Hospital Report

SSM Health St. Mary's Hospital

700 Park Street South
Madison, Wisconsin, 53715
608-251-6100
http://www.ssmhealth.com/wisconsin

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Generated: Thursday, May 9, 2024
Measure Hospital Result State Average State Benchmark National Average Report Period
Cesarean Birth DNR 21.95 14.55 --- 1/1/2023-12/31/2023
Early Elective Delivery DNR 3.4 0 --- 1/1/2023-12/31/2023
Exclusive Breast Milk Feeding DNR 62.99 76.39 --- 1/1/2023-12/31/2023
Newborn Screening Card Transit Time 100 98.98 100 --- 1/1/2023-12/31/2023
Term Newborn Complications DNR 3.19 1.46 --- 1/1/2023-12/31/2023
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Measure Hospital Result State Average State Benchmark National Average Report Period
Hip and Knee Surgery Complications 3.1 3.1 2.6 3.2 4/1/2019-3/31/2022
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Measure Hospital Result State Average State Benchmark National Average Report Period
Catheter-Associated Urinary Tract Infections 0.144 0.61 0 1 10/1/2022-9/30/2023
Central Line Associated Blood Stream Infections 0.298 0.69 0 1 10/1/2022-9/30/2023
Clostridioides difficile Infections 0.144 0.67 0 1 10/1/2022-9/30/2023
Methicillin-Resistant Staph. aureus Infections 0.662 0.42 0 1 10/1/2022-9/30/2023
Surgical Site Infection - Abdominal Hysterectomy 0 1.15 0 1 10/1/2022-9/30/2023
Surgical Site Infection - Colon Surgery 1.236 0.88 0 1 10/1/2022-9/30/2023
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Measure Hospital Result State Average State Benchmark National Average Report Period
Acute Stroke 6.309 6.431 0 6.86 10/1/2022-9/30/2023
Chronic Obstructive Pulmonary Disease 9.7 9.3 7.8 9.2 7/1/2019-6/30/2022
GastrointestinaI Hemorrhage 1.573 2.336 0 2.51 10/1/2022-9/30/2023
Heart Attack 12.1 12.2 10.6 12.6 7/1/2019-6/30/2022
Heart Failure 13.4 12.4 9.9 11.8 7/1/2019-6/30/2022
Hip Fracture 2.008 2.376 0 1.96 10/1/2022-9/30/2023
Pneumonia 18.4 18.1 15.8 18.2 7/1/2019-6/30/2022
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Measure Hospital Result State Average State Benchmark National Average Report Period
Abdominal Aortic Aneurism Repair 9.858 1.854 0 3.61 10/1/2022-9/30/2023
Carotid Endarterectomy 0 0.082 0 0.43 10/1/2022-9/30/2023
Coronary Artery Bypass Graft 1.637 2.985 0 2.49 10/1/2022-9/30/2023
Percutaneous Coronary Intervention 2.982 2.262 0 3.26 10/1/2022-9/30/2023
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Measure Hospital Result State Average State Benchmark National Average Report Period
Always Quiet at Night 60 66 76 62 4/1/2022-3/31/2023
Definitely Recommend Hospital 73 73 83 69 4/1/2022-3/31/2023
Doctors Always Communicated Well 79 81 88 79 4/1/2022-3/31/2023
Nurses Always Communicated Well 78 82 89 79 4/1/2022-3/31/2023
Patient Rated Hospital High 74 75 87 71 4/1/2022-3/31/2023
Patients Always Received Requested Help 54 70 81 66 4/1/2022-3/31/2023
Patients Understood Their Care When They Left 53 55 64 52 4/1/2022-3/31/2023
Room Always Clean 73 77 86 72 4/1/2022-3/31/2023
Staff Always Explained Medications 60 66 75 62 4/1/2022-3/31/2023
Staff Provided Discharge Instructions 87 89 93 86 4/1/2022-3/31/2023
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Measure Hospital Result State Average State Benchmark National Average Report Period
Falls with Major Injury 0.042 0.035 0 --- 10/1/2022-9/30/2023
Healthcare Personnel Influenza Immunization 93.53 83.2 94.8 --- 10/1/2022-5/15/2023
Pneumothorax 0.008 0.01 0 0.02 10/1/2022-9/30/2023
Pressure Ulcers 0.044 0.064 0 0.07 10/1/2022-9/30/2023
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Measure Hospital Result State Average State Benchmark National Average Report Period
Perioperative Blood Clot 0.226 0.235 0 0.35 10/1/2022-9/30/2023
Perioperative Hemorrhage 0.222 0.253 0 0.23 10/1/2022-9/30/2023
Postoperative Respiratory Failure 0.493 0.537 0 0.73 10/1/2022-9/30/2023
Postoperative Sepsis 0.478 0.257 0 0.43 10/1/2022-9/30/2023
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Measure Hospital Result State Average State Benchmark National Average Report Period
All Cause Unplanned Readmissions 10.4 9.1 6.38 --- 7/1/2022-6/30/2023
Chronic Obstructive Pulmonary Disease 19 18.8 17.8 19.3 7/1/2019-6/30/2022
Coronary Artery Bypass Graft 9.9 11 9.9 11 7/1/2019-6/30/2022
Heart Attack 13.9 13.7 12.5 14 7/1/2019-6/30/2022
Heart Failure 17.7 19.9 18.3 20.2 7/1/2019-6/30/2022
Hip and Knee Surgery 3.5 4.2 3.5 4.3 7/1/2019-6/30/2022
Pneumonia 16.7 16.6 15.6 16.9 7/1/2019-6/30/2022
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