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Agnesian HealthCare/St. Agnes Hospital (Fond du Lac)
87
Amery Regional Medical Center (Amery)
3
Aspirus Langlade Hospital (Antigo)
55
Aspirus Medford Hospital & Clinics, Inc. (Medford)
58
Aspirus Riverview Hospital and Clinics, Inc. (Wisconsin Rapids)
76
Aspirus Wausau Hospital (Wausau)
120
Aurora BayCare Medical Center in Green Bay (Green Bay)
5
Aurora Lakeland Medical Center in Elkhorn (Elkhorn)
6
Aurora Medical Center in Grafton (Grafton)
146
Aurora Medical Center in Hartford (Hartford)
9
Aurora Medical Center in Kenosha (Kenosha)
7
Aurora Medical Center in Oshkosh (Oshkosh)
127
Aurora Medical Center in Summit (Summit)
145
Aurora Medical Center of Manitowoc County (Two Rivers)
8
Aurora Memorial Hospital of Burlington (Burlington)
59
Aurora Sheboygan Memorial Medical Center (Sheboygan)
10
Aurora Sinai Medical Center (Milwaukee)
11
Aurora St. Luke's Medical Center - South Shore (Cudahy)
123
Aurora St. Luke's Medical Center (Milwaukee)
97
Aurora West Allis Medical Center (West Allis)
121
Bay Area Medical Center (Marinette)
15
Beaver Dam Community Hospitals, Inc. (Beaver Dam)
16
Bellin Health Oconto Hospital (Oconto)
130
Bellin Hospital (Green Bay)
17
Beloit Health System (Beloit)
18
Black River Memorial Hospital (Black River Falls)
20
Burnett Medical Center (Grantsburg)
23
Calumet Medical Center (Chilton)
24
Children's Hospital of Wisconsin (Milwaukee)
148
Children's Hospital of Wisconsin-Fox Valley (Neenah)
149
Chippewa Valley Hospital (Durand)
25
Columbia Center Birth Hospital (Mequon)
132
Columbia St. Mary's Hospital Milwaukee (Milwaukee)
134
Columbia St. Mary's Hospital Ozaukee (Mequon)
27
Columbus Community Hospital (Columbus)
29
Crossing Rivers Health (Prairie du Chien)
71
Cumberland Healthcare (Cumberland)
32
Divine Savior Healthcare (Portage)
33
Door County Medical Center (Sturgeon Bay)
34
Edgerton Hospital and Health Services (Edgerton)
57
Essentia Health St. Mary's Hospital - Superior (Superior)
101
Flambeau Hospital (Park Falls)
37
Fort HealthCare (Fort Atkinson)
38
Froedtert & The Medical College of Wisconsin Community Memorial Hospital Campus (Menomonee Falls)
30
Froedtert & The Medical College of Wisconsin Froedtert Hospital Campus (Milwaukee)
42
Froedtert & The Medical College of Wisconsin St. Josephs Hospital Campus (West Bend)
93
Grant Regional Health Center (Lancaster)
44
Gundersen Boscobel Area Hospital and Clinics (Boscobel)
22
Gundersen Health System (La Crosse)
45
Gundersen St. Joseph's Hospital and Clinics (Hillsboro)
96
Gundersen Tri County Hospital & Clinics (Whitehall)
112
Hayward Area Memorial Hospital (Hayward)
46
Holy Family Memorial Inc (Manitowoc)
48
Howard Young Medical Center (Woodruff)
49
HSHS Sacred Heart Hospital (Eau Claire)
78
HSHS St. Clare Memorial Hospital (Oconto Falls)
31
HSHS St. Joseph's Hospital (Chippewa Falls)
94
HSHS St. Mary's Hospital Medical Center (Green Bay)
100
HSHS St. Nicholas Hospital (Sheboygan)
105
HSHS St. Vincent Hospital (Green Bay)
106
Hudson Hospital & Clinics (Hudson)
50
Indianhead Medical Center/Shell Lake (Shell Lake)
51
Lakeview Medical Center (Rice lake)
54
Mayo Clinic Health System - Chippewa Valley (Bloomer)
21
Mayo Clinic Health System - Eau Claire (Eau Claire)
56
Mayo Clinic Health System - Franciscan Healthcare in La Crosse (La Crosse)
40
Mayo Clinic Health System - Franciscan Healthcare in Sparta (Sparta)
41
Mayo Clinic Health System - Northland in Barron (Barron)
14
Mayo Clinic Health System - Oakridge in Osseo (Osseo)
70
Mayo Clinic Health System - Red Cedar in Menomonie (Menomonie)
67
Memorial Hospital of Lafayette Co. (Darlington)
60
Memorial Medical Center (Ashland)
61
Memorial Medical Center (Neillsville)
62
Mercy Hospital and Trauma Center (Janesville)
63
Mercy Medical Center (Oshkosh)
64
Mercy Walworth Hospital and Medical Center (Lake Geneva)
140
Midwest Orthopedic Specialty Hospital (Franklin)
144
Mile Bluff Medical Center (Mauston)
66
Ministry Eagle River Memorial Hospital (Eagle River)
35
Ministry Good Samaritan Health Center (Merrill)
43
Ministry Our Lady of Victory Hospital (Stanley)
116
Ministry Sacred Heart Hospital (Tomahawk)
79
Ministry Saint Clare's Hospital (Weston)
131
Ministry Saint Joseph's Hospital (Marshfield)
80
Ministry Saint Mary's Hospital (Rhinelander)
102
Ministry Saint Michael's Hospital (Stevens Point)
82
Monroe Clinic (Monroe)
108
Moundview Memorial Hospital & Clinics, Inc. (Friendship)
2
OakLeaf Surgical Hospital (Altoona)
133
Oconomowoc Memorial Hospital (Oconomowoc)
69
Orthopaedic Hospital of Wisconsin (Glendale)
128
Osceola Medical Center (Osceola)
126
Reedsburg Area Medical Center (Reedsburg)
72
Ripon Medical Center, Inc. (Ripon)
73
River Falls Area Hospital (River Falls)
74
Rusk County Memorial Hospital (Ladysmith)
77
Sauk Prairie Healthcare (Prairie du Sac)
83
Southwest Health Center (Platteville)
85
Spooner Health (Spooner)
86
SSM Health St. Clare Hospital (Baraboo)
89
SSM Health St. Mary's Hospital - Janesville (Janesville)
147
SSM Health St. Mary's Hospital - Madison (Madison)
99
St. Croix Regional Medical Center (St. Croix Falls)
90
St. Elizabeth Hospital (Appleton)
91
Stoughton Hospital Association (Stoughton)
107
The Richland Hospital, Inc. (Richland Center)
109
ThedaCare Medical Center - Berlin (Berlin)
19
ThedaCare Medical Center - New London (New London)
68
ThedaCare Medical Center - Shawano (Shawano)
84
ThedaCare Medical Center - Waupaca (Waupaca)
75
ThedaCare Medical Center - Wild Rose (Wild Rose)
122
ThedaCare Regional Medical Center - Appleton (Appleton)
4
ThedaCare Regional Medical Center - Neenah (Neenah)
110
Tomah Memorial Hospital (Tomah)
111
United Hospital System (Kenosha)
52
UnityPoint Health - Meriter (Madison)
65
University of Wisconsin Hospital & Clinics Authority (Madison)
113
Upland Hills Health, Inc. (Dodgeville)
114
Vernon Memorial Hospital (Viroqua)
115
Watertown Regional Medical Center (Watertown)
117
Waukesha Memorial Hospital (Waukesha)
118
Waupun Memorial Hospital (Waupun)
119
Western Wisconsin Health (Baldwin)
13
Westfields Hospital & Clinic (New Richmond)
47
Wheaton Franciscan Healthcare - All Saints, Inc (Racine)
81
Wheaton Franciscan Healthcare - Franklin (Franklin)
143
Wheaton Franciscan Healthcare - St. Francis (Milwaukee)
92
Wheaton Franciscan, Inc. - St. Joseph, Elmbrook, TWHH (Milwaukee)
95
Froedtert & The Medical College of Wisconsin St. Josephs Hospital Campus
Demographic Information

3200 Pleasant Valley Rd
West Bend, WI  53095
-334-5533
http://www.froedtert.com/st-josephs
Services: Adult Intensive Care, Emergency, Hospice/Palliative Care, Obstetrics, Orthopedics

View this hospital’s charges for the 75 most common hospitalizations in WI
Discharges/Yr: 4787
Population: Suburban
Staffed Beds: 70
Report generated Dec 4 2016 8:12 AM
 
The stroke (STK-6 and STK-8) measures are being retired by CMS and will be removed from CheckPoint in December, 2016



Patient Safety

Patient safety data are from 10/1/2014 — 9/30/2015 (The next update will be upon release of AHRQ software allowing calculation of risk-adjusted, ICD-10-based results)
Falls with Major Injury data are from 4/1/2015 — 3/31/2016
Medication reconciliation data are from 1/1/2016—6/30/2016
All Patients Rate State Benchmark State Average
Patient Safety Composite Index (PSI-90) 1.26 0.70 0.91
Pressure Ulcers (PSI-3) % 0.00 0.00 0.03
Pneumothorax/Collapsed Lung (PSI-6) % 0.07 0.00 0.01
Falls with Major Injury (Rate per 1,000) 0.05 0.00 0.04
Medication Reconciliation % DNR 100 93
Patients with Surgery Rate State Benchmark State Average
Post-Op Hip Fracture (PSI-8) % 0.00 0.00 0.00
Post-Op Bleeding (PSI-9) % 0.95 0.00 0.37
Post-Op Kidney Complications (PSI-10) % 0.00 0.00 0.00
Post-Op Respiratory Failure (PSI-11) % 0.54 0.00 0.43
Post-Op Blood Clot (PSI-12) % 1.06 0.00 0.21
Post-Op Sepsis/Blood Infection (PSI-13) % 7.94 0.00 0.62
Post-Op Abdominal Wound Complication (PSI-14) % 0.00 0.00 0.00
Accidental Puncture or Cut (PSI-15) % 0.17 0.00 0.12

Deaths Data (2014)
MeasureRateNational AverageState Average
Stroke 4.848.329.92
Gastrointestinal (GI) Hemorrhage 0.002.242.54
Abdominal Aortic Aneurysm Repair 3.682.66
Heart Bypass - CABG 2.543.05
Carotid Endarterectomy +0.440.21
Craniotomy 5.765.85
Angioplasty - PTCA Mortality 2.132.59
Incidental Appendectomy Rate 2.381.000.86
High Risk Procedure - Volumes Volume
AAA Volume
CABG Volume
CEA Volume11
PTCA Volume

     
Birth Measures Data  (7/1/2015 - 6/30/2016)
MeasureRateState AverageState Benchmark
Cesarean Section 232314
Early Elective Delivery740
Exclusive Breastfeeding (PC-05)655777
Infant ComplicationsIP31
Newborn Screening Turnaround Time9997100

     
Patient Satisfaction (1/1/2015 - 12/31/2015)
Measure Rate National Average State Average State Benchmark
Patients rated hospital high 73 72 77 84
Definitely recommend hospital 72 72 76 83
Doctors always communicated well 83 82 84 89
Nurses always communicated well 81 80 83 88
Patients always received requested help 64 68 73 84
Staff always explained medications 66 65 68 76
Pain always well controlled 71 71 72 78
Staff provided discharge instructions 89 87 90 93
Patients who Strongly Agreed that they understood their care when they left the hospital 58 52 56 64
Always quiet at night 72 62 65 74
Room always clean 77 74 79 87

     
Stroke Data (1/1/2015 — 12/31/2015)
Measure Rate National Average State Average State Benchmark
STK-6: Discharge on Statin Medication 100 97 97 100
STK-8: Stroke Education 95 95 96 100

     
CMS 30-Day Mortality Data (7/1/2012 - 6/30/2015)
Measure Rate (%) National Average State Average
Pneumonia 12.1 16.3 16.5
Heart Failure 12.1 12.1 12.7
Heart Attack 14.2 14.1 14.1

     
CMS 30-Day Readmission Data (7/1/2012 - 6/30/2015)
Measure Rate (%) National Average State Average
Pneumonia 15.8 17.1 16.6
Heart Failure 23.6 21.9 21.1
Heart Attack + 16.8 16.5
Chronic Obstructive Pulmonary Disease (COPD) Readmission Rate 18.5 20.0 19.5
Stroke Readmissions 13.6 12.5 11.9

     
Hip and Knee Replacement Surgery
Measure Rate National Average State Average State Benchmark
Hip and Knee Replacement Readmission (7/1/2012 — 6/30/2015) 5.1 4.6 4.5 n/a
Hip and Knee Replacement Complication Rate (4/1/2012 — 3/31/2015) 3.6 3.0 3.0 2.5
Hip Fracture Mortality Rate (2014) 6.82 2.53 2.48 n/a
Hip Replacement Mortality Rate (2014) 0.00 0.07 0.02 n/a

     
All Cause Readmissions (Risk Adjusted) (1/1/2015 — 12/31/2015)
Measure Rate State Benchmark State Average
All Cause Readmission 9.7 6.5 9.0

     
CLABSI - Central Line Associated Blood Stream Infections (ICU and other select units) (4/1/2015 - 3/31/2016)
Measure Ratio National Comparison State Comparison
CLABSI 0.000 1.00 0.44

     
CAUTI - Catheter Associated Urinary Tract Infections (4/1/2015 - 3/31/2016)
Measure Ratio National Comparison State Comparison
CAUTI 0.000 1.00 0.51

     
Surgical Site Infections (SSI) - Colon Surgery (4/1/2015 - 3/31/2016)
Measure Ratio National Comparison State Comparison
SSI - Colon Surgery 2.097 1.00 1.00

     
Surgical Site Infections (SSI) - Abdominal Hysterectomy (4/1/2015 - 3/31/2016)
Measure Ratio National Comparison State Comparison
SSI - Abdominal Hysterectomy + 1.00 0.83

     
Clostridium difficile infections (4/1/2015 - 3/31/2016)
Measure Ratio National Comparison State Comparison
C. difficile 1.105 1.00 0.97

     
Methicillin-Resistant Staphylococcus aureus (MRSA) Infections (4/1/2015 - 3/31/2016)
Measure Ratio National Comparison State Comparison
MRSA 0.000 1.00 0.54

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