Reports Detail

Home WHA.org News Contact Us Hospital Login Related Links

Froedtert Health Community Memorial Hospital
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 data collected at this time or no cases met criteria. [MORE INFO]
+ Data collected, but not enough cases to be representative of care provided in this reporting period. As CheckPoint adds data, more hospitals will report this measure. [MORE INFO]
n/a Not applicable.
n/r Hospital opted not to report data for this measure.

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 24 May 2013 6:13 PM

Medical Services Measurement data are from 7/1/2011—6/30/2012
Heart Attack	Hosp. Score	State Benchmark	State Average	National Average
Aspirin at discharge (%)	100	100	99	99
PCI <90 min	97	100	94	94
Throm Med <30 min	—	—	—	—

Heart Failure	Hosp. Score	State Benchmark	State Average	National Average
LVF assessment (%)	100	100	98	99
ACEI for LVSD (%)	100	100	95	97
Discharge Instructions (%)	94	100	92	94

Pneumonia	Hosp. Score	State Benchmark	State Average	National Average
Approp Anbtc	99	100	96	96
Blood Culture Collected	100	100	98	98
Error Prevention Measurement data are from 7/1/2012

National Safety Goals	Hosp. Score	State Benchmark	State Average
Site marking (%)	—	100	98
Procedure verification (%)	—	100	98
Med Rec at Discharge (%)	—	100	87

Surgical Services Measurement data are from 7/1/2011—6/30/2012
Colon Surgery	Hosp. Score	State Benchmark	National Average
Start Antibiotics (%)	96	100	97
Appropriate Antibiotics (%)	92	100	94
Stop Antibiotics (%)	98	100	94
Hip Surgery	Hosp. Score	State Benchmark	National Average
Start Antibiotics (%)	99	100	98
Appropriate Antibiotics (%)	100	100	100
Stop Antibiotics (%)	100	100	98
Hysterectomy	Hosp. Score	State Benchmark	National Average
Start Antibiotics (%)	100	100	98
Appropriate Antibiotics (%)	100	100	97
Stop Antibiotics (%)	99	100	97
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	100	99
Appropriate Antibiotics (%)	100	100	100
Stop Antibiotics (%)	97	100	98
Blood Sugar Controlled (%)	86	100	—
Vascular Surgery	Hosp. Score	State Benchmark	National Average
Start Antibiotics (%)	+	99	97
Appropriate Antibiotics (%)	+	100	99
Stop Antibiotics (%)	+	100	95
CABG	Hosp. Score	State Benchmark	National Average
Start Antibiotics (%)	100	100	99
Appropriate Antibiotics (%)	100	100	100
Stop Antibiotics (%)	98	100	98
Blood Sugar Controlled (%)	93	100	—
Index	Hosp. Score	State Benchmark	State Average
Surgical Infection Prevention index (%)	94	97	92
Surgical Care – All Procedures	Hosp. Score	State Benchmark	National Average
Start Antibiotics (%)	99	100	98
Appropriate Antibiotics (%)	99	100	99
Stop Antibiotics (%)	99	100	97
Clot Prevention Ordered (%)	100	100	98
Clot Prevention Given (%)	100	100	98
Cath Removal (%)	96	100	95
Temp Management (%)	100	100	100
Beta Blocker Received (%)	99	100	97

Deaths data (2011)

Deaths due to Illness	Experience	Nat'l Avg(%)	State Avg(%)
Acute stroke mortality rate	As Expected	9.24	8.85
Gastrointestinal (GI) hemorrhage mortality rate	As Expected	2.08	1.51
Hip fracture mortality rate	As Expected	2.58	2.19

Deaths During a Procedure	Experience	Nat'l Avg(%)	State Avg(%)
AAA repair mortality rate	+	4.45	3.32
CABG mortality rate	As Expected	2.24	1.45
CEA mortality rate	As Expected	0.33	0.34
Craniotomy mortality rate	+	5.77	4.05
Esophageal resection mortality rate	+	5.49	2.31
Hip replacement mortality rate	As Expected	0.07	0.06
PTCA mortality rate	Worse	1.20	1.03

	High Risk Procedure - Volumes	Volume
	AAA Volume	7
	CABG Volume	131
	CEA Volume	58
	Esophageal Resection Volume	+
	PTCA Volume	130
	Pancreatic Resection Volume	—
	Incidental Appendectomy (%)	1.18

Birth Measures Data (1/1/2012 - 12/31/2012)
Please note, the C-Section w/Labor and C-Section w/out Labor measures will be discontinued from CheckPoint as of second quarter, 2013.
Hospital opted not to report data for this measure set.

Patient Experience of Care Survey Data (7/1/2011 - 6/30/2012)
Measure	Rate	National Average	State Average	State Benchmark
Patients ranked hospital high	73	70	74	84
Definitely recommend hospital	77	71	74	84
Doctors always communicated well	82	81	83	88
Nurses always communicated well	79	78	81	87
Patients always received requested help	64	67	72	82
Staff always explained medications	64	63	68	74
Pain always well controlled	73	71	72	78
Always quiet at night	59	60	63	72
Room always clean	75	73	79	87
Staff provided discharge instructions	87	84	88	91

Stroke Data (Measure Data are from 7/1/2011 – 6/30/2012)
Measure	Rate	National Average	State Average	State Benchmark
STK-2: AntiThrom on Dischg	100	98	96	100
STK-3: Anticoag for AFib/AFlut	+	93	93	100
STK-5: Early AntiThrom	97	97	89	100
STK-6: Dischg on Statin Med	96	91	88	100
STK-8: Stroke Education	93	88	85	100
STK-10: Assess for Rehab	95	97	96	100

CMS 30-Day Mortality Data (7/1/2008 - 6/30/2011)
Measure	Rate	National Average	State Average
Pneumonia	10.8	12.0	12.2
Heart Failure	12.8	11.6	12.0
Heart Attack	16.4	15.5	15.7

CMS 30-Day Readmission Data (7/1/2008 - 6/30/2011)
Measure	Rate	National Average	State Average
Pneumonia	18.6	18.5	17.9
Heart Failure	25.3	24.7	23.6
Heart Attack	19.8	19.7	18.9

CLABSI - Central Line Associated Blood Stream Infection Data (ICU Patients) (1/1/2011 - 12/31/2011)
Measure	Ratio	National Comparison	State Comparison
CLABSI	0.919	1.000	0.606