Select by Hospital

Agnesian HealthCare/St. Agnes Hospital (Fond du Lac)
87
Amery Regional Medical Center (Amery)
3
Aspirus Medford Hospital & Clinics, Inc. (Medford)
58
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
Baldwin Area Medical Center, Inc. (Baldwin)
13
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
Bellin Psychiatric Center (Green Bay)
142
Beloit Health System (Beloit)
18
Berlin Memorial Hospital (Berlin)
19
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
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
Langlade Hospital - An Aspirus Partner (Antigo)
55
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
Meriter-UnityPoint Health (Madison)
65
Midwest Orthopedic Specialty Hospital (Franklin)
144
Mile Bluff Medical Center (Mauston)
66
Ministry Door County Medical Center (Sturgeon Bay)
34
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
Riverview Hospital Association (Wisconsin Rapids)
76
Rusk County Memorial Hospital (Ladysmith)
77
Sauk Prairie Healthcare (Prairie du Sac)
83
Shawano Medical Center (Shawano)
84
Southwest Health Center (Platteville)
85
Spooner Health System (Spooner)
86
St. Clare Hospital & Health Services (Baraboo)
89
St. Croix Regional Medical Center (St. Croix Falls)
90
St. Elizabeth Hospital (Appleton)
91
St. Mary's Hospital (Madison)
99
St. Mary's Janesville Hospital (Janesville)
147
Stoughton Hospital Association (Stoughton)
107
The Richland Hospital, Inc. (Richland Center)
109
ThedaCare Medical Center - New London (New London)
68
ThedaCare Medical Center-Waupaca (Waupaca)
75
ThedaCare Regional Medical Center- Appleton (Appleton)
4
ThedaCare Regional Medical Center- Neenah (Neenah)
110
Tomah Memorial Hospital (Tomah)
111
United Hospital System (Kenosha)
52
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
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
Wild Rose Community Memorial Hospital (Wild Rose)
122
Please note the following upcoming measure retirements:
  • December, 2015
    1. Acute MI - PCI within 90 minutes (AMI-8a)
    2. Heart Failure - LVF Assessment (HF-2)
    3. Pneumonia - Antibiotic Selection (PN-6)
    4. Stroke
      1. Discharged on Antithrombotic Therapy (STK-2)
      2. Anticoagulation Therapy for Atrial Fibrillation (STK-3)
      3. Antithrombotic Therapy by End of Day 2 (STK-5)
      4. Assessed for Rehab (STK-10)
    5. SCIP
      1. Antibiotics within 1 hour of incision (SCIP-Inf-1)
      2. Appropriate Antibiotic (SCIP-Inf-2)
      3. Antibiotics stopped with 24 hours of surgery (SCIP-Inf-3)
      4. Urinary Catheter Removal (SCIP-Inf-9)
      5. Perioperative beta-blockers (SCIP-Card-2)
      6. VTE Received (SCIP-VTE-2)
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, Adult Intensive Care, Urology/Nephrology, Cardiovascular

View this hospital’s charges for the 75 most common hospitalizations in WI
Discharges/Yr: 23560
Population: Urban
Staffed Beds: 394
Report generated Aug 31 2015 10:16 AM
 

Medical Services

Measurement data are from 10/1/2013 — 9/30/2014
Heart Attack Hosp.
Score
State
Benchmark
State
Average
National
Average
PCI within 90 minutes + 100 96 96
Heart Failure Hosp.
Score
State
Benchmark
State
Average
National
Average
LVF assessment (%) 100 100 99 99
Pneumonia Hosp.
Score
State
Benchmark
State
Average
National
Average
Appropriate Antibiotic 94 100 97 96

Error Prevention

Measurement data are from 7/1/2014—12/31/2014
National Safety Goals Hosp.
Score
State
Benchmark
State
Average
 
Medication reconciliation (%) 90 100 94  

Surgical Care

Measurement data are from 10/1/2013 — 9/30/2014
Surgical Care - All Procedures Hosp.
Score
State
Benchmark
State
Average
National
Average
Start antibiotic (%) 99 100 99 99
Appropriate antibiotic (%) 99 100 99 99
Stop antibiotic (%) 99 100 99 98
Clot Prevention Given (%) 100 100 100 99
Urinary Catheter Removal (%) 99 100 99 98
Beta Blocker Received (%) 100 100 99 98

Deaths Data (2013)
Deaths due to IllnessExperienceNat'l Avg(%)State Avg(%)
Acute stroke mortality rateAs Expected9.139.44
Gastrointestinal (GI) hemorrhage mortality rateAs Expected2.412.44
Hip fracture mortality rateAs Expected2.783.39
Deaths During a ProcedureExperienceNat'l Avg(%)State Avg(%)
CABG mortality rateAs Expected2.583.39
CEA mortality rateAs Expected0.400.31
Craniotomy mortality rateAs Expected5.704.75
Hip replacement mortality rateAs Expected0.090.02
PTCA mortality rateAs Expected1.731.83
High Risk Procedure - Volumes Volume
AAA Volume 56
CABG Volume 220
CEA Volume 136
PTCA Volume 616
Incidental Appendectomy Rate (%) 0.32

 
   
Birth Measures Data  (4/1/2014 - 3/31/2015)
 DNR

     
Patient Experience of Care Survey (10/1/2013 - 9/30/2014)
Measure Rate National Average State Average State Benchmark
Patients ranked hospital high 85 71 76 84
Definitely recommend hospital 86 71 75 85
Doctors always communicated well 82 82 84 90
Nurses always communicated well 85 79 83 88
Patients always received requested help 72 68 73 84
Staff always explained medications 73 65 69 78
Pain always well controlled 71 71 73 79
Always quiet at night 66 62 65 73
Room always clean 82 74 80 87
Staff provided discharge instructions 90 86 90 93

     
Stroke Data (10/1/2013 — 9/30/2014)
Measure Rate National Average State Average State Benchmark
STK-2: Antithrombotic Therapy 99 99 99 100
STK-3: Anticoagulation Therapy 95 96 96 100
STK-5: Start Antithrombotic 98 98 99 100
STK-6: Discharge on Statin Medication 96 96 96 100
STK-8: Stroke Education 94 93 94 100
STK-10: Assessed for Rehab 99 98 99 100

     
CMS 30-Day Mortality Data (7/1/2010 - 6/30/2013)
Measure Rate National Average State Average
Pneumonia 9.6 11.9 12.2
Heart Failure 10.7 11.9 12.6
Heart Attack 13.6 14.9 15.1

     
CMS 30-Day Readmission Data (7/1/2010 - 6/30/2013)
Measure Rate National Average State Average
Pneumonia 15.8 17.3 16.9
Heart Failure 20.4 22.7 21.7
Heart Attack 15.2 17.8 17.3

     
All Cause Readmissions (Non-Risk Adjusted) (7/1/2013 — 6/30/2014)
Measure Rate State Benchmark State Average
All Cause Readmission 9 5 10

     
CLABSI - Central Line Associated Blood Stream Infection Data (ICU Patients) (1/1/2014 - 12/31/2014)
Measure Ratio National Comparison State Comparison
CLABSI 0.958 1.000 0.332

     
CAUTI - Catheter Associated Urinary Tract Infections (1/1/2014 - 12/31/2014)
Measure Ratio National Comparison State Comparison
CAUTI 0.655 1.000 0.822

     
Surgical Site Infections (SSI) - Colon Surgery (1/1/2014 - 12/31/2014)
Measure Ratio National Comparison State Comparison
SSI - Colon Surgery 1.854 1.000 0.981

     
Surgical Site Infections (SSI) - Abdominal Hysterectomy (1/1/2014 - 12/31/2014)
Measure Ratio National Comparison State Comparison
SSI - Abdominal Hysterectomy 0 1.000 0.931

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