JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Church

Ascension All Saints Hospital

2 / 5

At a glance

Ascension All Saints Hospital carries a 2-star CMS overall rating — below the national norm. On healthcare-associated infection measures, it performs better than the national average on 6 and worse on 0.

Healthcare-Associated Infections

lower is better · 36 measures reported

Rates of infections patients can acquire while receiving care, such as central-line and catheter-associated infections, MRSA, and C. difficile.

MeasureScoreCompared to national
Central Line Associated Bloodstream Infection (ICU + select Wards): Lower Confidence Limit0.831Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit3.759Same as national
Central Line Associated Bloodstream Infection: Number of Device Days3851Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases3.684Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases7Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)1.900Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.099Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit1.956Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days3277Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases3.378Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases2Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.592Same as national
SSI - Colon Surgery: Lower Confidence LimitNot available
SSI - Colon Surgery: Upper Confidence LimitNot available
SSI - Colon Surgery: Number of Procedures34Not available
SSI - Colon Surgery: Predicted Cases0.944Not available
SSI - Colon Surgery: Observed Cases0Not available
SSI - Colon SurgeryNot available
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures72Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.588Not available
SSI - Abdominal Hysterectomy: Observed Cases1Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitSame as national
MRSA Bacteremia: Upper Confidence Limit1.668Same as national
MRSA Bacteremia: Patient Days31723Same as national
MRSA Bacteremia: Predicted Cases1.796Same as national
MRSA Bacteremia: Observed Cases0Same as national
MRSA Bacteremia0.000Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.101Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.765Better than national
Clostridium Difficile (C.Diff): Patient Days27622Better than national
Clostridium Difficile (C.Diff): Predicted Cases12.615Better than national
Clostridium Difficile (C.Diff): Observed Cases4Better than national
Clostridium Difficile (C.Diff)0.317Better than national

Complications & Deaths

lower is better · 20 measures reported

Rates of serious complications (like hip/knee replacement problems or accidental cuts during surgery) and 30-day mortality rates for common conditions.

MeasureScoreCompared to nationalSample
Rate of complications for hip/knee replacement patients3.4Same as national26
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4.4Same as national344
Death rate for heart attack patients12.9Same as national82
Death rate for CABG surgery patientsNot available
Death rate for COPD patients8.3Same as national72
Death rate for heart failure patients12.1Same as national160
Death rate for pneumonia patients17.8Same as national216
Death rate for stroke patients15.6Same as national85
Pressure ulcer rate0.31Same as national1551
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.19Same as national2175
In-hospital fall-associated fracture rate0.25Same as national2183
Postoperative hemorrhage or hematoma rate2.17Same as national303
Postoperative acute kidney injury requiring dialysis rate1.64Same as national68
Postoperative respiratory failure rate8.27Same as national71
Perioperative pulmonary embolism or deep vein thrombosis rate3.49Same as national320
Postoperative sepsis rate4.91Same as national68
Postoperative wound dehiscence rate1.70Same as national68
Abdominopelvic accidental puncture or laceration rate1.26Same as national339
CMS Medicare PSI 90: Patient safety and adverse events composite0.86Same as national

Unplanned Hospital Visits & Readmissions

lower is better · 14 measures reported

How often patients return to the hospital unexpectedly within 30 days of discharge — a marker of care quality and discharge planning.

MeasureScoreCompared to nationalSample
Hospital return days for heart attack patients8.6Not available78
Hospital return days for heart failure patients6.9Not available180
Hospital return days for pneumonia patients-7.3Not available241
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.1Same as national509
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)12.9Same as national326
Rate of inpatient admissions for patients receiving outpatient chemotherapy9.6Same as national41
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy5.1Same as national41
Ratio of unplanned hospital visits after hospital outpatient surgery1Same as national66
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate14.7Same as national78
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients17.3Same as national79
Heart failure (HF) 30-Day Readmission Rate19.4Same as national180
Rate of readmission after hip/knee replacement5.2Same as national26
Pneumonia (PN) 30-Day Readmission Rate16.6Same as national241

Patient Experience (HCAHPS)

higher is better · 9 measures reported

What patients say about their hospital stay — communication with nurses and doctors, responsiveness, cleanliness, pain management, and whether they would recommend the hospital.

MeasureScoreSample
Nurse communication - star rating3282
Doctor communication - star rating3282
Communication about medicines - star rating2282
Discharge information - star rating3282
Cleanliness - star rating3282
Quietness - star rating2282
Overall hospital rating - star rating2282
Recommend hospital - star rating2282
Summary star rating3282

Timely & Effective Care

higher is better (unless a wait time) · 30 measures reported

How consistently hospitals follow recommended care processes — for example, giving heart-attack patients aspirin on arrival, or the average time spent in the emergency department.

MeasureScoreSample
Emergency department volume
Global Malnutrition Composite Score
Global Malnutrition Composite Score: Malnutrition Diagnosis Documented
Global Malnutrition Composite Score: Malnutrition Risk Screening
Global Malnutrition Composite Score: Nutrition Assessment
Global Malnutrition Composite Score: Nutritional Care Plan
Hospital Harm - Severe Hyperglycemia
Hospital Harm - Severe Hypoglycemia
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination902659
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 better149283
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 better148264
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better20212
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better
Left before being seen
Head CT results7117
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing
Appropriate care for severe sepsis and septic shock7973
Septic Shock 3-Hour Bundle7536
Septic Shock 6-Hour Bundle10026
Severe Sepsis 3-Hour Bundle9273
Severe Sepsis 6-Hour Bundle10048
Discharged on Antithrombotic Therapy
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 2
Venous Thromboembolism Prophylaxis
Intensive Care Unit Venous Thromboembolism Prophylaxis

Maternal Health

lower is better · 4 measures reported

Measures of maternal outcomes and safe delivery practices, including severe complications during childbirth.

MeasureScoreSample
Cesarean Birth
Risk Adjusted Severe Obstetric Complications (All)
Risk Adjusted Severe Obstetric Complications (excluding blood-transfusion-only cases)
Maternal Morbidity Structural MeasureYes

Frequently asked questions

How is Ascension All Saints Hospital rated?
Ascension All Saints Hospital has a 2 out of 5 CMS overall star rating as of the latest CMS release.
Does Ascension All Saints Hospital have emergency services?
Yes. Ascension All Saints Hospital operates a 24/7 emergency department.
Where is Ascension All Saints Hospital located?
Ascension All Saints Hospital is located at 3801 Spring St, Racine, WI 53405.
What type of hospital is Ascension All Saints Hospital?
Ascension All Saints Hospital is classified by CMS as a Acute Care Hospitals facility (Voluntary non-profit - Church).

Data as of 2026-06-14. Source: CMS Provider Data Catalog. This is public data provided for informational purposes only and is not medical advice. See our methodology and editorial policy.

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