JCIPatientSafety.orgHospital Quality Directory

Critical Access Hospitals · Voluntary non-profit - Private

Madison Regional Health System

Not rated overall

CMS reports safety and quality measures for this hospital but does not assign an overall star rating. See scores below.

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 LimitNot available
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence LimitNot available
Central Line Associated Bloodstream Infection: Number of Device Days201Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases0.055Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases0Not available
Central Line Associated Bloodstream Infection (ICU + select Wards)Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence LimitNot available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence LimitNot available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days293Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases0.192Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases0Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards)Not available
SSI - Colon Surgery: Lower Confidence LimitNot available
SSI - Colon Surgery: Upper Confidence LimitNot available
SSI - Colon Surgery: Number of ProceduresNot available
SSI - Colon Surgery: Predicted CasesNot available
SSI - Colon Surgery: Observed CasesNot available
SSI - Colon SurgeryNot available
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of ProceduresNot available
SSI - Abdominal Hysterectomy: Predicted CasesNot available
SSI - Abdominal Hysterectomy: Observed CasesNot available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitNot available
MRSA Bacteremia: Upper Confidence LimitNot available
MRSA Bacteremia: Patient Days3135Not available
MRSA Bacteremia: Predicted Cases0.065Not available
MRSA Bacteremia: Observed Cases0Not available
MRSA BacteremiaNot available
Clostridium Difficile (C.Diff): Lower Confidence LimitNot available
Clostridium Difficile (C.Diff): Upper Confidence LimitNot available
Clostridium Difficile (C.Diff): Patient Days3135Not available
Clostridium Difficile (C.Diff): Predicted Cases0.692Not available
Clostridium Difficile (C.Diff): Observed Cases0Not available
Clostridium Difficile (C.Diff)Not available

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 patientsNot available
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4.7Same as national101
Death rate for heart attack patientsNot available
Death rate for CABG surgery patientsNot available
Death rate for COPD patientsNot available
Death rate for heart failure patients11.5Same as national27
Death rate for pneumonia patients15.3Same as national56
Death rate for stroke patientsNot available
Pressure ulcer rateNot available
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rateNot available
In-hospital fall-associated fracture rateNot available
Postoperative hemorrhage or hematoma rateNot available
Postoperative acute kidney injury requiring dialysis rateNot available
Postoperative respiratory failure rateNot available
Perioperative pulmonary embolism or deep vein thrombosis rateNot available
Postoperative sepsis rateNot available
Postoperative wound dehiscence rateNot available
Abdominopelvic accidental puncture or laceration rateNot available
CMS Medicare PSI 90: Patient safety and adverse events compositeNot available

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 patientsNot available
Hospital return days for heart failure patientsNot available
Hospital return days for pneumonia patients-50.4Not available48
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.8Same as national141
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)Not available
Rate of inpatient admissions for patients receiving outpatient chemotherapyNot available
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapyNot available
Ratio of unplanned hospital visits after hospital outpatient surgeryNot available
Acute Myocardial Infarction (AMI) 30-Day Readmission RateNot available
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patientsNot available
Heart failure (HF) 30-Day Readmission RateNot available
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate15.1Same as national48

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 rating89
Doctor communication - star rating89
Communication about medicines - star rating89
Discharge information - star rating89
Cleanliness - star rating89
Quietness - star rating89
Overall hospital rating - star rating89
Recommend hospital - star rating89
Summary star rating89

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 volumelow
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 vaccination84370
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 better104269
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 better104258
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better9711
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 seen03216
Head CT results
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 shock9111
Septic Shock 3-Hour Bundle
Septic Shock 6-Hour Bundle
Severe Sepsis 3-Hour Bundle9111
Severe Sepsis 6-Hour Bundle
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 Measure

Frequently asked questions

How is Madison Regional Health System rated?
CMS does not assign an overall star rating to Madison Regional Health System, but does publish underlying safety and quality measures shown on this page.
Does Madison Regional Health System have emergency services?
Yes. Madison Regional Health System operates a 24/7 emergency department.
Where is Madison Regional Health System located?
Madison Regional Health System is located at 323 Sw 10th St, Madison, SD 57042.
What type of hospital is Madison Regional Health System?
Madison Regional Health System is classified by CMS as a Critical Access Hospitals facility (Voluntary non-profit - Private).

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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