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
St. Mary's Hospital
Demographic Information

700 South Park Street
Madison, WI  53715
608-251-6100
http://www.stmarysmadison.com
Services: Emergency, Gynecology, Neonatal Intensive Care, Neurology, Obstetrics, Oncology, Orthopedics, Pediatric Intensive Care, Pediatrics, Psychiatry, Pulmonary, Urology/Nephrology, Adult Intensive Care, Cardiovascular
Discharges/Yr: 23560
Population: Urban
Staffed Beds: 394
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 Jul 13 2014 5:06 PM

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 97 100 96 96
Heart Failure Hosp.
Score
State
Benchmark
State
Average
National
Average
LVF assessment (%) 100 100 99 99
ACEI for LVSD (%) 95 100 97 97
Discharge Instructions (%) 96 100 96 94
Pneumonia Hosp.
Score
State
Benchmark
State
Average
National
Average
Approp Anbtc 99 100 96 95
Blood Culture Collected 96 100 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 (%) 100 100 98  
Procedure verification (%) 100 100 98  
Medication reconciliation (%) 91 100 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 (%) 100 100 96
Stop Antibiotics (%) 87 100 96
Hip Surgery Hosp.
Score
State
Benchmark
National
Average
Start Antibiotics (%) 99 100 99
Appropriate Antibiotics (%) 100 100 100
Stop Antibiotics (%) 100 100 98
Hysterectomy Hosp.
Score
State
Benchmark
National
Average
Start Antibiotics (%) 97 100 99
Appropriate Antibiotics (%) 100 100 98
Stop Antibiotics (%) 97 100 98
Knee Surgery Hosp.
Score
State
Benchmark
National
Average
Start Antibiotics (%) 99 100 99
Appropriate Antibiotics (%) 100 100 100
Stop Antibiotics (%) 100 100 98
Other Cardiac Hosp.
Score
State
Benchmark
National
Average
Start Antibiotics (%) 98 100 99
Appropriate Antibiotics (%) 100 100 100
Stop Antibiotics (%) 99 100 98
Blood Sugar Controlled (%) 93 100
Vascular Surgery Hosp.
Score
State
Benchmark
National
Average
Start Antibiotics (%) 100 100 98
Appropriate Antibiotics (%) 100 100 99
Stop Antibiotics (%) 97 100 96
CABG Hosp.
Score
State
Benchmark
National
Average
Start Antibiotics (%) 98 100 99
Appropriate Antibiotics (%) 100 100 100
Stop Antibiotics (%) 100 100 99
Blood Sugar Controlled (%) 89
Index Hosp.
Score
State
Benchmark
State
Average
Surgical Infection Prevention index (%) 95 99 95
Surgical Care – All Procedures Hosp.
Score
State
Benchmark
National
Average
Start Antibiotics (%) 99 100 99
Appropriate Antibiotics (%) 100 100 99
Stop Antibiotics (%) 99 100 98
Clot Prevention Given (%) 99 100 98
Cath Removal (%) 99 100 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 rateBetter9.136.91
Gastrointestinal (GI) hemorrhage mortality rateBetter2.411.40
Hip fracture mortality rateBetter2.780.61
Deaths During a ProcedureExperienceNat'l Avg(%)State Avg(%)
AAA repair mortality rateAs Expected4.121.75
CABG mortality rateBetter2.581.14
CEA mortality rateBetter0.400.01
Craniotomy mortality rateAs Expected5.706.41
Hip replacement mortality rateBetter0.090.00
PTCA mortality rateBetter1.730.59
High Risk Procedure - Volumes Volume
AAA Volume 71
CABG Volume 351
CEA Volume 157
PTCA Volume 822
Incidental Appendectomy (%) 0.92

 
   
 Birth Measures Data (1/1/2013 - 12/31/2013)
 DNR

     
 Patient Experience of Care Survey Data (7/1/2012 - 6/30/2013)
Measure Rate National Average State Average State Benchmark
Patients ranked hospital high 80 70 74 83
Definitely recommend hospital 85 71 74 84
Doctors always communicated well 83 82 83 88
Nurses always communicated well 86 79 82 87
Patients always received requested help 73 67 72 82
Staff always explained medications 74 64 68 75
Pain always well controlled 76 71 72 77
Always quiet at night 66 61 63 72
Room always clean 81 73 79 87
Staff provided discharge instructions 90 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 89 92 100
STK-5: Early AntiThrom 98 96 100
STK-6: Dischg on Statin Med 98 88 100
STK-8: Stroke Education 96 91 100
STK-10: Assess for Rehab 99 97 100

     
 CMS 30-Day Mortality Data (7/1/2009 - 6/30/2012)
Measure Rate National Average State Average
Pneumonia 9.0 11.9 12.0
Heart Failure 10.7 11.7 12.4
Heart Attack 13.2 15.2 15.4

     
 CMS 30-Day Readmission Data (7/1/2009 - 6/30/2012)
Measure Rate National Average State Average
Pneumonia 16.1 17.6 17.1
Heart Failure 21.5 23.0 22.0
Heart Attack 15.8 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 0.819 1.000 0.464

     
 CAUTI – Catheter Associated Urinary Tract Infections (1/1/2013 - 12/31/2013)
Measure Ratio National Comparison State Comparison
CAUTI 0.306 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 1.261 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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