Hospital Report
Ascension Columbia St. Mary's Hospital Milwaukee
2301 North Lake Drive
Milwaukee, Wisconsin, 53211
414-585-1000
http://healthcare.ascension.org/locations/wisconsin
Generated: Monday, June 9, 2025
Birth
| Measure | Hospital Result | State Average | State Benchmark | National Average | Report Period |
|---|---|---|---|---|---|
| Newborn Screening Card Transit Time | 95.16 | 97.61 | 100 | --- | 1/1/2024-12/31/2024 |
Hip and Knee Surgical Complications
| Measure | Hospital Result | State Average | State Benchmark | National Average | Report Period |
|---|---|---|---|---|---|
| Hip and Knee Surgery Complications | 3.285 | 2.76 | 3.5 | 7/1/2020-6/30/2023 |
Infections
| Measure | Hospital Result | State Average | State Benchmark | National Average | Report Period |
|---|---|---|---|---|---|
| Catheter-Associated Urinary Tract Infections | 0 | 0.61 | 0 | 1 | 1/1/2024-12/31/2024 |
| Central Line Associated Blood Stream Infections | 0 | 0.53 | 0 | 1 | 1/1/2024-12/31/2024 |
| Clostridioides difficile Infections | 0.78 | 0.57 | 0 | 1 | 1/1/2024-12/31/2024 |
| Methicillin-Resistant Staph. aureus Infections | 0.842 | 0.44 | 0 | 1 | 1/1/2024-12/31/2024 |
| Surgical Site Infection - Abdominal Hysterectomy | 1.66 | 0 | 1 | 1/1/2024-12/31/2024 | |
| Surgical Site Infection - Colon Surgery | 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 | 5.456 | 5.936 | 0 | 6.83 | 1/1/2024-12/31/2024 |
| Chronic Obstructive Pulmonary Disease | 8.5 | 9.518 | 7.97 | 9.4 | 7/1/2020-6/30/2023 |
| GastrointestinaI Hemorrhage | 1.309 | 1.555 | 0 | 2.54 | 1/1/2024-12/31/2024 |
| Heart Attack | 12.3 | 12.112 | 10.86 | 12.6 | 7/1/2020-6/30/2023 |
| Heart Failure | 11.7 | 12.496 | 10.2 | 11.9 | 7/1/2020-6/30/2023 |
| Hip Fracture | 0 | 1.247 | 0 | 1.95 | 1/1/2024-12/31/2024 |
| Pneumonia | 14.7 | 17.418 | 14.58 | 17.9 | 7/1/2020-6/30/2023 |
Mortality - Procedures
| Measure | Hospital Result | State Average | State Benchmark | National Average | Report Period |
|---|---|---|---|---|---|
| Abdominal Aortic Aneurism Repair | 0.977 | 0 | 3.64 | 1/1/2024-12/31/2024 | |
| Carotid Endarterectomy | 0.268 | 0 | 0.43 | 1/1/2024-12/31/2024 | |
| Coronary Artery Bypass Graft | 0 | 2.138 | 0 | 2.48 | 1/1/2024-12/31/2024 |
| Percutaneous Coronary Intervention | 2.645 | 2.306 | 0 | 3.31 | 1/1/2024-12/31/2024 |
Patient Experience
| Measure | Hospital Result | State Average | State Benchmark | National Average | Report Period |
|---|---|---|---|---|---|
| Always Quiet at Night | 57 | 66 | 78 | 62 | 7/1/2023-6/30/2024 |
| Definitely Recommend Hospital | 59 | 74 | 85 | 70 | 7/1/2023-6/30/2024 |
| Doctors Always Communicated Well | 75 | 82 | 89 | 80 | 7/1/2023-6/30/2024 |
| Nurses Always Communicated Well | 73 | 83 | 90 | 80 | 7/1/2023-6/30/2024 |
| Patient Rated Hospital High | 60 | 76 | 87 | 72 | 7/1/2023-6/30/2024 |
| Patients Always Received Requested Help | 49 | 71 | 83 | 67 | 7/1/2023-6/30/2024 |
| Patients Understood Their Care When They Left | 45 | 56 | 63 | 52 | 7/1/2023-6/30/2024 |
| Room Always Clean | 66 | 77 | 88 | 74 | 7/1/2023-6/30/2024 |
| Staff Always Explained Medications | 51 | 66 | 75 | 62 | 7/1/2023-6/30/2024 |
| Staff Provided Discharge Instructions | 84 | 90 | 94 | 86 | 7/1/2023-6/30/2024 |
Patient Safety - All Patients
| Measure | Hospital Result | State Average | State Benchmark | National Average | Report Period |
|---|---|---|---|---|---|
| Healthcare Personnel Influenza Immunization | DNR | 83.41 | 94.79 | --- | 10/1/2023-5/15/2024 |
| In Hospital Fall Associated Fracture Rate | 0 | 0.034 | 0 | 0.03 | 1/1/2024-12/31/2024 |
| Pneumothorax | 0.016 | 0.01 | 0 | 0.02 | 1/1/2024-12/31/2024 |
| Pressure Ulcers | 0.036 | 0.025 | 0 | 0.07 | 1/1/2024-12/31/2024 |
| Sepsis-1 | 61 | 70 | 69.5 | 63 | 7/1/2023-6/30/2024 |
Patient Safety - Patients with Surgery
| Measure | Hospital Result | State Average | State Benchmark | National Average | Report Period |
|---|---|---|---|---|---|
| Perioperative Blood Clot | 0.348 | 0.149 | 0 | 0.31 | 1/1/2024-12/31/2024 |
| Perioperative Hemorrhage | 0.057 | 0.23 | 0 | 0.23 | 1/1/2024-12/31/2024 |
| Postoperative Respiratory Failure | 0.544 | 0.364 | 0 | 0.73 | 1/1/2024-12/31/2024 |
| Postoperative Sepsis | 0.26 | 0.283 | 0 | 0.42 | 1/1/2024-12/31/2024 |
Perinatal
| Measure | Hospital Result | State Average | State Benchmark | National Average | Report Period |
|---|---|---|---|---|---|
| Cesarean Birth | 21.075 | 14.87 | --- | 1/1/2024-12/31/2024 | |
| Severe Obstetric Complications | 0 | 1.448 | 0 | --- | 1/1/2024-12/31/2024 |
Readmissions
| Measure | Hospital Result | State Average | State Benchmark | National Average | Report Period |
|---|---|---|---|---|---|
| All Cause Unplanned Readmissions | 10.6 | 9.71 | 7.2 | --- | 10/1/2023-9/30/2024 |
| Chronic Obstructive Pulmonary Disease | 17.6 | 18.139 | 17.3 | 18.5 | 7/1/2020-6/30/2023 |
| Coronary Artery Bypass Graft | 11.6 | 10.679 | 9.8 | 10.7 | 7/1/2020-6/30/2023 |
| Heart Attack | 14 | 13.55 | 12.6 | 13.7 | 7/1/2020-6/30/2023 |
| Heart Failure | 19.7 | 19.4 | 17.91 | 19.8 | 7/1/2020-6/30/2023 |
| Hip and Knee Surgery | 4.33 | 3.76 | 4.5 | 7/1/2020-6/30/2023 | |
| Pneumonia | 15.4 | 16.134 | 15.2 | 16.4 | 7/1/2020-6/30/2023 |