Bottom quartile Middle Top quartile Percentile badges compare this hospital to all 5,426 hospitals nationally.

Overview

Address
725 AMERICAN AVE, WAUKESHA, WI 53188
Phone
(262) 928-1000
Hospital Type
Acute Care
Ownership
Non-Profit
Emergency Services
Yes
Birthing Friendly
Yes
5 /5
CMS Overall Rating
p89
Acute Care — General medical and surgical hospital participating in Medicare IPPS. Subject to CMS quality reporting and payment adjustment programs (VBP, HRRP, HAC).

CMS Star Rating — Quality Domain Breakdown

CMS computes the overall star rating from five quality domains. Each domain compares this hospital's measures against national benchmarks.

Mortality 7 of 7 measures reported
7
Better No different Worse
30-day death rates for heart attack, heart failure, pneumonia, COPD, stroke, CABG, and kidney disease.
Safety of Care 7 of 8 measures reported
2
5
Better No different Worse
Healthcare-associated infections and patient safety indicators (PSI-90 composite).
Readmission 10 of 11 measures reported
1
9
Better No different Worse
30-day unplanned readmission rates for heart attack, heart failure, pneumonia, COPD, hip/knee replacement, and CABG.
Patient Experience 8 of 8 measures reported
8 measures reported (comparative data not available for this domain)
HCAHPS survey scores — patient-reported experience with communication, responsiveness, cleanliness, and discharge planning.
Timely & Effective Care 12 of 12 measures reported
12 measures reported (comparative data not available for this domain)
Process-of-care measures including flu immunization, blood clot prevention, and appropriate use of imaging.

Readmissions — Hospital Readmissions Reduction Program

The Excess Readmission Ratio (ERR) compares this hospital's 30-day readmission rate to expected, adjusting for patient mix. An ERR of 1.0 means readmissions are as expected; > 1.0 triggers a Medicare payment penalty (up to 3%).

This hospital has excess readmissions in at least one condition and is subject to HRRP payment reduction.
Acute Myocardial Infarction (Heart Attack) 184 discharges
1.0298 p68
Heart Failure 568 discharges
0.9306 p11
Pneumonia 477 discharges
0.9797 p38
COPD 152 discharges
1.0226 p70
Hip/Knee Replacement
— Not reported
CABG Surgery
0.8517 p5
Expected (1.0) National median

Value-Based Purchasing

The Hospital VBP Program adjusts Medicare payments based on clinical quality. The Total Performance Score (TPS) is a weighted composite of four domains, each worth 25%. This hospital's TPS is above the national median, suggesting a positive payment adjustment.

30.1 p52
Total Performance Score
National median: 29.5
Clinical Outcomes 25% weight
5.5 p52
Nat'l median: 5.0
Measures mortality rates for conditions like heart attack, heart failure, pneumonia, and COPD. Based on 30-day risk-standardized mortality.
Safety 25% weight
9.6 p45
Nat'l median: 10.0
Patient safety measures including healthcare-associated infections (CLABSI, CAUTI, SSI, MRSA, C. diff) and perioperative complications.
Person & Community Engagement 25% weight
15.0 p84
Nat'l median: 8.8
Based on HCAHPS patient experience survey results — communication with nurses and doctors, hospital cleanliness, pain management, discharge information.
Efficiency & Cost Reduction 25% weight
0.0 p0
Nat'l median: 2.5
Based on Medicare Spending Per Beneficiary (MSPB). Measures episode-of-care costs from 3 days before admission through 30 days after discharge.

CMS Payment Programs

Three Medicare programs adjust hospital payments based on quality performance. Hospitals can be penalized under multiple programs simultaneously.

Readmissions (HRRP)
Penalized
Worst ERR: 1.0298
Value-Based Purchasing
30.1 TPS
Above national median
HAC Reduction
No Reduction
HAC Score: -0.4077

Complications & Deaths

30-day mortality rates, patient safety indicators, and complication rates. "Better" means statistically significantly better than the national rate.

Measure Score vs. National Denominator
COMP_HIP_KNEE Number of Cases Too Small
Hybrid_HWM 3.90 No Different Than the National Rate 1,401
MORT_30_AMI 12.80 No Different Than the National Rate 168
MORT_30_CABG 2.10 No Different Than the National Rate 51
MORT_30_COPD 7.80 No Different Than the National Rate 139
MORT_30_HF 13.40 No Different Than the National Rate 508
MORT_30_PN 19.30 No Different Than the National Rate 460
MORT_30_STK 15.20 No Different Than the National Rate 146
PSI_03 0.19 No Different Than the National Rate 4,643
PSI_04 148.65 No Different Than the National Rate 59
PSI_06 0.20 No Different Than the National Rate 5,800
PSI_08 0.33 No Different Than the National Rate 5,931
PSI_09 2.22 No Different Than the National Rate 1,159
PSI_10 1.33 No Different Than the National Rate 521
PSI_11 7.64 No Different Than the National Rate 524
PSI_12 4.23 No Different Than the National Rate 1,236
PSI_13 6.42 No Different Than the National Rate 501
PSI_14 1.67 No Different Than the National Rate 321
PSI_15 1.30 No Different Than the National Rate 1,042
PSI_90 0.90 No Different Than the National Value

Patient Experience (HCAHPS)

Hospital Consumer Assessment of Healthcare Providers and Systems — standardized patient survey measuring satisfaction with care.

Measure Score Star Rating
H_COMP_1_A_P: Nurses "always" communicated well 82%
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 2%
H_COMP_1_U_P: Nurses "usually" communicated well 16%
H_COMP_1_LINEAR_SCORE: Nurse communication - linear mean score
H_COMP_1_STAR_RATING: Nurse communication - star rating 4
H_NURSE_RESPECT_A_P: Nurses "always" treated them with courtesy and respect 90%
H_NURSE_RESPECT_SN_P: Nurses "sometimes" or "never" treated them with courtesy and respect 2%
H_NURSE_RESPECT_U_P: Nurses "usually" treated them with courtesy and respect 8%
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 79%
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 3%
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 18%
H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand 78%
H_NURSE_EXPLAIN_SN_P: Nurses "sometimes" or "never" explained things so they could understand 3%
H_NURSE_EXPLAIN_U_P: Nurses "usually" explained things so they could understand 19%
H_COMP_2_A_P: Doctors "always" communicated well 81%
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 4%
H_COMP_2_U_P: Doctors "usually" communicated well 15%
H_COMP_2_LINEAR_SCORE: Doctor communication - linear mean score
H_COMP_2_STAR_RATING: Doctor communication - star rating 4
H_DOCTOR_RESPECT_A_P: Doctors "always" treated them with courtesy and respect 89%
H_DOCTOR_RESPECT_SN_P: Doctors "sometimes" or "never" treated them with courtesy and respect 3%
H_DOCTOR_RESPECT_U_P: Doctors "usually" treated them with courtesy and respect 8%
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 81%
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 5%
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 14%
H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand 73%
H_DOCTOR_EXPLAIN_SN_P: Doctors "sometimes" or "never" explained things so they could understand 5%
H_DOCTOR_EXPLAIN_U_P: Doctors "usually" explained things so they could understand 22%
H_COMP_5_A_P: Staff "always" explained 63%
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 17%
H_COMP_5_U_P: Staff "usually" explained 20%
H_COMP_5_LINEAR_SCORE: Communication about medicines - linear mean score
H_COMP_5_STAR_RATING: Communication about medicines - star rating 3
H_MED_FOR_A_P: Staff "always" explained new medications 79%
H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications 7%
H_MED_FOR_U_P: Staff "usually" explained new medications 14%
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 47%
H_SIDE_EFFECTS_SN_P: Staff "sometimes" or "never" explained possible side effects 27%
H_SIDE_EFFECTS_U_P: Staff "usually" explained possible side effects 26%
H_COMP_6_N_P: No, staff "did not" give patients this information 9%
H_COMP_6_Y_P: Yes, staff "did" give patients this information 91%
H_COMP_6_LINEAR_SCORE: Discharge information - linear mean score
H_COMP_6_STAR_RATING: Discharge information - star rating 4
H_DISCH_HELP_N_P: No, staff "did not" give patients information about help after discharge 10%
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge 90%
H_SYMPTOMS_N_P: No, staff "did not" give patients information about possible symptoms 8%
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms 92%
H_CLEAN_HSP_A_P: Room was "always" clean 72%
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 9%
H_CLEAN_HSP_U_P: Room was "usually" clean 19%
H_CLEAN_LINEAR_SCORE: Cleanliness - linear mean score
H_CLEAN_STAR_RATING: Cleanliness - star rating 3
H_QUIET_HSP_A_P: "Always" quiet at night 64%
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 7%
H_QUIET_HSP_U_P: "Usually" quiet at night 29%
H_QUIET_LINEAR_SCORE: Quietness - linear mean score
H_QUIET_STAR_RATING: Quietness - star rating 4
H_HSP_RATING_0_6: Patients who gave a rating of "6" or lower (low) 5%
H_HSP_RATING_7_8: Patients who gave a rating of "7" or "8" (medium) 18%
H_HSP_RATING_9_10: Patients who gave a rating of "9" or "10" (high) 77%
H_HSP_RATING_LINEAR_SCORE: Overall hospital rating - linear mean score
H_HSP_RATING_STAR_RATING: Overall hospital rating - star rating 4
H_RECMND_DN: "NO", patients would not recommend the hospital (they probably would not or definitely would not recommend it) 4%
H_RECMND_DY: "YES", patients would definitely recommend the hospital 74%
H_RECMND_PY: "YES", patients would probably recommend the hospital 22%
H_RECMND_LINEAR_SCORE: Recommend hospital - linear mean score
H_RECMND_STAR_RATING: Recommend hospital - star rating 4
H_STAR_RATING: Summary star rating 4

Healthcare Associated Infections

Standardized Infection Ratios (SIR). A SIR < 1.0 means fewer infections than predicted based on national baseline data.

Measure Score (SIR) vs. National
HAI_1_CILOWER 0.009 Better than the National Benchmark
HAI_1_CIUPPER 0.860 Better than the National Benchmark
HAI_1_DOPC 6226.000 Better than the National Benchmark
HAI_1_ELIGCASES 5.736 Better than the National Benchmark
HAI_1_NUMERATOR 1.000 Better than the National Benchmark
HAI_1_SIR 0.174 Better than the National Benchmark
HAI_2_CILOWER 0.057 No Different than National Benchmark
HAI_2_CIUPPER 1.115 No Different than National Benchmark
HAI_2_DOPC 6112.000 No Different than National Benchmark
HAI_2_ELIGCASES 5.925 No Different than National Benchmark
HAI_2_NUMERATOR 2.000 No Different than National Benchmark
HAI_2_SIR 0.338 No Different than National Benchmark
HAI_3_CILOWER 0.345 No Different than National Benchmark
HAI_3_CIUPPER 2.085 No Different than National Benchmark
HAI_3_DOPC 214.000 No Different than National Benchmark
HAI_3_ELIGCASES 5.315 No Different than National Benchmark
HAI_3_NUMERATOR 5.000 No Different than National Benchmark
HAI_3_SIR 0.941 No Different than National Benchmark
HAI_4_CILOWER N/A No Different than National Benchmark
HAI_4_CIUPPER 2.837 No Different than National Benchmark
HAI_4_DOPC 117.000 No Different than National Benchmark
HAI_4_ELIGCASES 1.056 No Different than National Benchmark
HAI_4_NUMERATOR 0.000 No Different than National Benchmark
HAI_4_SIR 0.000 No Different than National Benchmark
HAI_5_CILOWER 0.022 No Different than National Benchmark
HAI_5_CIUPPER 2.127 No Different than National Benchmark
HAI_5_DOPC 65715.000 No Different than National Benchmark
HAI_5_ELIGCASES 2.319 No Different than National Benchmark
HAI_5_NUMERATOR 1.000 No Different than National Benchmark
HAI_5_SIR 0.431 No Different than National Benchmark
HAI_6_CILOWER 0.194 Better than the National Benchmark
HAI_6_CIUPPER 0.680 Better than the National Benchmark
HAI_6_DOPC 60392.000 Better than the National Benchmark
HAI_6_ELIGCASES 26.205 Better than the National Benchmark
HAI_6_NUMERATOR 10.000 Better than the National Benchmark
HAI_6_SIR 0.382 Better than the National Benchmark

Timely & Effective Care

Process-of-care measures including ED wait times, treatment timeliness, and preventive care.

Measure Score Condition
EDV medium Emergency Department
GMCS Electronic Clinical Quality Measure
GMCS_Malnutrition_Diagnosis_Documented Electronic Clinical Quality Measure
GMCS_Malnutrition_Screening Electronic Clinical Quality Measure
GMCS_Nutrition_Assessment Electronic Clinical Quality Measure
GMCS_Nutritional_Care_Plan Electronic Clinical Quality Measure
HH_HYPER Electronic Clinical Quality Measure
HH_HYPO 1.0 Electronic Clinical Quality Measure
HH_ORAE Electronic Clinical Quality Measure
IMM_3 97.0 Healthcare Personnel Vaccination
OP_18a 144.0 Emergency Department
OP_18b 142.0 Emergency Department
OP_18c 197.0 Emergency Department
OP_18d Emergency Department
OP_22 0.0 Emergency Department
OP_23 51.0 Emergency Department
OP_29 99.0 Colonoscopy care
OP_31 Cataract surgery outcome
OP_40 43.0 Electronic Clinical Quality Measure
SAFE_USE_OF_OPIOIDS 17.0 Electronic Clinical Quality Measure
SEP_1 74.0 Sepsis Care
SEP_SH_3HR 81.0 Sepsis Care
SEP_SH_6HR 87.0 Sepsis Care
SEV_SEP_3HR 88.0 Sepsis Care
SEV_SEP_6HR 89.0 Sepsis Care
STK_02 Electronic Clinical Quality Measure
STK_03 Electronic Clinical Quality Measure
STK_05 Electronic Clinical Quality Measure
VTE_1 99.0 Electronic Clinical Quality Measure
VTE_2 100.0 Electronic Clinical Quality Measure

Unplanned Hospital Visits

Readmission and ED return rates within 30 days of discharge.

Measure Score vs. National
EDAC_30_AMI 13.60 More Days Than Average per 100 Discharges
EDAC_30_HF -10.10 Fewer Days Than Average per 100 Discharges
EDAC_30_PN -2.50 Average Days per 100 Discharges
Hybrid_HWR 15.50 No Different Than the National Rate
OP_32 14.60 No Different Than the National Rate
OP_35_ADM 9.20 No Different Than the National Rate
OP_35_ED 4.80 No Different Than the National Rate
OP_36 1.10 No Different than expected
READM_30_AMI 13.90 No Different Than the National Rate
READM_30_CABG 9.00 No Different Than the National Rate
READM_30_COPD 18.60 No Different Than the National Rate
READM_30_HF 18.40 No Different Than the National Rate
READM_30_HIP_KNEE Number of Cases Too Small
READM_30_PN 15.60 No Different Than the National Rate

Medicare Spending Per Beneficiary

MSPB ratio: values > 1.0 mean this hospital's episode spending is higher than the national median hospital.

Value
1.05

Financial Health (Cost Report — FY 2023)

All Data

Every labeled metric surfaced for this hospital, with national medians and percentiles where a benchmark is available.

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Show 91 rows
Source Metric Value National Median Pctl. Raw key
Cost Report Cost-to-Charge Ratio 0.23 metrics.cost_to_charge_ratio
Cost Report Current Ratio 1.74 metrics.current_ratio
Cost Report Employees per Bed 6.04 metrics.employees_per_bed
Cost Report fiscal_year 2,023 fiscal_year
Cost Report Fund Balance ($) $274,968,802 metrics.fund_balance
Cost Report Net Income ($) $22,002,095 metrics.net_income
Cost Report Net Patient Revenue ($) $540,596,374 metrics.net_patient_revenue
Cost Report Operating Margin (%) 0.5% metrics.operating_margin
Cost Report Total Assets ($) $615,953,907 metrics.total_assets
Cost Report Total Costs ($) $479,114,695 metrics.total_costs
Cost Report Total Liabilities ($) $340,985,105 metrics.total_liabilities
Cost Report Total Margin (%) 3.9% metrics.total_margin
Cost Report Uncompensated Care (%) 0.9% metrics.uncompensated_care_pct
General Information Address 725 AMERICAN AVE Address
General Information City/Town WAUKESHA City/Town
General Information Count of Facility MORT Measures 7 Count of Facility MORT Measures
General Information Count of Facility Pt Exp Measures 8 Count of Facility Pt Exp Measures
General Information Count of Facility READM Measures 10 Count of Facility READM Measures
General Information Count of Facility Safety Measures 7 Count of Facility Safety Measures
General Information Count of Facility TE Measures 12 Count of Facility TE Measures
General Information Count of MORT Measures Better 0 Count of MORT Measures Better
General Information Count of MORT Measures No Different 7 Count of MORT Measures No Different
General Information Count of MORT Measures Worse 0 Count of MORT Measures Worse
General Information Count of READM Measures Better 1 Count of READM Measures Better
General Information Count of READM Measures No Different 9 Count of READM Measures No Different
General Information Count of READM Measures Worse 0 Count of READM Measures Worse
General Information Count of Safety Measures Better 2 Count of Safety Measures Better
General Information Count of Safety Measures No Different 5 Count of Safety Measures No Different
General Information Count of Safety Measures Worse 0 Count of Safety Measures Worse
General Information County/Parish WAUKESHA County/Parish
General Information Emergency Services Yes Emergency Services
General Information Facility ID 520008 Facility ID
General Information Facility Name WAUKESHA MEMORIAL HOSPITAL Facility Name
General Information Hospital overall rating 5 Hospital overall rating
General Information Hospital overall rating footnote Hospital overall rating footnote
General Information Hospital Ownership Voluntary non-profit - Private Hospital Ownership
General Information Hospital Type Acute Care Hospitals Hospital Type
General Information Meets criteria for birthing friendly designation Y Meets criteria for birthing friendly designation
General Information MORT Group Footnote MORT Group Footnote
General Information MORT Group Measure Count 7 MORT Group Measure Count
General Information Pt Exp Group Footnote Pt Exp Group Footnote
General Information Pt Exp Group Measure Count 8 Pt Exp Group Measure Count
General Information READM Group Footnote READM Group Footnote
General Information READM Group Measure Count 11 READM Group Measure Count
General Information Safety Group Footnote Safety Group Footnote
General Information Safety Group Measure Count 8 Safety Group Measure Count
General Information State WI State
General Information TE Group Footnote TE Group Footnote
General Information TE Group Measure Count 12 TE Group Measure Count
General Information Telephone Number (262) 928-1000 Telephone Number
General Information ZIP Code 53188 ZIP Code
HAC Reduction Program fiscal_year 2,026 fiscal_year
HAC Reduction Program measures — cauti — sir 0.42 measures.cauti.sir
HAC Reduction Program measures — cdi — sir 0.45 measures.cdi.sir
HAC Reduction Program measures — clabsi — sir 0.17 measures.clabsi.sir
HAC Reduction Program measures — mrsa — sir 0.64 measures.mrsa.sir
HAC Reduction Program measures — ssi — sir 0.47 measures.ssi.sir
HAC Reduction Program payment_reduction No payment_reduction
HAC Reduction Program total_hac_score -0.41 total_hac_score
Medicare Spending per Beneficiary End Date 12/31/2024 End Date
Medicare Spending per Beneficiary Measure ID MSPB-1 Measure ID
Medicare Spending per Beneficiary Start Date 01/01/2024 Start Date
Medicare Spending per Beneficiary Value 1.05 Value
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Excess readmission ratio 1.03 0.9995 p68 READM-30-AMI-HRRP.excess_readmission_ratio
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Expected readmission rate 13.5% READM-30-AMI-HRRP.expected_readmission_rate
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of discharges 184 READM-30-AMI-HRRP.num_discharges
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of readmissions 27 READM-30-AMI-HRRP.num_readmissions
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Predicted readmission rate 13.9% READM-30-AMI-HRRP.predicted_readmission_rate
Readmissions (HRRP) CABG Surgery — Excess readmission ratio 0.85 1.0000 p5 READM-30-CABG-HRRP.excess_readmission_ratio
Readmissions (HRRP) CABG Surgery — Expected readmission rate 9.5% READM-30-CABG-HRRP.expected_readmission_rate
Readmissions (HRRP) CABG Surgery — Predicted readmission rate 8.1% READM-30-CABG-HRRP.predicted_readmission_rate
Readmissions (HRRP) COPD — Excess readmission ratio 1.02 0.9969 p70 READM-30-COPD-HRRP.excess_readmission_ratio
Readmissions (HRRP) COPD — Expected readmission rate 18.9% READM-30-COPD-HRRP.expected_readmission_rate
Readmissions (HRRP) COPD — Number of discharges 152 READM-30-COPD-HRRP.num_discharges
Readmissions (HRRP) COPD — Number of readmissions 31 READM-30-COPD-HRRP.num_readmissions
Readmissions (HRRP) COPD — Predicted readmission rate 19.3% READM-30-COPD-HRRP.predicted_readmission_rate
Readmissions (HRRP) Heart Failure — Excess readmission ratio 0.93 0.9983 p11 READM-30-HF-HRRP.excess_readmission_ratio
Readmissions (HRRP) Heart Failure — Expected readmission rate 18.9% READM-30-HF-HRRP.expected_readmission_rate
Readmissions (HRRP) Heart Failure — Number of discharges 568 READM-30-HF-HRRP.num_discharges
Readmissions (HRRP) Heart Failure — Number of readmissions 95 READM-30-HF-HRRP.num_readmissions
Readmissions (HRRP) Heart Failure — Predicted readmission rate 17.6% READM-30-HF-HRRP.predicted_readmission_rate
Readmissions (HRRP) Pneumonia — Excess readmission ratio 0.98 0.9955 p38 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 15.5% READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Number of discharges 477 READM-30-PN-HRRP.num_discharges
Readmissions (HRRP) Pneumonia — Number of readmissions 71 READM-30-PN-HRRP.num_readmissions
Readmissions (HRRP) Pneumonia — Predicted readmission rate 15.2% READM-30-PN-HRRP.predicted_readmission_rate
Value-Based Purchasing Clinical Outcomes 5.50 5.00 p52 clinical_outcomes_score
Value-Based Purchasing Efficiency & Cost Reduction 0.00 2.50 p0 efficiency_score
Value-Based Purchasing Person & Community Engagement 15.00 8.75 p84 person_community_score
Value-Based Purchasing Safety 9.58 10.00 p45 safety_score
Value-Based Purchasing Total Performance Score 30.08 29.50 p52 total_performance_score
Methodology

Full methodology →