JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Ssm Health St Clare Hospital - Baraboo

4 / 5

At a glance

Ssm Health St Clare Hospital - Baraboo carries a 4-star CMS overall rating — above 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 LimitNot available
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence LimitNot available
Central Line Associated Bloodstream Infection: Number of Device Days239Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases0.166Not 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 Days679Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases0.395Not 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 Procedures6Not available
SSI - Colon Surgery: Predicted Cases0.147Not available
SSI - Colon Surgery: Observed Cases1Not available
SSI - Colon SurgeryNot available
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures5Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.043Not available
SSI - Abdominal Hysterectomy: Observed Cases1Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitNot available
MRSA Bacteremia: Upper Confidence LimitNot available
MRSA Bacteremia: Patient Days6177Not available
MRSA Bacteremia: Predicted Cases0.139Not available
MRSA Bacteremia: Observed Cases0Not available
MRSA BacteremiaNot available
Clostridium Difficile (C.Diff): Lower Confidence LimitBetter than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.887Better than national
Clostridium Difficile (C.Diff): Patient Days5898Better than national
Clostridium Difficile (C.Diff): Predicted Cases3.377Better than national
Clostridium Difficile (C.Diff): Observed Cases0Better than national
Clostridium Difficile (C.Diff)0.000Better 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 patientsNot available
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4.1Same as national178
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 national87
Death rate for pneumonia patients15.5Same as national114
Death rate for stroke patients13.5Same as national25
Pressure ulcer rate0.51Same as national629
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.21Same as national833
In-hospital fall-associated fracture rate0.40Same as national809
Postoperative hemorrhage or hematoma rate2.32Same as national52
Postoperative acute kidney injury requiring dialysis rateNot available
Postoperative respiratory failure rateNot available
Perioperative pulmonary embolism or deep vein thrombosis rate3.42Same as national61
Postoperative sepsis rateNot available
Postoperative wound dehiscence rateNot available
Abdominopelvic accidental puncture or laceration rate1.04Same as national65
CMS Medicare PSI 90: Patient safety and adverse events composite0.98Same 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 patientsNot available
Hospital return days for heart failure patients-24Not available87
Hospital return days for pneumonia patients-15.1Not available110
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14Same as national271
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)12.5Same as national657
Rate of inpatient admissions for patients receiving outpatient chemotherapy10.7Same as national40
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy6.1Same as national40
Ratio of unplanned hospital visits after hospital outpatient surgery1.1Same as national116
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 Rate18.8Same as national87
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate15.8Same as national110

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 rating4325
Doctor communication - star rating4325
Communication about medicines - star rating3325
Discharge information - star rating5325
Cleanliness - star rating3325
Quietness - star rating4325
Overall hospital rating - star rating4325
Recommend hospital - star rating3325
Summary star rating4325

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 volumemedium
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 Hypoglycemia1386
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination71471
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 better125404
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 better120376
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better21111
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better34221
Left before being seen021289
Head CT results8217
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients9980
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing10268
Appropriate care for severe sepsis and septic shock5788
Septic Shock 3-Hour Bundle6128
Septic Shock 6-Hour Bundle6712
Severe Sepsis 3-Hour Bundle7588
Severe Sepsis 6-Hour Bundle10046
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 Ssm Health St Clare Hospital - Baraboo rated?
Ssm Health St Clare Hospital - Baraboo has a 4 out of 5 CMS overall star rating as of the latest CMS release.
Does Ssm Health St Clare Hospital - Baraboo have emergency services?
Yes. Ssm Health St Clare Hospital - Baraboo operates a 24/7 emergency department.
Where is Ssm Health St Clare Hospital - Baraboo located?
Ssm Health St Clare Hospital - Baraboo is located at 707 14th St, Baraboo, WI 53913.
What type of hospital is Ssm Health St Clare Hospital - Baraboo?
Ssm Health St Clare Hospital - Baraboo is classified by CMS as a Acute Care 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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