Hospital

ASCENSION ST FRANCIS HOSPITAL

CCN: 520078 · MILWAUKEE, WI 53215 · MILWAUKEE County

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

Overview

Address
3237 S 16TH ST, MILWAUKEE, WI 53215
Phone
(414) 647-5000
Hospital Type
Acute Care
Ownership
Non-Profit
Emergency Services
Yes
4 /5
★★★★★
CMS Overall Rating
p63
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 3 of 7 measures reported
3
Better No different Worse
30-day death rates for heart attack, heart failure, pneumonia, COPD, stroke, CABG, and kidney disease.
Safety of Care 4 of 8 measures reported
4
Better No different Worse
Healthcare-associated infections and patient safety indicators (PSI-90 composite).
Readmission 8 of 11 measures reported
7
1
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 7 of 12 measures reported
7 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)
— Not reported
Heart Failure
0.9362 p13
Pneumonia 44 discharges
1.0373 p74
COPD
0.9432 p7
Hip/Knee Replacement
— Not reported
CABG Surgery
— Not reported
Expected (1.0) National median

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: 1.0373
Value-Based Purchasing
—
HAC Reduction
No Reduction
HAC Score: -0.0992

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 4.10 No Different Than the National Rate 73
MORT_30_AMI — Number of Cases Too Small —
MORT_30_CABG — — —
MORT_30_COPD 9.60 No Different Than the National Rate 33
MORT_30_HF 12.70 No Different Than the National Rate 47
MORT_30_PN 13.80 No Different Than the National Rate 41
MORT_30_STK — Number of Cases Too Small —
PSI_03 0.48 No Different Than the National Rate 472
PSI_04 — Number of Cases Too Small —
PSI_06 0.20 No Different Than the National Rate 623
PSI_08 0.27 No Different Than the National Rate 615
PSI_09 2.31 No Different Than the National Rate 70
PSI_10 — Number of Cases Too Small —
PSI_11 — Number of Cases Too Small —
PSI_12 3.91 No Different Than the National Rate 70
PSI_13 — Number of Cases Too Small —
PSI_14 — Number of Cases Too Small —
PSI_15 1.05 No Different Than the National Rate 97
PSI_90 0.96 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 72% —
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 9% —
H_COMP_1_U_P: Nurses "usually" communicated well 19% —
H_COMP_1_LINEAR_SCORE: Nurse communication - linear mean score — —
H_COMP_1_STAR_RATING: Nurse communication - star rating — —
H_NURSE_RESPECT_A_P: Nurses "always" treated them with courtesy and respect 74% —
H_NURSE_RESPECT_SN_P: Nurses "sometimes" or "never" treated them with courtesy and respect 6% —
H_NURSE_RESPECT_U_P: Nurses "usually" treated them with courtesy and respect 20% —
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 70% —
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 11% —
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 19% —
H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand 71% —
H_NURSE_EXPLAIN_SN_P: Nurses "sometimes" or "never" explained things so they could understand 12% —
H_NURSE_EXPLAIN_U_P: Nurses "usually" explained things so they could understand 17% —
H_COMP_2_A_P: Doctors "always" communicated well 73% —
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 8% —
H_COMP_2_U_P: Doctors "usually" communicated well 19% —
H_COMP_2_LINEAR_SCORE: Doctor communication - linear mean score — —
H_COMP_2_STAR_RATING: Doctor communication - star rating — —
H_DOCTOR_RESPECT_A_P: Doctors "always" treated them with courtesy and respect 78% —
H_DOCTOR_RESPECT_SN_P: Doctors "sometimes" or "never" treated them with courtesy and respect 8% —
H_DOCTOR_RESPECT_U_P: Doctors "usually" treated them with courtesy and respect 14% —
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 76% —
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 8% —
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 16% —
H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand 65% —
H_DOCTOR_EXPLAIN_SN_P: Doctors "sometimes" or "never" explained things so they could understand 7% —
H_DOCTOR_EXPLAIN_U_P: Doctors "usually" explained things so they could understand 28% —
H_COMP_5_A_P: Staff "always" explained 63% —
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 20% —
H_COMP_5_U_P: Staff "usually" explained 17% —
H_COMP_5_LINEAR_SCORE: Communication about medicines - linear mean score — —
H_COMP_5_STAR_RATING: Communication about medicines - star rating — —
H_MED_FOR_A_P: Staff "always" explained new medications 80% —
H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications 11% —
H_MED_FOR_U_P: Staff "usually" explained new medications 9% —
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 46% —
H_SIDE_EFFECTS_SN_P: Staff "sometimes" or "never" explained possible side effects 30% —
H_SIDE_EFFECTS_U_P: Staff "usually" explained possible side effects 24% —
H_COMP_6_N_P: No, staff "did not" give patients this information 23% —
H_COMP_6_Y_P: Yes, staff "did" give patients this information 77% —
H_COMP_6_LINEAR_SCORE: Discharge information - linear mean score — —
H_COMP_6_STAR_RATING: Discharge information - star rating — —
H_DISCH_HELP_N_P: No, staff "did not" give patients information about help after discharge 27% —
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge 73% —
H_SYMPTOMS_N_P: No, staff "did not" give patients information about possible symptoms 18% —
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms 82% —
H_CLEAN_HSP_A_P: Room was "always" clean 68% —
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 10% —
H_CLEAN_HSP_U_P: Room was "usually" clean 22% —
H_CLEAN_LINEAR_SCORE: Cleanliness - linear mean score — —
H_CLEAN_STAR_RATING: Cleanliness - star rating — —
H_QUIET_HSP_A_P: "Always" quiet at night 55% —
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 9% —
H_QUIET_HSP_U_P: "Usually" quiet at night 36% —
H_QUIET_LINEAR_SCORE: Quietness - linear mean score — —
H_QUIET_STAR_RATING: Quietness - star rating — —
H_HSP_RATING_0_6: Patients who gave a rating of "6" or lower (low) 14% —
H_HSP_RATING_7_8: Patients who gave a rating of "7" or "8" (medium) 23% —
H_HSP_RATING_9_10: Patients who gave a rating of "9" or "10" (high) 63% —
H_HSP_RATING_LINEAR_SCORE: Overall hospital rating - linear mean score — —
H_HSP_RATING_STAR_RATING: Overall hospital rating - star rating — —
H_RECMND_DN: "NO", patients would not recommend the hospital (they probably would not or definitely would not recommend it) 13% —
H_RECMND_DY: "YES", patients would definitely recommend the hospital 53% —
H_RECMND_PY: "YES", patients would probably recommend the hospital 34% —
H_RECMND_LINEAR_SCORE: Recommend hospital - linear mean score — —
H_RECMND_STAR_RATING: Recommend hospital - star rating — —
H_STAR_RATING: Summary star rating — —

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 — —
HAI_1_CIUPPER — —
HAI_1_DOPC 451.000 —
HAI_1_ELIGCASES 0.365 —
HAI_1_NUMERATOR 0.000 —
HAI_1_SIR — —
HAI_2_CILOWER — —
HAI_2_CIUPPER — —
HAI_2_DOPC 387.000 —
HAI_2_ELIGCASES 0.308 —
HAI_2_NUMERATOR 0.000 —
HAI_2_SIR — —
HAI_3_CILOWER — —
HAI_3_CIUPPER — —
HAI_3_DOPC — —
HAI_3_ELIGCASES — —
HAI_3_NUMERATOR — —
HAI_3_SIR — —
HAI_4_CILOWER — —
HAI_4_CIUPPER — —
HAI_4_DOPC — —
HAI_4_ELIGCASES — —
HAI_4_NUMERATOR — —
HAI_4_SIR — —
HAI_5_CILOWER — —
HAI_5_CIUPPER — —
HAI_5_DOPC 5176.000 —
HAI_5_ELIGCASES 0.230 —
HAI_5_NUMERATOR 0.000 —
HAI_5_SIR — —
HAI_6_CILOWER 0.181 No Different than National Benchmark
HAI_6_CIUPPER 3.568 No Different than National Benchmark
HAI_6_DOPC 5176.000 No Different than National Benchmark
HAI_6_ELIGCASES 1.852 No Different than National Benchmark
HAI_6_NUMERATOR 2.000 No Different than National Benchmark
HAI_6_SIR 1.080 No Different than National Benchmark

Timely & Effective Care

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

Measure Score Condition
EDV — 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 — Electronic Clinical Quality Measure
HH_ORAE — Electronic Clinical Quality Measure
IMM_3 86.0 Healthcare Personnel Vaccination
OP_18a 140.0 Emergency Department
OP_18b 140.0 Emergency Department
OP_18c — Emergency Department
OP_18d — Emergency Department
OP_22 — Emergency Department
OP_23 — Emergency Department
OP_29 — Colonoscopy care
OP_31 — Cataract surgery outcome
OP_40 — Electronic Clinical Quality Measure
SAFE_USE_OF_OPIOIDS — Electronic Clinical Quality Measure
SEP_1 77.0 Sepsis Care
SEP_SH_3HR 93.0 Sepsis Care
SEP_SH_6HR — Sepsis Care
SEV_SEP_3HR 79.0 Sepsis Care
SEV_SEP_6HR 100.0 Sepsis Care
STK_02 — Electronic Clinical Quality Measure
STK_03 — Electronic Clinical Quality Measure
STK_05 — Electronic Clinical Quality Measure
VTE_1 — Electronic Clinical Quality Measure
VTE_2 — Electronic Clinical Quality Measure

Unplanned Hospital Visits

Readmission and ED return rates within 30 days of discharge.

Measure Score vs. National
EDAC_30_AMI — Number of Cases Too Small
EDAC_30_HF -72.30 Fewer Days Than Average per 100 Discharges
EDAC_30_PN 82.90 More Days Than Average per 100 Discharges
Hybrid_HWR 14.30 No Different Than the National Rate
OP_32 12.60 No Different Than the National Rate
OP_35_ADM 11.50 No Different Than the National Rate
OP_35_ED 5.10 No Different Than the National Rate
OP_36 — Number of cases too small
READM_30_AMI — Number of Cases Too Small
READM_30_CABG — —
READM_30_COPD 17.10 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 16.60 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.

Footnote
1.00

Financial Health (Cost Report — FY 2024)

All Data

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

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Source Metric Value National Median Pctl. Raw key
Cost Report Cost-to-Charge Ratio 0.30 — metrics.cost_to_charge_ratio
Cost Report Current Ratio 1.20 — metrics.current_ratio
Cost Report Employees per Bed 5.30 — metrics.employees_per_bed
Cost Report fiscal_year 2,024 — fiscal_year
Cost Report Fund Balance ($) $38,251,711 — metrics.fund_balance
Cost Report Net Income ($) $-7,953,555 — metrics.net_income
Cost Report Net Patient Revenue ($) $113,307,865 — metrics.net_patient_revenue
Cost Report Operating Margin (%) -1.5% — metrics.operating_margin
Cost Report Total Assets ($) $63,513,387 — metrics.total_assets
Cost Report Total Costs ($) $123,572,545 — metrics.total_costs
Cost Report Total Liabilities ($) $25,261,676 — metrics.total_liabilities
Cost Report Total Margin (%) -6.4% — metrics.total_margin
Cost Report Uncompensated Care (%) 5.9% — metrics.uncompensated_care_pct
General Information Address 3237 S 16TH ST — Address
General Information City/Town MILWAUKEE — City/Town
General Information Count of Facility MORT Measures 3 — 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 8 — Count of Facility READM Measures
General Information Count of Facility Safety Measures 4 — Count of Facility Safety Measures
General Information Count of Facility TE Measures 7 — 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 3 — 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 0 — Count of READM Measures Better
General Information Count of READM Measures No Different 7 — Count of READM Measures No Different
General Information Count of READM Measures Worse 1 — Count of READM Measures Worse
General Information Count of Safety Measures Better 0 — Count of Safety Measures Better
General Information Count of Safety Measures No Different 4 — Count of Safety Measures No Different
General Information Count of Safety Measures Worse 0 — Count of Safety Measures Worse
General Information County/Parish MILWAUKEE — County/Parish
General Information Emergency Services Yes — Emergency Services
General Information Facility ID 520078 — Facility ID
General Information Facility Name ASCENSION ST FRANCIS HOSPITAL — Facility Name
General Information Hospital overall rating 4 — 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 — — 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 (414) 647-5000 — Telephone Number
General Information ZIP Code 53215 — ZIP Code
HAC Reduction Program fiscal_year 2,026 — fiscal_year
HAC Reduction Program measures — cauti — sir 0.51 — measures.cauti.sir
HAC Reduction Program measures — cdi — sir 0.43 — measures.cdi.sir
HAC Reduction Program measures — clabsi — sir 0.47 — measures.clabsi.sir
HAC Reduction Program payment_reduction No — payment_reduction
HAC Reduction Program total_hac_score -0.10 — total_hac_score
Medicare Spending per Beneficiary End Date 12/31/2024 — End Date
Medicare Spending per Beneficiary Footnote 1 — Footnote
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 N/A — Value
Readmissions (HRRP) COPD — Excess readmission ratio 0.94 0.9969 p7 READM-30-COPD-HRRP.excess_readmission_ratio
Readmissions (HRRP) COPD — Expected readmission rate 17.3% — READM-30-COPD-HRRP.expected_readmission_rate
Readmissions (HRRP) COPD — Predicted readmission rate 16.3% — READM-30-COPD-HRRP.predicted_readmission_rate
Readmissions (HRRP) Heart Failure — Excess readmission ratio 0.94 0.9983 p13 READM-30-HF-HRRP.excess_readmission_ratio
Readmissions (HRRP) Heart Failure — Expected readmission rate 18.8% — READM-30-HF-HRRP.expected_readmission_rate
Readmissions (HRRP) Heart Failure — Predicted readmission rate 17.6% — READM-30-HF-HRRP.predicted_readmission_rate
Readmissions (HRRP) Pneumonia — Excess readmission ratio 1.04 0.9955 p74 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 18.6% — READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Number of discharges 44 — READM-30-PN-HRRP.num_discharges
Readmissions (HRRP) Pneumonia — Number of readmissions 11 — READM-30-PN-HRRP.num_readmissions
Readmissions (HRRP) Pneumonia — Predicted readmission rate 19.3% — READM-30-PN-HRRP.predicted_readmission_rate
Methodology

Full methodology →