195 patients
- Period from 07/01/2023
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies) As expected13.5
- State average 13.21 (computed here)
- National average 13
- No different than the national rate
- 1,404 patients
- Period from 01/01/2022
Ratio of unplanned hospital visits after hospital outpatient surgery As expected1
- State average 1.03 (computed here)
- National average 1.01 (computed here)
- No different than expected
- 394 patients
- Period from 01/01/2024

Measures CMS does not publish for this facility (2)

Hybrid Hospital-Wide All-Cause Readmission Measure (HWR) — 4
Rate of readmission after hip/knee replacement — 1

Other hospitals in Janesville, WI

SSM Health St Mary's Hospital - Janesville

Sources for this page

Provider of Services: the certification, provider type, beds and status.
Medicare Care Compare: the star rating and every measure on this page, with the state and national rates CMS publishes beside them, and the clinicians who list this facility as an affiliation.
NPPES NPI Registry: the NPI records connected to this certification and the names of the providers listed above.

Better and worse are CMS's own comparison with the national rate, not ours: for most measures a low score is the good one (deaths, infections) and for others a high one is, so measures where CMS states no comparison are left uncoloured. The exception is star ratings, which are read against the national average here. Quality measures are published by CMS and are not adjusted or re-scored here. Averages marked “computed here” are the mean of every facility reporting that measure, worked out by NPIMap because CMS publishes no comparison for it. Confirm anything you rely on at Medicare Care Compare.