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3
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55
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58
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76
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120
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23
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24
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148
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149
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132
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134
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27
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29
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71
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32
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34
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57
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101
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37
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38
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30
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42
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93
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44
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22
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45
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96
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112
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46
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48
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49
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78
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31
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94
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100
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105
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106
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50
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51
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54
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21
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56
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40
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41
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14
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70
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67
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60
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61
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62
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64
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140
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63
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144
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66
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35
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43
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116
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79
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131
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80
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102
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82
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108
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2
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133
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69
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128
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126
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72
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73
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74
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77
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83
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85
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86
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89
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147
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99
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90
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91
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107
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109
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19
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68
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84
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75
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122
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4
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110
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111
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52
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65
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113
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114
Vernon Memorial Hospital (Viroqua)
115
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117
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118
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119
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13
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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 Community Memorial Hospital Campus
The Medication Reconciliation and Incidental Appendectomy Rate measures will be retired in September 2017.

Demographic Information
W180 N8085 Town Hall Road
Menomonee Falls, WI  53051
-251-1000
http://www.froedtert.com/community-memorial
Services: Adult Intensive Care, Emergency, Obstetrics, Orthopedics, Psychiatry, Cardiovascular

View this hospital’s charges for the 75 most common hospitalizations in WI
Discharges/Yr: 8615
Population: Suburban
Staffed Beds: 202
Report generated May 23 2017 9:18 PM
 
Composite scores are calculated from the most recent publicly reported CheckPoint data available on the calculation date. There may be different date ranges for the component measures within a single composite score. Composite calculation date: 5/1/2017.
Measure Star Rating Hospital Result WI Average National Average Hospital Trend Desired Direction Report Period
Birth
Birth Composite
Cesarean Section (PC-02) 21 23 1/1/2016 - 12/31/2016
Early Elective Delivery (PC-01) 1 5 1/1/2016 - 12/31/2016
Exclusive Breastfeeding (PC-05) 65 64 1/1/2016 - 12/31/2016
Infant Complications NDA 3 1/1/2016 - 12/31/2016
Newborn Screening Turnaround Time 100 99 1/1/2016 - 12/31/2016
High-Risk Procedure Volume
Abdominal Aortic Aneurysm Repair 10/1/2015 - 9/30/2016
Angioplasty-PTCA 128 10/1/2015 - 9/30/2016
Carotid Endarterectomy 5 10/1/2015 - 9/30/2016
Heart Bypass-CABG 66 10/1/2015 - 9/30/2016
Incidental Appendectomy Rate 1.54 2.33 10/1/2015 - 9/30/2016
Hip and Knee Replacement Surgery
Hip and Knee Composite
Hip and Knee Replacement Complications 3.0 3.0 3.0 4/1/2012 - 3/31/2015
Hip and Knee Replacement Readmissions (CMS 30-day) 5.2 4.5 4.6 7/1/2012 - 6/30/2015
Hip Fracture Mortality 2.20 2.29 10/1/2015 - 9/30/2016
Hip Replacement Mortality 0.00 0.14 10/1/2015 - 9/30/2016
Infections
Infection Composite
Catheter Associated Urinary Tract Infections 0.113 0.42 1.00 10/1/2015 - 9/30/2016
Central Line Associated Blood Stream Infections 0.000 0.39 1.00 10/1/2015 - 9/30/2016
Clostridium difficile Infections 1.038 0.88 1.00 10/1/2015 - 9/30/2016
Methicillin Resistant Staph Aureus Infections + + 0.43 1.00 10/1/2015 - 9/30/2016
SSI - Abdominal Hysterectomy + + 0.62 1.00 10/1/2015 - 9/30/2016
SSI - Colon Surgery 1.148 0.99 1.00 10/1/2015 - 9/30/2016
Mortality Rates
Mortality Composite
Abdominal Aortic Aneurysm Repair 4.45 10/1/2015 - 9/30/2016
Angioplasty - PTCA 3.28 3.13 10/1/2015 - 9/30/2016
Carotid Endarterectomy + + 0.13 10/1/2015 - 9/30/2016
Craniotomy 4.66 10/1/2015 - 9/30/2016
Gastrointestinal (GI) Hemorrhage 1.59 2.55 10/1/2015 - 9/30/2016
Heart Attack (CMS 30-day) 16.0 14.1 14.1 7/1/2012 - 6/30/2015
Heart Bypass - CABG 1.54 3.44 10/1/2015 - 9/30/2016
Heart Failure (CMS 30-day) 14.6 12.7 12.1 7/1/2012 - 6/30/2015
Pneumonia (CMS 30-day) 17.6 16.5 16.3 7/1/2012 - 6/30/2015
Stroke 5.76 6.30 10/1/2015 - 9/30/2016
Patient Safety
Patient Safety Composite (PSI-90) DNR 0.64 0.91 10/1/2014 - 9/30/2015
Accidental Puncture or Cut (PSI-15) 0.00 0.00 10/1/2015 - 9/30/2016
Falls with Major Injury (Rate per 1,000 discharges) 0.00 0.02 10/1/2015 - 9/30/2016
Medication Reconciliation Completed DNR 94 7/1/2016 - 12/31/2016
Pneumothorax/Collapsed Lung (PSI-6) 0.01 0.01 10/1/2015 - 9/30/2016
Post-Op Abdominal Wound Complication (PSI-14) 0.00 0.00 10/1/2015 - 9/30/2016
Post-Op Bleeding (PSI-9) 0.10 0.18 10/1/2015 - 9/30/2016
Post-Op Blood Clot (PSI-12) 0.18 0.21 10/1/2015 - 9/30/2016
Post-Op Hip Fracture (PSI-8) 0.00 0.00 10/1/2015 - 9/30/2016
Post-Op Kidney Complications (PSI-10) 0.00 0.00 10/1/2015 - 9/30/2016
Post-Op Respiratory Failure (PSI-11) 0.00 0.42 10/1/2015 - 9/30/2016
Post-Op Sepsis/Blood Infection (PSI-13) 0.28 0.45 10/1/2015 - 9/30/2016
Pressure Ulcers (PSI-3) 0.00 0.02 10/1/2015 - 9/30/2016
Patient Satisfaction
Patient Satisfaction Composite 7/1/2015 - 6/30/2016
Always Quiet at Night 63 65 63 7/1/2015 - 6/30/2016
Definitely Recommend Hospital 77 76 72 7/1/2015 - 6/30/2016
Doctors Always Communicated Well 82 84 82 7/1/2015 - 6/30/2016
Nurses Always Communicated Well 82 83 80 7/1/2015 - 6/30/2016
Pain Always Well Controlled 71 72 71 7/1/2015 - 6/30/2016
Patient Rated Hospital High 77 77 72 7/1/2015 - 6/30/2016
Patients Always Received Requested Help 66 74 69 7/1/2015 - 6/30/2016
Patients Understood Their Care When They Left 59 57 52 7/1/2015 - 6/30/2016
Room Always Clean 76 80 74 7/1/2015 - 6/30/2016
Staff Always Explained Medications 67 69 65 7/1/2015 - 6/30/2016
Staff Provided Discharge Instructions 90 90 87 7/1/2015 - 6/30/2016
Readmissions
Readmissions Composite
All Causes 11.0 9.1 7/1/2015 - 6/30/2016
COPD (CMS 30-day) 18.0 19.5 20.0 7/1/2012 - 6/30/2015
Heart Attack (CMS 30-day) 18.4 16.5 16.8 7/1/2012 - 6/30/2015
Heart Failure (CMS 30-day) 21.9 21.1 21.9 7/1/2012 - 6/30/2015
Hip and Knee Replacement (CMS 30-day) 5.2 4.5 4.6 7/1/2012 - 6/30/2015
Pneumonia (CMS 30-day) 16.0 16.6 17.1 7/1/2012 - 6/30/2015
Stroke (CMS 30-day) 11.1 11.9 12.5 7/1/2012 - 6/30/2015
Stroke
Stroke Mortality Rate 5.76 6.30 10/1/2015 - 9/30/2016
Stroke Readmissions (CMS 30-day) 11.1 11.9 12.5 7/1/2012 - 6/30/2015

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