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Overview

Address
5000 W CHAMBERS ST, MILWAUKEE, WI 53210
Phone
(414) 447-2130
Hospital Type
Acute Care
Ownership
Non-Profit (Church)
Emergency Services
Yes
Birthing Friendly
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 6 of 7 measures reported
6
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
1
6
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 11 of 12 measures reported
11 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) 74 discharges
1.0904 p91
Heart Failure 298 discharges
0.8945 p4
Pneumonia 192 discharges
1.0001 p53
COPD
0.9898 p43
Hip/Knee Replacement
0.9848 p47
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: 1.0904
Value-Based Purchasing
HAC Reduction
No Reduction
HAC Score: 0.2283

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 2.90 No Different Than the National Rate 135
Hybrid_HWM 3.90 No Different Than the National Rate 452
MORT_30_AMI 12.50 No Different Than the National Rate 66
MORT_30_CABG
MORT_30_COPD 9.40 No Different Than the National Rate 52
MORT_30_HF 9.70 No Different Than the National Rate 248
MORT_30_PN 15.10 No Different Than the National Rate 188
MORT_30_STK 11.50 No Different Than the National Rate 78
PSI_03 0.27 No Different Than the National Rate 2,068
PSI_04 Number of Cases Too Small
PSI_06 0.18 No Different Than the National Rate 2,882
PSI_08 0.24 No Different Than the National Rate 2,878
PSI_09 2.60 No Different Than the National Rate 590
PSI_10 1.58 No Different Than the National Rate 241
PSI_11 10.37 No Different Than the National Rate 250
PSI_12 4.25 No Different Than the National Rate 632
PSI_13 5.13 No Different Than the National Rate 227
PSI_14 1.67 No Different Than the National Rate 165
PSI_15 0.89 No Different Than the National Rate 611
PSI_90 0.93 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 80%
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 5%
H_COMP_1_U_P: Nurses "usually" communicated well 15%
H_COMP_1_LINEAR_SCORE: Nurse communication - linear mean score
H_COMP_1_STAR_RATING: Nurse communication - star rating 3
H_NURSE_RESPECT_A_P: Nurses "always" treated them with courtesy and respect 86%
H_NURSE_RESPECT_SN_P: Nurses "sometimes" or "never" treated them with courtesy and respect 4%
H_NURSE_RESPECT_U_P: Nurses "usually" treated them with courtesy and respect 10%
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 79%
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 6%
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 15%
H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand 76%
H_NURSE_EXPLAIN_SN_P: Nurses "sometimes" or "never" explained things so they could understand 6%
H_NURSE_EXPLAIN_U_P: Nurses "usually" explained things so they could understand 18%
H_COMP_2_A_P: Doctors "always" communicated well 81%
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 5%
H_COMP_2_U_P: Doctors "usually" communicated well 14%
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 88%
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 9%
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 80%
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 6%
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 14%
H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand 76%
H_DOCTOR_EXPLAIN_SN_P: Doctors "sometimes" or "never" explained things so they could understand 6%
H_DOCTOR_EXPLAIN_U_P: Doctors "usually" explained things so they could understand 18%
H_COMP_5_A_P: Staff "always" explained 59%
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 23%
H_COMP_5_U_P: Staff "usually" explained 18%
H_COMP_5_LINEAR_SCORE: Communication about medicines - linear mean score
H_COMP_5_STAR_RATING: Communication about medicines - star rating 2
H_MED_FOR_A_P: Staff "always" explained new medications 74%
H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications 10%
H_MED_FOR_U_P: Staff "usually" explained new medications 16%
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 43%
H_SIDE_EFFECTS_SN_P: Staff "sometimes" or "never" explained possible side effects 37%
H_SIDE_EFFECTS_U_P: Staff "usually" explained possible side effects 20%
H_COMP_6_N_P: No, staff "did not" give patients this information 15%
H_COMP_6_Y_P: Yes, staff "did" give patients this information 85%
H_COMP_6_LINEAR_SCORE: Discharge information - linear mean score
H_COMP_6_STAR_RATING: Discharge information - star rating 3
H_DISCH_HELP_N_P: No, staff "did not" give patients information about help after discharge 15%
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge 85%
H_SYMPTOMS_N_P: No, staff "did not" give patients information about possible symptoms 14%
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms 86%
H_CLEAN_HSP_A_P: Room was "always" clean 64%
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 13%
H_CLEAN_HSP_U_P: Room was "usually" clean 23%
H_CLEAN_LINEAR_SCORE: Cleanliness - linear mean score
H_CLEAN_STAR_RATING: Cleanliness - star rating 2
H_QUIET_HSP_A_P: "Always" quiet at night 61%
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 8%
H_QUIET_HSP_U_P: "Usually" quiet at night 31%
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) 7%
H_HSP_RATING_7_8: Patients who gave a rating of "7" or "8" (medium) 21%
H_HSP_RATING_9_10: Patients who gave a rating of "9" or "10" (high) 72%
H_HSP_RATING_LINEAR_SCORE: Overall hospital rating - linear mean score
H_HSP_RATING_STAR_RATING: Overall hospital rating - star rating 3
H_RECMND_DN: "NO", patients would not recommend the hospital (they probably would not or definitely would not recommend it) 5%
H_RECMND_DY: "YES", patients would definitely recommend the hospital 70%
H_RECMND_PY: "YES", patients would probably recommend the hospital 25%
H_RECMND_LINEAR_SCORE: Recommend hospital - linear mean score
H_RECMND_STAR_RATING: Recommend hospital - star rating 4
H_STAR_RATING: Summary star rating 3

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 0.019 No Different than National Benchmark
HAI_1_CIUPPER 1.869 No Different than National Benchmark
HAI_1_DOPC 3246.000 No Different than National Benchmark
HAI_1_ELIGCASES 2.639 No Different than National Benchmark
HAI_1_NUMERATOR 1.000 No Different than National Benchmark
HAI_1_SIR 0.379 No Different than National Benchmark
HAI_2_CILOWER N/A No Different than National Benchmark
HAI_2_CIUPPER 1.167 No Different than National Benchmark
HAI_2_DOPC 2916.000 No Different than National Benchmark
HAI_2_ELIGCASES 2.568 No Different than National Benchmark
HAI_2_NUMERATOR 0.000 No Different than National Benchmark
HAI_2_SIR 0.000 No Different than National Benchmark
HAI_3_CILOWER N/A Better than the National Benchmark
HAI_3_CIUPPER 0.967 Better than the National Benchmark
HAI_3_DOPC 109.000 Better than the National Benchmark
HAI_3_ELIGCASES 3.097 Better than the National Benchmark
HAI_3_NUMERATOR 0.000 Better than the National Benchmark
HAI_3_SIR 0.000 Better than the National Benchmark
HAI_4_CILOWER
HAI_4_CIUPPER
HAI_4_DOPC 33.000
HAI_4_ELIGCASES 0.283
HAI_4_NUMERATOR 0.000
HAI_4_SIR
HAI_5_CILOWER N/A No Different than National Benchmark
HAI_5_CIUPPER 2.301 No Different than National Benchmark
HAI_5_DOPC 28110.000 No Different than National Benchmark
HAI_5_ELIGCASES 1.302 No Different than National Benchmark
HAI_5_NUMERATOR 0.000 No Different than National Benchmark
HAI_5_SIR 0.000 No Different than National Benchmark
HAI_6_CILOWER 0.078 Better than the National Benchmark
HAI_6_CIUPPER 0.833 Better than the National Benchmark
HAI_6_DOPC 24981.000 Better than the National Benchmark
HAI_6_ELIGCASES 9.805 Better than the National Benchmark
HAI_6_NUMERATOR 3.000 Better than the National Benchmark
HAI_6_SIR 0.306 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 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 87.0 Healthcare Personnel Vaccination
OP_18a 124.0 Emergency Department
OP_18b 122.0 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 73.0 Sepsis Care
SEP_SH_3HR 83.0 Sepsis Care
SEP_SH_6HR 92.0 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 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 19.90 Average Days per 100 Discharges
EDAC_30_HF -29.20 Fewer Days Than Average per 100 Discharges
EDAC_30_PN 20.90 More Days Than Average per 100 Discharges
Hybrid_HWR 13.60 Better Than the National Rate
OP_32 12.30 No Different Than the National Rate
OP_35_ADM 9.40 No Different Than the National Rate
OP_35_ED 4.80 No Different Than the National Rate
OP_36 1.00 No Different than expected
READM_30_AMI 14.70 No Different Than the National Rate
READM_30_CABG
READM_30_COPD 18.00 No Different Than the National Rate
READM_30_HF 17.70 No Different Than the National Rate
READM_30_HIP_KNEE 4.80 No Different Than the National Rate
READM_30_PN 16.00 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 0.28 metrics.cost_to_charge_ratio
Cost Report Current Ratio 1.17 metrics.current_ratio
Cost Report Employees per Bed 5.02 metrics.employees_per_bed
Cost Report fiscal_year 2,024 fiscal_year
Cost Report Fund Balance ($) $197,436,512 metrics.fund_balance
Cost Report Net Income ($) $-20,106,366 metrics.net_income
Cost Report Net Patient Revenue ($) $375,733,469 metrics.net_patient_revenue
Cost Report Operating Margin (%) 5.2% metrics.operating_margin
Cost Report Total Assets ($) $293,310,217 metrics.total_assets
Cost Report Total Costs ($) $365,989,459 metrics.total_costs
Cost Report Total Liabilities ($) $95,384,537 metrics.total_liabilities
Cost Report Total Margin (%) -5.2% metrics.total_margin
Cost Report Uncompensated Care (%) 2.4% metrics.uncompensated_care_pct
General Information Address 5000 W CHAMBERS ST Address
General Information City/Town MILWAUKEE City/Town
General Information Count of Facility MORT Measures 6 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 11 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 6 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 1 Count of Safety Measures Better
General Information Count of Safety Measures No Different 6 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 520136 Facility ID
General Information Facility Name ASCENSION SE WISCONSIN 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 - Church 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 (414) 447-2130 Telephone Number
General Information ZIP Code 53210 ZIP Code
HAC Reduction Program fiscal_year 2,026 fiscal_year
HAC Reduction Program measures — cauti — sir 0.80 measures.cauti.sir
HAC Reduction Program measures — cdi — sir 0.40 measures.cdi.sir
HAC Reduction Program measures — clabsi — sir 0.88 measures.clabsi.sir
HAC Reduction Program measures — mrsa — sir 0.89 measures.mrsa.sir
HAC Reduction Program measures — ssi — sir 0.85 measures.ssi.sir
HAC Reduction Program payment_reduction No payment_reduction
HAC Reduction Program total_hac_score 0.23 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) Acute Myocardial Infarction (Heart Attack) — Excess readmission ratio 1.09 0.9995 p91 READM-30-AMI-HRRP.excess_readmission_ratio
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Expected readmission rate 14.3% READM-30-AMI-HRRP.expected_readmission_rate
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of discharges 74 READM-30-AMI-HRRP.num_discharges
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of readmissions 16 READM-30-AMI-HRRP.num_readmissions
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Predicted readmission rate 15.6% READM-30-AMI-HRRP.predicted_readmission_rate
Readmissions (HRRP) COPD — Excess readmission ratio 0.99 0.9969 p43 READM-30-COPD-HRRP.excess_readmission_ratio
Readmissions (HRRP) COPD — Expected readmission rate 16.7% READM-30-COPD-HRRP.expected_readmission_rate
Readmissions (HRRP) COPD — Predicted readmission rate 16.5% READM-30-COPD-HRRP.predicted_readmission_rate
Readmissions (HRRP) Heart Failure — Excess readmission ratio 0.89 0.9983 p4 READM-30-HF-HRRP.excess_readmission_ratio
Readmissions (HRRP) Heart Failure — Expected readmission rate 19.1% READM-30-HF-HRRP.expected_readmission_rate
Readmissions (HRRP) Heart Failure — Number of discharges 298 READM-30-HF-HRRP.num_discharges
Readmissions (HRRP) Heart Failure — Number of readmissions 43 READM-30-HF-HRRP.num_readmissions
Readmissions (HRRP) Heart Failure — Predicted readmission rate 17.1% READM-30-HF-HRRP.predicted_readmission_rate
Readmissions (HRRP) Hip/Knee Replacement — Excess readmission ratio 0.98 0.9916 p47 READM-30-HIP-KNEE-HRRP.excess_readmission_ratio
Readmissions (HRRP) Hip/Knee Replacement — Expected readmission rate 5.4% READM-30-HIP-KNEE-HRRP.expected_readmission_rate
Readmissions (HRRP) Hip/Knee Replacement — Predicted readmission rate 5.3% READM-30-HIP-KNEE-HRRP.predicted_readmission_rate
Readmissions (HRRP) Pneumonia — Excess readmission ratio 1.00 0.9955 p53 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 15.1% READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Number of discharges 192 READM-30-PN-HRRP.num_discharges
Readmissions (HRRP) Pneumonia — Number of readmissions 29 READM-30-PN-HRRP.num_readmissions
Readmissions (HRRP) Pneumonia — Predicted readmission rate 15.1% READM-30-PN-HRRP.predicted_readmission_rate
Methodology

Full methodology →