Note: The following measure(s) will be retired from CheckPoint in December 2014:
  • AMI-2 – Aspirin on Discharge
  • PN-3b – Blood Culture before First Abx
  • HF-1 – Discharge Instructions
  • HF-3 – ACEI/ARB for LVSD
  • SCIP-Inf-10 – Periop Temp. Management
Froedtert & The Medical College of Wisconsin Community Memorial Hospital Campus
Demographic Information

W180 N8085 Town Hall Road
Menomonee Falls, WI  53051
262-251-1000
http://www.communitymemorial.com
Services: Emergency, Obstetrics, Psychiatry, Cardiovascular, Orthopedics
Discharges/Yr: 9597
Population: Suburban
Staffed Beds: 202
KEY
- No Cases Met Criteria. The hospital had no cases that met the measure criteria during the applicable time period.
+ Low Volume. The hospital collects data, but their volume of data was too small to report with statistical confidence.
IP In Progress. The hospital is collecting data, but does not have four quarters of data necessary for public reporting.
DNR Did not report. The hospital has not authorized CheckPoint to report this measure or the hospital has not provided data for this measure.
NA Not Applicable. The hospital does not provide this service.
Click here for definitions of Better, As Expected and Worse, with regard to Deaths.
State Benchmark - The 90th percentile of Wisconsin hospitals reporting each measure.
State Average - - The average of Wisconsin hospitals reporting each measure.
National Average - The average of hospitals in the U.S. accredited by The Joint Commission
Report generated Aug 1 2014 4:47 AM

Medical Services

Measurement data are from 10/1/2012—9/30/2013
Heart Attack Hosp.
Score
State
Benchmark
State
Average
National
Average
Aspirin at discharge (%) 100 100 100 99
PCI <90 min + 100 96 96
Heart Failure Hosp.
Score
State
Benchmark
State
Average
National
Average
LVF assessment (%) 100 100 99 99
ACEI for LVSD (%) 100 100 97 97
Discharge Instructions (%) 99 100 96 94
Pneumonia Hosp.
Score
State
Benchmark
State
Average
National
Average
Approp Anbtc 97 100 96 95
Blood Culture Collected 100 100 98 98

Error Prevention

Measurement data are from 7/1/2013—12/31/2013
National Safety Goals Hosp.
Score
State
Benchmark
State
Average
 
Site marking (%) DNR 100 98  
Procedure verification (%) DNR 100 98  
Medication reconciliation (%) DNR 100 91  

Surgical Services

Measurement data are from 10/1/2012—9/30/2013
Colon Surgery Hosp.
Score
State
Benchmark
National
Average
Start Antibiotics (%) 98 100 98
Appropriate Antibiotics (%) 96 100 96
Stop Antibiotics (%) 98 100 96
Hip Surgery Hosp.
Score
State
Benchmark
National
Average
Start Antibiotics (%) 98 100 99
Appropriate Antibiotics (%) 99 100 100
Stop Antibiotics (%) 100 100 98
Hysterectomy Hosp.
Score
State
Benchmark
National
Average
Start Antibiotics (%) 100 100 99
Appropriate Antibiotics (%) 99 100 98
Stop Antibiotics (%) 100 100 98
Knee Surgery Hosp.
Score
State
Benchmark
National
Average
Start Antibiotics (%) 100 100 99
Appropriate Antibiotics (%) 99 100 100
Stop Antibiotics (%) 100 100 98
Other Cardiac Hosp.
Score
State
Benchmark
National
Average
Start Antibiotics (%) + 100 99
Appropriate Antibiotics (%) + 100 100
Stop Antibiotics (%) + 100 98
Blood Sugar Controlled (%) + 100
Vascular Surgery Hosp.
Score
State
Benchmark
National
Average
Start Antibiotics (%) + 100 98
Appropriate Antibiotics (%) + 100 99
Stop Antibiotics (%) + 100 96
CABG Hosp.
Score
State
Benchmark
National
Average
Start Antibiotics (%) 99 100 99
Appropriate Antibiotics (%) 100 100 100
Stop Antibiotics (%) 100 100 99
Blood Sugar Controlled (%) 94 100
Index Hosp.
Score
State
Benchmark
State
Average
Surgical Infection Prevention index (%) 96 99 95
Surgical Care – All Procedures Hosp.
Score
State
Benchmark
National
Average
Start Antibiotics (%) 99 100 99
Appropriate Antibiotics (%) 99 100 99
Stop Antibiotics (%) 100 100 98
Clot Prevention Given (%) 100 100 98
Cath Removal (%) 98 100 97
Temp Management (%) 100 100 100
Beta Blocker Received (%) 100 100 98

 Deaths data (2012)
Deaths due to IllnessExperienceNat'l Avg(%)State Avg(%)
Acute stroke mortality rateAs Expected9.136.91
Gastrointestinal (GI) hemorrhage mortality rateAs Expected2.411.40
Hip fracture mortality rateAs Expected2.780.61
Deaths During a ProcedureExperienceNat'l Avg(%)State Avg(%)
AAA repair mortality rate+4.121.75
CABG mortality rateAs Expected2.581.14
CEA mortality rateBetter0.400.01
Craniotomy mortality rate+5.706.41
Hip replacement mortality rateBetter0.090.00
PTCA mortality rateAs Expected1.730.59
High Risk Procedure - Volumes Volume
AAA Volume 12
CABG Volume 168
CEA Volume 64
PTCA Volume 201
Incidental Appendectomy (%) 0.00

     
 Birth Measures Data (4/1/2013 - 3/31/2014)
MeasureRateState Average
Pre-Birth Steroids +93
Forceps Delivery11
Vacuum Delivery36
Breast Feeding6978
Infant Composite42
Early Elective Delivery30

     
 Patient Experience of Care Survey Data (7/1/2012 - 6/30/2013)
Measure Rate National Average State Average State Benchmark
Patients ranked hospital high 72 70 74 83
Definitely recommend hospital 75 71 74 84
Doctors always communicated well 82 82 83 88
Nurses always communicated well 79 79 82 87
Patients always received requested help 64 67 72 82
Staff always explained medications 64 64 68 75
Pain always well controlled 71 71 72 77
Always quiet at night 59 61 63 72
Room always clean 71 73 79 87
Staff provided discharge instructions 88 85 89 92

     
 Stroke Data (Measure Data are from 10/1/2012 – 9/30/2013)
Measure Rate State Average State Benchmark
STK-2: AntiThrom on Dischg 100 96 100
STK-3: Anticoag for AFib/AFlut + 92 100
STK-5: Early AntiThrom 100 96 100
STK-6: Dischg on Statin Med 96 88 100
STK-8: Stroke Education 98 91 100
STK-10: Assess for Rehab 100 97 100

     
 CMS 30-Day Mortality Data (7/1/2009 - 6/30/2012)
Measure Rate National Average State Average
Pneumonia 11.9 11.9 12.0
Heart Failure 14.1 11.7 12.4
Heart Attack 18.4 15.2 15.4

     
 CMS 30-Day Readmission Data (7/1/2009 - 6/30/2012)
Measure Rate National Average State Average
Pneumonia 18.1 17.6 17.1
Heart Failure 22.0 23.0 22.0
Heart Attack 18.8 18.3 17.7

     
 CLABSI - Central Line Associated Blood Stream Infection Data (ICU Patients) (1/1/2013 - 12/31/2013)
Measure Ratio National Comparison State Comparison
CLABSI 0.823 1.000 0.464

     
 CAUTI – Catheter Associated Urinary Tract Infections (1/1/2013 - 12/31/2013)
Measure Ratio National Comparison State Comparison
CAUTI 1.231 1.000 0.835

     
 Surgical Site Infections (SSI) - Colon Surgery(1/1/2013 - 12/31/2013)
Measure Ratio National Comparison State Comparison
SSI – Colon Surgery 0.741 1.000 0.962

     
 Surgical Site Infections (SSI) – Abdominal Hysterectomy (1/1/2013 - 12/31/2013)
Measure Ratio National Comparison State Comparison
SSI – Abdominal Hysterectomy + 1.000 1.016


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