Quality of Care

Caring for you is our specialty

At Mille Lacs Health System, Patient safety and quality of care are our highest priorities.

Mille Lacs Health System was founded with a mission to provide the people of the Mille Lacs region with the highest quality healthcare available. It remains our guiding mission and our highest priority. We are here to serve you and encourage you to ask questions about your care, or contact us should you have any concerns.

Click each to see the following pdfs.
Authorization to Release Patient Information
Patient Privacy Notice
Patient Bill of Rights
Health Care Directive Forms

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Quality of Care – Quality Management Department
In order to insure that our patients receive the highest quality care, our Quality Management Department reviews and analyzes the performance and quality of care provided by our doctors, nurses, staff, and by our organization as a whole.

Mille Lacs Health System also voluntarily participates in several major quality assurance programs, including:
Minnesota Hospital Association


The Board Quality Assessment Performance and Improvement (QAPI) Committee

The Chief of the Medical Staff supervises the medical staff and their credentialing (the process of validating the qualifications of licensed health professionals.)

The Director of Medical Staff Quality establishes the quality programs that will involve physicians and physician assistants, and incorporates this into the quality program developed by the Quality Management department.

The Board Quality Committee is a sub-committee of the Board of Directors. The MLHS Board of Directors holds quality to be such an important function in bringing care to the community that it decided greater attention could be provided to the subject if an independent committee spent its entire time overseeing this specific area. All quality programs and issues are brought to this committee for review and approval. Any necessary areas are then brought before the full Board of Directors.

The Board Quality Assessment Performance and Improvement (QAPI) Committee is composed of a board member, the Leadership Team, the Director of Medical Staff Quality, the COO, and the Quality Manager.

Greg Larson, Quality Manager
Greg’s duties encompass the “patient experience.” He coordinates and reports on our patient satisfaction survey process, and guides the investigation of customer complaints. In addition, Greg reviews performance information in a number of quality monitoring areas. Greg also performs investigations of care situations that may need improvement and brings together all individuals who may have an interest in how a particular process works or is improved.

How to Report an Issue or Concern
It is critical that you contact us if you ever have a question about the quality of care you receive at MLHS. All inquiries and submissions are treated with the highest degree of professionalism and respect for your privacy.

Greg Larson, Quality Manager

Satisfaction Surveys
We want to know how satisfied you are! A company called Press Ganey sends our patients a satisfaction survey after visits to MLHS areas such as Clinic, ER, Urgent Care, Long Term Care, Inpatient and Surgery areas. We compare our results with other hospitals to try and make changes based on what you tell us.

If you receive a survey, please complete it and send. By doing this, you’re helping us refine what we do to help make your experience the best it can be.

Mille Lacs Health System is considered a “Critical Access Hospital” and is regulated by the Minnesota Department of Health. Critical Access Hospitals have a comprehensive set of criteria they must meet to ensure that appropriate care is provided. The Minnesota Department of Health surveys Critical Access Hospitals to make sure they meet these requirements. Our performance is also monitored by the Centers for Medicare and Medicaid Services.

Accreditation is a certification by an outside agency that a healthcare facility meets that agency’s accreditation requirements and standards. Accreditation is not required to operate a Critical Access Hospital. The most common accreditation agency is the Joint Commission (it used to be called the Joint Commission on Accreditation of Hospital Organizations.)

Community Health Needs Assessment Reports
Click here to read the 2016 report

Click here to read the 2019 report

Awards and Recognition
The success of Mille Lacs Health System shines through its recognition by national organizations and other groups that rank the country’s healthcare facilities. We are proud to have earned the following awards of distinction and recognition of excellence:
Minnesota Hospital Association Patient Safety Excellence Awards
A Minnesota Hospital Association Patient Safety Excellence Award is given to hospitals that are actively participating in one of MHA’s safety campaigns and achieve 90 percent or higher of campaign roadmap steps.

  • Patient Safety Excellence Award for work on preventing pressure ulcers through the SAFE SKIN initiative
  • Patient Safety Excellence Award for work on preventing adverse surgical events (the wrong procedure being performed, or a procedure being performed on the wrong body part or patient) through the SAFE SITE initiative.
  • Patient Safety Excellence Award for work on preventing patients from falling during hospital stays through the SAFE from FALLS initiative. The SAFE from FALLS Roadmap to a Comprehensive Falls Prevention Program provides a detailed list of recommended actions that are organized under the SAFE from FALLS acronym:

Awards, Commendations, Appointments

  • CEO Bill Nelson appointed to Minnesota Hospital Association Board of Directors
  • CEO Bill Nelson appointed to the Governor's Workforce Development Council
  • Minnesota Hospital Association (MHA) recognition for performance in patient safety
  • Women’s Choice National Award - Emergency Care: 2014, 2015, 2016, 2017, 2018
  • Minnesota Bridges to Excellence-meeting the improvement goal for the optimal diabetic quality measure
  • Minnesota Bridges to Excellence-Quality Award for depression screening
  • Minnesota Hospital Assn. Health Strategy & Communication Network-1st place writing award to Mary Rains for newspaper feature story “Hands in Haiti.”
  • Health Strong Winner for Excellence in Outcomes-top quartile performance among all acute care hospitals in the nation
  • Deyta Hospice National Honor Recipient 2017
  • Acute Stroke Ready Hospital designation from the Minnesota Department of Health
  • Minnesota Hospital Association (MHA) recognition for commitment to patient safety
  • HHCAHPS HONORS recipient 2014, 2015, 2016 - Mille Lacs Health System Home Care
  • Blue Ribbon FluSafe Award 2016-17;  Red Ribbon FluSafe Award 2015-16 - from the MN Dept. of Health
  • Minnesota Family Physician of the Year 2015: Dr. Tom Bracken
  • Senior Care Unit- ranked 8th in nation for quality measures for High Performing In-Patient Psychiatric Facilities
  • Minnesota Hospital Assn. Health Strategy & Communication Network- Honorable Mention Award to Mary Rains in the Excellence in Communications category.
  • UCare Top Performing Clinic
  • Minnesota Hospital Assoc. Partnership for Patients Excellence Certificate