Hospital

MARSHFIELD MEDICAL CENTER - WESTON

CCN: 520202 · WESTON, WI 54476 · MARATHON County

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

Overview

Address
3400 MINISTRY PARKWAY, WESTON, WI 54476
Phone
(715) 393-3000
Hospital Type
Acute Care
Ownership
Non-Profit
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 5 of 7 measures reported
5
Better No different Worse
30-day death rates for heart attack, heart failure, pneumonia, COPD, stroke, CABG, and kidney disease.
Safety of Care 5 of 8 measures reported
5
Better No different Worse
Healthcare-associated infections and patient safety indicators (PSI-90 composite).
Readmission 9 of 11 measures reported
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 9 of 12 measures reported
9 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) 196 discharges
0.9935 p45
Heart Failure 179 discharges
1.0283 p68
Pneumonia 131 discharges
1.0360 p73
COPD
0.9867 p40
Hip/Knee Replacement
— Not reported
CABG Surgery
— Not reported
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.

43.0 p85
Total Performance Score
National median: 29.5
Clinical Outcomes 25% weight
5.0 p47
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
11.0 p55
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
14.5 p82
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
12.5 p83
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: 1.0360
Value-Based Purchasing
43.0 TPS
Above national median
HAC Reduction
Payment Reduced
HAC Score: 0.4322

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 4.40 No Different Than the National Rate 524
MORT_30_AMI 11.30 No Different Than the National Rate 171
MORT_30_CABG — Number of Cases Too Small —
MORT_30_COPD 8.50 No Different Than the National Rate 44
MORT_30_HF 12.60 No Different Than the National Rate 156
MORT_30_PN 18.70 No Different Than the National Rate 135
MORT_30_STK 14.40 No Different Than the National Rate 51
PSI_03 0.29 No Different Than the National Rate 1,528
PSI_04 — Number of Cases Too Small —
PSI_06 0.17 No Different Than the National Rate 2,055
PSI_08 0.25 No Different Than the National Rate 2,112
PSI_09 2.12 No Different Than the National Rate 402
PSI_10 2.03 No Different Than the National Rate 165
PSI_11 18.57 Worse Than the National Rate 171
PSI_12 4.29 No Different Than the National Rate 418
PSI_13 4.66 No Different Than the National Rate 166
PSI_14 1.72 No Different Than the National Rate 80
PSI_15 0.97 No Different Than the National Rate 321
PSI_90 1.15 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 3% —
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 — 4
H_NURSE_RESPECT_A_P: Nurses "always" treated them with courtesy and respect 89% —
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 9% —
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 81% —
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 3% —
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 16% —
H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand 77% —
H_NURSE_EXPLAIN_SN_P: Nurses "sometimes" or "never" explained things so they could understand 4% —
H_NURSE_EXPLAIN_U_P: Nurses "usually" explained things so they could understand 19% —
H_COMP_2_A_P: Doctors "always" communicated well 83% —
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 3% —
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 89% —
H_DOCTOR_RESPECT_SN_P: Doctors "sometimes" or "never" treated them with courtesy and respect 2% —
H_DOCTOR_RESPECT_U_P: Doctors "usually" treated them with courtesy and respect 9% —
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 82% —
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 4% —
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 14% —
H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand 77% —
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 18% —
H_COMP_5_A_P: Staff "always" explained 63% —
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 18% —
H_COMP_5_U_P: Staff "usually" explained 19% —
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 73% —
H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications 9% —
H_MED_FOR_U_P: Staff "usually" explained new medications 18% —
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 53% —
H_SIDE_EFFECTS_SN_P: Staff "sometimes" or "never" explained possible side effects 26% —
H_SIDE_EFFECTS_U_P: Staff "usually" explained possible side effects 21% —
H_COMP_6_N_P: No, staff "did not" give patients this information 10% —
H_COMP_6_Y_P: Yes, staff "did" give patients this information 90% —
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 11% —
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge 89% —
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 80% —
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 5% —
H_CLEAN_HSP_U_P: Room was "usually" clean 15% —
H_CLEAN_LINEAR_SCORE: Cleanliness - linear mean score — —
H_CLEAN_STAR_RATING: Cleanliness - star rating — 4
H_QUIET_HSP_A_P: "Always" quiet at night 62% —
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 7% —
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) 19% —
H_HSP_RATING_9_10: Patients who gave a rating of "9" or "10" (high) 74% —
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 75% —
H_RECMND_PY: "YES", patients would probably recommend the hospital 21% —
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 N/A No Different than National Benchmark
HAI_1_CIUPPER 1.612 No Different than National Benchmark
HAI_1_DOPC 2671.000 No Different than National Benchmark
HAI_1_ELIGCASES 1.858 No Different than National Benchmark
HAI_1_NUMERATOR 0.000 No Different than National Benchmark
HAI_1_SIR 0.000 No Different than National Benchmark
HAI_2_CILOWER 1.037 Worse than the National Benchmark
HAI_2_CIUPPER 5.324 Worse than the National Benchmark
HAI_2_DOPC 3304.000 Worse than the National Benchmark
HAI_2_ELIGCASES 2.344 Worse than the National Benchmark
HAI_2_NUMERATOR 6.000 Worse than the National Benchmark
HAI_2_SIR 2.560 Worse than the National Benchmark
HAI_3_CILOWER 0.020 No Different than National Benchmark
HAI_3_CIUPPER 2.018 No Different than National Benchmark
HAI_3_DOPC 94.000 No Different than National Benchmark
HAI_3_ELIGCASES 2.444 No Different than National Benchmark
HAI_3_NUMERATOR 1.000 No Different than National Benchmark
HAI_3_SIR 0.409 No Different than National Benchmark
HAI_4_CILOWER — —
HAI_4_CIUPPER — —
HAI_4_DOPC 31.000 —
HAI_4_ELIGCASES 0.230 —
HAI_4_NUMERATOR 0.000 —
HAI_4_SIR — —
HAI_5_CILOWER — —
HAI_5_CIUPPER — —
HAI_5_DOPC 16587.000 —
HAI_5_ELIGCASES 0.638 —
HAI_5_NUMERATOR 0.000 —
HAI_5_SIR — —
HAI_6_CILOWER 0.170 Better than the National Benchmark
HAI_6_CIUPPER 0.874 Better than the National Benchmark
HAI_6_DOPC 15797.000 Better than the National Benchmark
HAI_6_ELIGCASES 14.284 Better than the National Benchmark
HAI_6_NUMERATOR 6.000 Better than the National Benchmark
HAI_6_SIR 0.420 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 low 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 90.0 Healthcare Personnel Vaccination
OP_18a 139.0 Emergency Department
OP_18b 136.0 Emergency Department
OP_18c 217.0 Emergency Department
OP_18d — Emergency Department
OP_22 2.0 Emergency Department
OP_23 67.0 Emergency Department
OP_29 — Colonoscopy care
OP_31 — Cataract surgery outcome
OP_40 — Electronic Clinical Quality Measure
SAFE_USE_OF_OPIOIDS 7.0 Electronic Clinical Quality Measure
SEP_1 72.0 Sepsis Care
SEP_SH_3HR 84.0 Sepsis Care
SEP_SH_6HR 95.0 Sepsis Care
SEV_SEP_3HR 81.0 Sepsis Care
SEV_SEP_6HR 95.0 Sepsis Care
STK_02 100.0 Electronic Clinical Quality Measure
STK_03 — Electronic Clinical Quality Measure
STK_05 100.0 Electronic Clinical Quality Measure
VTE_1 — Electronic Clinical Quality Measure
VTE_2 95.0 Electronic Clinical Quality Measure

Unplanned Hospital Visits

Readmission and ED return rates within 30 days of discharge.

Measure Score vs. National
EDAC_30_AMI 6.30 Average Days per 100 Discharges
EDAC_30_HF 15.20 Average Days per 100 Discharges
EDAC_30_PN 18.20 More Days Than Average per 100 Discharges
Hybrid_HWR 15.40 No Different Than the National Rate
OP_32 15.00 No Different Than the National Rate
OP_35_ADM 10.80 No Different Than the National Rate
OP_35_ED 5.10 No Different Than the National Rate
OP_36 1.00 No Different than expected
READM_30_AMI 13.60 No Different Than the National Rate
READM_30_CABG — Number of Cases Too Small
READM_30_COPD 18.20 No Different Than the National Rate
READM_30_HF 20.40 No Different Than the National Rate
READM_30_HIP_KNEE — Number of Cases Too Small
READM_30_PN 16.90 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
0.93

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.

Download CSV

Show 84 rows
Source Metric Value National Median Pctl. Raw key
Cost Report Cost-to-Charge Ratio 0.39 — metrics.cost_to_charge_ratio
Cost Report Current Ratio 8.21 — metrics.current_ratio
Cost Report Employees per Bed 5.69 — metrics.employees_per_bed
Cost Report fiscal_year 2,023 — fiscal_year
Cost Report Fund Balance ($) $-68,267,868 — metrics.fund_balance
Cost Report Net Income ($) $-138,621,562 — metrics.net_income
Cost Report Net Patient Revenue ($) $105,842,631 — metrics.net_patient_revenue
Cost Report Total Assets ($) $914,287,460 — metrics.total_assets
Cost Report Total Costs ($) $172,031,240 — metrics.total_costs
Cost Report Total Liabilities ($) $982,555,328 — metrics.total_liabilities
Cost Report Uncompensated Care (%) 1.9% — metrics.uncompensated_care_pct
General Information Address 3400 MINISTRY PARKWAY — Address
General Information City/Town WESTON — City/Town
General Information Count of Facility MORT Measures 5 — 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 9 — Count of Facility READM Measures
General Information Count of Facility Safety Measures 5 — Count of Facility Safety Measures
General Information Count of Facility TE Measures 9 — 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 5 — 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 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 0 — 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 MARATHON — County/Parish
General Information Emergency Services Yes — Emergency Services
General Information Facility ID 520202 — Facility ID
General Information Facility Name MARSHFIELD MEDICAL CENTER - WESTON — 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 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 (715) 393-3000 — Telephone Number
General Information ZIP Code 54476 — ZIP Code
HAC Reduction Program fiscal_year 2,026 — fiscal_year
HAC Reduction Program measures — cauti — sir 1.41 — measures.cauti.sir
HAC Reduction Program measures — cdi — sir 0.61 — measures.cdi.sir
HAC Reduction Program measures — clabsi — sir 0.74 — measures.clabsi.sir
HAC Reduction Program measures — mrsa — sir 0 — measures.mrsa.sir
HAC Reduction Program measures — ssi — sir 0.62 — measures.ssi.sir
HAC Reduction Program payment_reduction Yes — payment_reduction
HAC Reduction Program total_hac_score 0.43 — 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 0.93 — Value
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Excess readmission ratio 0.99 0.9995 p45 READM-30-AMI-HRRP.excess_readmission_ratio
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Expected readmission rate 12.5% — READM-30-AMI-HRRP.expected_readmission_rate
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of discharges 196 — READM-30-AMI-HRRP.num_discharges
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of readmissions 24 — READM-30-AMI-HRRP.num_readmissions
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Predicted readmission rate 12.4% — READM-30-AMI-HRRP.predicted_readmission_rate
Readmissions (HRRP) COPD — Excess readmission ratio 0.99 0.9969 p40 READM-30-COPD-HRRP.excess_readmission_ratio
Readmissions (HRRP) COPD — Expected readmission rate 15.6% — READM-30-COPD-HRRP.expected_readmission_rate
Readmissions (HRRP) COPD — Predicted readmission rate 15.4% — READM-30-COPD-HRRP.predicted_readmission_rate
Readmissions (HRRP) Heart Failure — Excess readmission ratio 1.03 0.9983 p68 READM-30-HF-HRRP.excess_readmission_ratio
Readmissions (HRRP) Heart Failure — Expected readmission rate 18.5% — READM-30-HF-HRRP.expected_readmission_rate
Readmissions (HRRP) Heart Failure — Number of discharges 179 — READM-30-HF-HRRP.num_discharges
Readmissions (HRRP) Heart Failure — Number of readmissions 36 — READM-30-HF-HRRP.num_readmissions
Readmissions (HRRP) Heart Failure — Predicted readmission rate 19.0% — READM-30-HF-HRRP.predicted_readmission_rate
Readmissions (HRRP) Pneumonia — Excess readmission ratio 1.04 0.9955 p73 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 14.5% — READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Number of discharges 131 — READM-30-PN-HRRP.num_discharges
Readmissions (HRRP) Pneumonia — Number of readmissions 22 — READM-30-PN-HRRP.num_readmissions
Readmissions (HRRP) Pneumonia — Predicted readmission rate 15.0% — READM-30-PN-HRRP.predicted_readmission_rate
Value-Based Purchasing Clinical Outcomes 5.00 5.00 p47 clinical_outcomes_score
Value-Based Purchasing Efficiency & Cost Reduction 12.50 2.50 p83 efficiency_score
Value-Based Purchasing Person & Community Engagement 14.50 8.75 p82 person_community_score
Value-Based Purchasing Safety 11.00 10.00 p55 safety_score
Value-Based Purchasing Total Performance Score 43.00 29.50 p85 total_performance_score
Methodology

Full methodology →