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Our Achievements in Quality Care

Providing the highest quality health care is the cornerstone of all we do. Quality data reporting allows us to share with the communities we service how we are doing on key quality measures. Quality measures allow us to show how we compare to national standards.

As a patient, this data may help you make decisions regarding your health care and will help you be a more informed partner along with your health care team.

Overall Score

This scorecard provides a comparison of Carle Foundation Hospital’s performance with that of other large, specialized complex care medical centers as part of the Vizient Quality & Accountability Study. The data was obtained from existing Vizient data resources, including the Clinical Data Base (July 2021 – June 2022) and HCAHPS data from vendor files, Core Measures Database, and National Healthcare Safety Network (April 2021 – March 2022). The goal of the Quality and Accountability ranking is to assess organizational performance across a broad spectrum of high-priority dimensions of patient care. The 2022 scoring and ranking cover the domains of mortality, effectiveness, safety, patient centeredness, efficiency and equity using measures developed by national organizations or the federal government. Refer to the methodology white paper (available at for specifics regarding the metrics, scoring methods, and data sources used.

Vizient Q&A Scorecard


Morality – includes risk-adjusted mortality performance across 13 service lines / subspecialties

Efficiency – includes measures of direct cost and length of stay across 18 service lines / subspecialties

Safety – includes 12 measures of hospital-acquired conditions and infections

Effectiveness – includes measures of Readmissions, revisits, excess days in care, and timely care of certain conditions

Patient Centeredness – includes measures of patient satisfaction, as reported through patient surveys

Equity – includes measures of care and outcome disparity for a variety of conditions across gender, race, and socioeconomic status

Infection Prevention

Patients can be at risk for infection while receiving medical care. Our teams follow strict guidelines for keeping our patients safe from infection using standard precautions – such as handwashing, wearing gloves and cleaning surfaces – to special precautions required for higher risk illnesses.

Find out why these measures are important

Central line-associated bloodstream infections (CLABSI) in ICUs and select wards

Lower numbers are better.


No different than national benchmark

National benchmark: 1.000

Catheter-associated urinary tract infections (CAUTI) in ICUs and select wards

Lower numbers are better.


No different than national benchmark

National benchmark: 1.000

Surgical site infections (SSI) from colon surgery

Lower numbers are better.


No different than national benchmark

National benchmark: 1.000

Surgical site infections (SSI) from abdominal hysterectomy

Lower numbers are better.


No different than national benchmark

National benchmark: 1.000

Methicillin-resistant Staphylococcus Aureus (MRSA) blood infections

Lower numbers are better.


No different than national benchmark

National benchmark: 1.000

Clostridium difficile (C.diff.) intestinal infections

Lower numbers are better.


No different than national benchmark

National benchmark: 1.000

Data Collection Time period: 10/01/2019 - 03/31/2021
Last updated: 02/2022


Carle Orthopedics offers comprehensive care through the collaboration of our physicians, therapists and advanced practice providers. We perform the most hip and joint replacements in the area, using state-of-the-art techniques that are minimally invasive, improve pain control and reduce recovery times.

How Carle Foundation Hospital is Performing

At Carle, we work tirelessly to provide the highest quality of care for our patients. We regularly review quality data to understand how we compare to regional and national standards of care to confirm what we are doing well and to identify the areas in which we need to improve. By regularly evaluating how we are doing against quality standards, we are able to work together to ensure safe and effective delivery of care.

Accreditation Matters

The DNV Hip and Knee Replacement Program Certification, based on standards set forth by and considering the guidelines of the American Academy of Orthopedic Surgeons, recognizes program excellence in patient care and outcomes.

DNV certification as a Hip & Knee Replacement Center validates the hospital’s excellence across the spectrum of hip and knee replacement care, from diagnosis to treatment, rehabilitation, education and outcomes.

“This certification tells our community that we have the resources and commitment to provide the best possible care for Hip and Knee replacement. It’s a combination of the right equipment, personnel and training to exhibit excellence in orthopedic surgery within the scope of Hip and Knee Replacement and related procedures. Achieving certification validates all the effort we have put into this program to ensure the health and safety of our patients.”

– Lakita Scott, MSN, RN, CPHQ, NE-BC Vice President of Quality

  • DNV Certification Hip & Knee Replacement

Cancer Care

Our comprehensive team of experts specialize in the treatment of numerous types of cancer, including complex and advanced stage cases. Our Cancer Institute houses state-of-the-art equipment that allows our team to more accurately locate, stage and treat the disease.

Our cancer care teams follow the latest evidence-based treatment protocols resulting in the best possible outcomes for our patients.

How Carle Foundation Hospital is Performing

Accreditation Matters

Achieving accreditation by the CoC means patients receive comprehensive, patient-centered care through a multidisciplinary team-approach, access to information on clinical and new treatment options, ongoing monitoring of care and lifelong patient follow-up, and psychosocial support and survivorship care.
  • CoC Accredited
  • NAP BC Accredited

Brain and Spine Care

Carle Foundation Hospital is the only certified Comprehensive Stroke Center in the region in a Level I Trauma Center. We have neurosurgeons and neurointerventional specialists available 24/7 to ensure faster treatment and help improve outcomes for patients having a stroke. We strive to intervene as early as possible for patients with stroke symptoms, and we continue to provide quality care to patients after a stroke with the goal of optimizing recovery.

How Carle Foundation Hospital is Performing

Accreditation Matters

The DNV Comprehensive Stroke Center Certification is based on standards set forth by the Brain Attack Coalition and the American Stroke Association, and affirms that the medical center addresses the full spectrum of stroke care – diagnosis, treatment, rehabilitation and education – and establishes clear metrics to evaluate outcomes.

“The DNV Comprehensive Stroke Certification survey process integrates requirements related to the CMS Conditions for Participation for hospitals. The certification also incorporates a Quality Management System to develop, implement, and maintain an ongoing system for measuring, monitoring, and managing quality and patient safety to continually improve the care of patients."

– Robert Healy, MD Associate Chief Medical Officer, Quality, Patient Safety and Experience.

  • NAEC Level 3
  • Comprehensive Stroke Center

Patient Experience

Our mission is to be your trusted partner in all healthcare decisions, and we strive to make sure you feel well cared for while receiving our services. The Centers for Medicare and Medicaid collect data through a national, standardized survey. This survey is provided to a random sample of our patients recently discharged from the hospital. We use patient feedback through these and other surveys to make improvements to our processes and communication to serve you better.

See how Carle performs on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey measures via the Illinois Hospital Report Card.


Following clinical best practices and scientific evidence are the best ways to avoid preventable complications and hospital-acquired infections. At Carle, we have numerous clinical workgroups and committees that are regularly reviewing the latest literature and clinical recommendations to ensure we are providing the most up-to-date, safe processes and treatments for our patients. When adverse events occur, our Patient Safety team partners with the clinical teams to review root causes and opportunities for improvement as part of a continuous learning cycle.

The Centers for Medicare & Medicaid Services (CMS) tracks various complications that may occur in the hospital setting, providing national comparisons for benchmarking. Carle Foundation Hospital’s most recent performance on these measures is displayed below.

Rate of complications for hip/knee replacement patients - April 2017 - Dec 2019


No different than national average

National result: 2.4%
Number of included patients: 413

Serious complications - July 2018 - Dec 2019

Patient Safety and Adverse Events Composite - Rate per 1000 hospitalizations


No different than the national value

National result: 1.00

Deaths among patients with serious treatable complications after surgery - July 2018 - Dec 2019

Rate per 1000 hospitalizations


No different than national rate

National result: 159.03

Cardiac Care

Experts from Carle Heart and Vascular Institute collaborate to provide the highest level of patient care, research and education to patients with cardiac, vascular and related conditions.

Heart care quality measures focus on all non-surgical care of the heart. Measures look at how we compare to national standards for caring for heart related disorders. Treatments range from medications to more invasive procedures.

How Carle Foundation Hospital is Performing

Accreditation Matters

“Program certification lets the communities we serve know we have the resources and commitment to provide the best possible care for the patients we serve. Achieving and maintaining certifications validates all the effort we have put into this program to ensure the health and safety of our patients."

– Napoleon Knight, MD, MBA Executive Vice President and Chief Medical Officer

  • IAC Echocardiography
  • IAC Vascular Testing
  • DNV Certified Heart Failure Program

Inpatient Rehabilitation

After a hospital stay or a major health event, patients may need additional care getting back to their daily lives. Our inpatient rehabilitation team works to help patients recover from injury or illness to achieve the best possible outcomes.

How Carle Foundation Hospital is Performing

Accreditation Matters

Accreditation demonstrates a provider's commitment to continuously improve service quality and to focus on the satisfaction of the persons served.
  • CARF Accredited

Pregnancy and Newborn Care

With the area’s only Level III Perinatal services, we care for women with healthy pregnancies but also those with high risk pregnancies and their babies. We use the most advanced diagnostics to monitor the health of mothers and their babies during pregnancy. And we are here to provide the highest quality care after the baby is born.

See how Carle performs on Maternal and Pediatric Quality measures via the Illinois Hospital Report Card.

Medical Care

Research shows that outcomes of care are improved when patients receive appropriate screening and treatment in a timely manner, along with appropriate utilization of resources. Time to treatment, appropriate intervention and follow-up, and survival rates are all important ways to measure quality care.


Sepsis care - July 2020 - March 2021

Sepsis is a complication that occurs when your body has an extreme response to an infection. It causes damage to organs in the body and can be life-threatening if not treated. Sepsis can sometimes turn into septic shock, which has a higher risk of death. Identifying sepsis early and starting appropriate care quickly increase the chances of survival. At Carle Foundation Hospital, our Sepsis Workgroup focuses on efficient identification and implementation of care processes for septic patients, as well as provider education to ensure compliance with evidence-based screening and treatment.

Percentage of patients who received appropriate care for severe sepsis and septic shock

Higher percentages are better.


of 190 patients

National average: 57%
Illinois average: 54%

Colonoscopy follow-up - Jan - Dec 2020

A colonoscopy is one test doctors can use to find precancerous polyps (abnormal growths) or colorectal cancer. Scientific evidence shows that the following measures represent best practices for follow-up colonoscopies.

Percentage of patients who received appropriate recommendation for follow-up screening colonoscopy

Higher percentages are better.


of 94 patients

National average: 90%
Illinois average: 87%

Critical care

Carle is proud to be recognized by Healthgrades for a number of areas of care, including overall hospital performance. These awards tell patients which hospitals deliver superior quality care. Healthgrades evaluates hospital performance using objective quality measures including clinical outcomes and patient safety, as well as patient experience. Carle Foundation Hospital has been recognized in all areas of Critical Care by Healthgrades for multiple consecutive years.


Mortality Based Conditions: Pulmonary Embolism - Mortality in hospital - better than expected. Mortality within 30 days - better than expected. Respiratory Failure - Mortality in hospital - better than expected. Mortality within 30 days - better than expected. Sepsis - Mortality in hospital - better than expected. Mortality within 30 days - better than expected.

Carle has been awarded the Specialty Excellence Award
America's 100 Best Hositals for Critical Care Award - 2022, 2021, 2020