Hospital Report
ProHealth Waukesha Memorial Hospital
725 American Avenue
Waukesha, Wisconsin, 53188
800-326-2011
http://www.prohealthcare.org/facility-waukesha-waukesha-memorial-hospital.aspx
Generated: Friday, September 5, 2025
Birth
| Measure | Hospital Result | State Average | State Benchmark | National Average | Report Period |
|---|---|---|---|---|---|
| Newborn Screening Card Transit Time | 97.111 | 97.3 | 100 | --- | 4/1/2024-3/31/2025 |
Hip and Knee Surgical Complications
| Measure | Hospital Result | State Average | State Benchmark | National Average | Report Period |
|---|---|---|---|---|---|
| Hip and Knee Surgery Complications | 3.294 | 2.66 | 3.6 | 7/1/2021-6/30/2024 |
Infections
| Measure | Hospital Result | State Average | State Benchmark | National Average | Report Period |
|---|---|---|---|---|---|
| Catheter-Associated Urinary Tract Infections | 0.539 | 0.61 | 0 | 1 | 1/1/2024-12/31/2024 |
| Central Line Associated Blood Stream Infections | 0.184 | 0.53 | 0 | 1 | 1/1/2024-12/31/2024 |
| Clostridioides difficile Infections | 0.391 | 0.57 | 0 | 1 | 1/1/2024-12/31/2024 |
| Methicillin-Resistant Staph. aureus Infections | 0.86 | 0.44 | 0 | 1 | 1/1/2024-12/31/2024 |
| Surgical Site Infection - Abdominal Hysterectomy | 0.888 | 1.66 | 0 | 1 | 1/1/2024-12/31/2024 |
| Surgical Site Infection - Colon Surgery | 0.215 | 0.91 | 0 | 1 | 1/1/2024-12/31/2024 |
Mortality - Conditions
| Measure | Hospital Result | State Average | State Benchmark | National Average | Report Period |
|---|---|---|---|---|---|
| Acute Stroke | 0.365 | 5.197 | 0 | 6.83 | 4/1/2024-3/31/2025 |
| Chronic Obstructive Pulmonary Disease | 7.8 | 8.882 | 7.3 | 8.8 | 7/1/2021-6/30/2024 |
| GastrointestinaI Hemorrhage | 0.745 | 1.31 | 0 | 2.54 | 4/1/2024-3/31/2025 |
| Heart Attack | 12.8 | 11.898 | 10.64 | 12.2 | 7/1/2021-6/30/2024 |
| Heart Failure | 13.4 | 12.329 | 9.7 | 11.6 | 7/1/2021-6/30/2024 |
| Hip Fracture | 0.759 | 1.559 | 0 | 1.95 | 4/1/2024-3/31/2025 |
| Pneumonia | 19.3 | 15.989 | 13.03 | 16.2 | 7/1/2021-6/30/2024 |
Mortality - Procedures
| Measure | Hospital Result | State Average | State Benchmark | National Average | Report Period |
|---|---|---|---|---|---|
| Abdominal Aortic Aneurism Repair | 1.551 | 0 | 3.64 | 4/1/2024-3/31/2025 | |
| Carotid Endarterectomy | 0 | 0.257 | 0 | 0.43 | 4/1/2024-3/31/2025 |
| Coronary Artery Bypass Graft | 0 | 1.955 | 0 | 2.48 | 4/1/2024-3/31/2025 |
| Percutaneous Coronary Intervention | 0.444 | 2.238 | 0 | 3.31 | 4/1/2024-3/31/2025 |
Patient Experience
| Measure | Hospital Result | State Average | State Benchmark | National Average | Report Period |
|---|---|---|---|---|---|
| Always Quiet at Night | 61 | 66 | 78 | 62 | 10/1/2023-9/30/2024 |
| Definitely Recommend Hospital | 75 | 74 | 87 | 70 | 10/1/2023-9/30/2024 |
| Doctors Always Communicated Well | 81 | 82 | 89 | 80 | 10/1/2023-9/30/2024 |
| Nurses Always Communicated Well | 81 | 83 | 91 | 80 | 10/1/2023-9/30/2024 |
| Patient Rated Hospital High | 76 | 76 | 87 | 72 | 10/1/2023-9/30/2024 |
| Patients Always Received Requested Help | 58 | 71 | 83 | 66 | 10/1/2023-9/30/2024 |
| Patients Understood Their Care When They Left | 54 | 55 | 64 | 52 | 10/1/2023-9/30/2024 |
| Room Always Clean | 69 | 77 | 87 | 74 | 10/1/2023-9/30/2024 |
| Staff Always Explained Medications | 61 | 65 | 74 | 62 | 10/1/2023-9/30/2024 |
| Staff Provided Discharge Instructions | 90 | 90 | 93 | 86 | 10/1/2023-9/30/2024 |
Patient Safety - All Patients
| Measure | Hospital Result | State Average | State Benchmark | National Average | Report Period |
|---|---|---|---|---|---|
| Healthcare Personnel Influenza Immunization | 96.885 | 79.62 | 94.09 | --- | 10/1/2024-5/15/2025 |
| In Hospital Fall Associated Fracture Rate | 0.009 | 0.041 | 0 | 0.03 | 4/1/2024-3/31/2025 |
| Pneumothorax | 0 | 0.011 | 0 | 0.02 | 4/1/2024-3/31/2025 |
| Pressure Ulcers | 0.058 | 0.027 | 0 | 0.07 | 4/1/2024-3/31/2025 |
| Sepsis-1 | 72 | 70 | 71 | 63 | 10/1/2023-9/30/2024 |
Patient Safety - Patients with Surgery
| Measure | Hospital Result | State Average | State Benchmark | National Average | Report Period |
|---|---|---|---|---|---|
| Perioperative Blood Clot | 0.131 | 0.163 | 0 | 0.31 | 4/1/2024-3/31/2025 |
| Perioperative Hemorrhage | 0.147 | 0.165 | 0 | 0.23 | 4/1/2024-3/31/2025 |
| Postoperative Respiratory Failure | 0.695 | 0.299 | 0 | 0.73 | 4/1/2024-3/31/2025 |
| Postoperative Sepsis | 0.346 | 0.178 | 0 | 0.42 | 4/1/2024-3/31/2025 |
Perinatal
Readmissions
| Measure | Hospital Result | State Average | State Benchmark | National Average | Report Period |
|---|---|---|---|---|---|
| All Cause Unplanned Readmissions | 11.6 | 9.65 | 7 | --- | 1/1/2024-12/31/2024 |
| Chronic Obstructive Pulmonary Disease | 18.6 | 17.911 | 17.3 | 18.2 | 7/1/2021-6/30/2024 |
| Coronary Artery Bypass Graft | 9 | 10.483 | 9.22 | 10.6 | 7/1/2021-6/30/2024 |
| Heart Attack | 13.9 | 13.484 | 12.52 | 13.6 | 7/1/2021-6/30/2024 |
| Heart Failure | 18.4 | 19.339 | 18.01 | 19.7 | 7/1/2021-6/30/2024 |
| Hip and Knee Surgery | 4.722 | 3.9 | 4.8 | 7/1/2021-6/30/2024 | |
| Pneumonia | 15.6 | 15.778 | 14.62 | 16 | 7/1/2021-6/30/2024 |