Hospital

DOOR COUNTY MEDICAL CENTER

CCN: 521358 · STURGEON BAY, WI 54235 · DOOR County

Overview

Address
323 SOUTH 18TH AVENUE, STURGEON BAY, WI 54235
Phone
(920) 743-5566
Hospital Type
Critical Access (CAH)
Ownership
Non-Profit
Emergency Services
Yes
Birthing Friendly
Yes
5 /5
★★★★★
CMS Overall Rating
p89
Critical Access (CAH) — Small rural hospital (≤25 inpatient beds) at least 35 miles from the nearest hospital. Reimbursed at 101% of cost rather than standard DRG rates. Exempt from most CMS payment adjustment programs.

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 1 of 8 measures reported
1
Better No different Worse
Healthcare-associated infections and patient safety indicators (PSI-90 composite).
Readmission 4 of 11 measures reported
4
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.

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 4.70 No Different Than the National Rate 164
MORT_30_AMI — Number of Cases Too Small —
MORT_30_CABG — — —
MORT_30_COPD 10.10 No Different Than the National Rate 38
MORT_30_HF 12.70 No Different Than the National Rate 69
MORT_30_PN 16.90 No Different Than the National Rate 59
MORT_30_STK — Number of Cases Too Small —
PSI_03 — — —
PSI_04 — — —
PSI_06 — — —
PSI_08 — — —
PSI_09 — — —
PSI_10 — — —
PSI_11 — — —
PSI_12 — — —
PSI_13 — — —
PSI_14 — — —
PSI_15 — — —
PSI_90 — — —

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 87% —
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 1% —
H_COMP_1_U_P: Nurses "usually" communicated well 12% —
H_COMP_1_LINEAR_SCORE: Nurse communication - linear mean score — —
H_COMP_1_STAR_RATING: Nurse communication - star rating — 5
H_NURSE_RESPECT_A_P: Nurses "always" treated them with courtesy and respect 92% —
H_NURSE_RESPECT_SN_P: Nurses "sometimes" or "never" treated them with courtesy and respect 0% —
H_NURSE_RESPECT_U_P: Nurses "usually" treated them with courtesy and respect 8% —
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 86% —
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 1% —
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 13% —
H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand 83% —
H_NURSE_EXPLAIN_SN_P: Nurses "sometimes" or "never" explained things so they could understand 1% —
H_NURSE_EXPLAIN_U_P: Nurses "usually" explained things so they could understand 16% —
H_COMP_2_A_P: Doctors "always" communicated well 86% —
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 1% —
H_COMP_2_U_P: Doctors "usually" communicated well 13% —
H_COMP_2_LINEAR_SCORE: Doctor communication - linear mean score — —
H_COMP_2_STAR_RATING: Doctor communication - star rating — 5
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 1% —
H_DOCTOR_RESPECT_U_P: Doctors "usually" treated them with courtesy and respect 10% —
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 87% —
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 1% —
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 12% —
H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand 82% —
H_DOCTOR_EXPLAIN_SN_P: Doctors "sometimes" or "never" explained things so they could understand 2% —
H_DOCTOR_EXPLAIN_U_P: Doctors "usually" explained things so they could understand 16% —
H_COMP_5_A_P: Staff "always" explained 66% —
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 12% —
H_COMP_5_U_P: Staff "usually" explained 22% —
H_COMP_5_LINEAR_SCORE: Communication about medicines - linear mean score — —
H_COMP_5_STAR_RATING: Communication about medicines - star rating — 4
H_MED_FOR_A_P: Staff "always" explained new medications 80% —
H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications 5% —
H_MED_FOR_U_P: Staff "usually" explained new medications 15% —
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 54% —
H_SIDE_EFFECTS_SN_P: Staff "sometimes" or "never" explained possible side effects 18% —
H_SIDE_EFFECTS_U_P: Staff "usually" explained possible side effects 28% —
H_COMP_6_N_P: No, staff "did not" give patients this information 5% —
H_COMP_6_Y_P: Yes, staff "did" give patients this information 95% —
H_COMP_6_LINEAR_SCORE: Discharge information - linear mean score — —
H_COMP_6_STAR_RATING: Discharge information - star rating — 5
H_DISCH_HELP_N_P: No, staff "did not" give patients information about help after discharge 5% —
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge 95% —
H_SYMPTOMS_N_P: No, staff "did not" give patients information about possible symptoms 6% —
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms 94% —
H_CLEAN_HSP_A_P: Room was "always" clean 88% —
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 2% —
H_CLEAN_HSP_U_P: Room was "usually" clean 10% —
H_CLEAN_LINEAR_SCORE: Cleanliness - linear mean score — —
H_CLEAN_STAR_RATING: Cleanliness - star rating — 5
H_QUIET_HSP_A_P: "Always" quiet at night 73% —
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 2% —
H_QUIET_HSP_U_P: "Usually" quiet at night 25% —
H_QUIET_LINEAR_SCORE: Quietness - linear mean score — —
H_QUIET_STAR_RATING: Quietness - star rating — 5
H_HSP_RATING_0_6: Patients who gave a rating of "6" or lower (low) 2% —
H_HSP_RATING_7_8: Patients who gave a rating of "7" or "8" (medium) 9% —
H_HSP_RATING_9_10: Patients who gave a rating of "9" or "10" (high) 89% —
H_HSP_RATING_LINEAR_SCORE: Overall hospital rating - linear mean score — —
H_HSP_RATING_STAR_RATING: Overall hospital rating - star rating — 5
H_RECMND_DN: "NO", patients would not recommend the hospital (they probably would not or definitely would not recommend it) 1% —
H_RECMND_DY: "YES", patients would definitely recommend the hospital 84% —
H_RECMND_PY: "YES", patients would probably recommend the hospital 15% —
H_RECMND_LINEAR_SCORE: Recommend hospital - linear mean score — —
H_RECMND_STAR_RATING: Recommend hospital - star rating — 5
H_STAR_RATING: Summary star rating — 5

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 390.000 —
HAI_1_ELIGCASES 0.107 —
HAI_1_NUMERATOR 1.000 —
HAI_1_SIR — —
HAI_2_CILOWER — —
HAI_2_CIUPPER — —
HAI_2_DOPC 683.000 —
HAI_2_ELIGCASES 0.446 —
HAI_2_NUMERATOR 0.000 —
HAI_2_SIR — —
HAI_3_CILOWER — —
HAI_3_CIUPPER — —
HAI_3_DOPC 14.000 —
HAI_3_ELIGCASES 0.386 —
HAI_3_NUMERATOR 0.000 —
HAI_3_SIR — —
HAI_4_CILOWER — —
HAI_4_CIUPPER — —
HAI_4_DOPC 3.000 —
HAI_4_ELIGCASES 0.021 —
HAI_4_NUMERATOR 0.000 —
HAI_4_SIR — —
HAI_5_CILOWER — —
HAI_5_CIUPPER — —
HAI_5_DOPC 5360.000 —
HAI_5_ELIGCASES 0.113 —
HAI_5_NUMERATOR 0.000 —
HAI_5_SIR — —
HAI_6_CILOWER 0.030 No Different than National Benchmark
HAI_6_CIUPPER 2.929 No Different than National Benchmark
HAI_6_DOPC 5029.000 No Different than National Benchmark
HAI_6_ELIGCASES 1.684 No Different than National Benchmark
HAI_6_NUMERATOR 1.000 No Different than National Benchmark
HAI_6_SIR 0.594 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 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 2.0 Electronic Clinical Quality Measure
HH_ORAE — Electronic Clinical Quality Measure
IMM_3 94.0 Healthcare Personnel Vaccination
OP_18a 153.0 Emergency Department
OP_18b 145.0 Emergency Department
OP_18c 325.0 Emergency Department
OP_18d 278.0 Emergency Department
OP_22 0.0 Emergency Department
OP_23 — Emergency Department
OP_29 100.0 Colonoscopy care
OP_31 — Cataract surgery outcome
OP_40 — Electronic Clinical Quality Measure
SAFE_USE_OF_OPIOIDS 18.0 Electronic Clinical Quality Measure
SEP_1 — Sepsis Care
SEP_SH_3HR — Sepsis Care
SEP_SH_6HR — Sepsis Care
SEV_SEP_3HR — Sepsis Care
SEV_SEP_6HR — Sepsis Care
STK_02 — Electronic Clinical Quality Measure
STK_03 — Electronic Clinical Quality Measure
STK_05 — Electronic Clinical Quality Measure
VTE_1 67.0 Electronic Clinical Quality Measure
VTE_2 62.0 Electronic Clinical Quality Measure

Unplanned Hospital Visits

Readmission and ED return rates within 30 days of discharge.

Measure Score vs. National
EDAC_30_AMI — Number of Cases Too Small
EDAC_30_HF 13.70 Average Days per 100 Discharges
EDAC_30_PN 41.40 More Days Than Average per 100 Discharges
Hybrid_HWR 14.40 No Different Than the National Rate
OP_32 — Number of Cases Too Small
OP_35_ADM — Number of Cases Too Small
OP_35_ED — Number of Cases Too Small
OP_36 — —
READM_30_AMI — Number of Cases Too Small
READM_30_CABG — —
READM_30_COPD 17.70 No Different Than the National Rate
READM_30_HF 19.10 No Different Than the National Rate
READM_30_HIP_KNEE — Number of Cases Too Small
READM_30_PN 15.70 No Different Than the National Rate

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 0.47 — metrics.cost_to_charge_ratio
Cost Report Current Ratio 2.88 — metrics.current_ratio
Cost Report Employees per Bed 19.29 — metrics.employees_per_bed
Cost Report fiscal_year 2,024 — fiscal_year
Cost Report Fund Balance ($) $141,429,908 — metrics.fund_balance
Cost Report Net Income ($) $10,267,849 — metrics.net_income
Cost Report Net Patient Revenue ($) $111,048,394 — metrics.net_patient_revenue
Cost Report Operating Margin (%) -2.1% — metrics.operating_margin
Cost Report Total Assets ($) $162,487,088 — metrics.total_assets
Cost Report Total Costs ($) $99,806,340 — metrics.total_costs
Cost Report Total Liabilities ($) $18,163,190 — metrics.total_liabilities
Cost Report Total Margin (%) 8.3% — metrics.total_margin
Cost Report Uncompensated Care (%) 2.4% — metrics.uncompensated_care_pct
General Information Address 323 SOUTH 18TH AVENUE — Address
General Information City/Town STURGEON BAY — 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 4 — Count of Facility READM Measures
General Information Count of Facility Safety Measures 1 — 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 4 — 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 1 — Count of Safety Measures No Different
General Information Count of Safety Measures Worse 0 — Count of Safety Measures Worse
General Information County/Parish DOOR — County/Parish
General Information Emergency Services Yes — Emergency Services
General Information Facility ID 521358 — Facility ID
General Information Facility Name DOOR COUNTY MEDICAL CENTER — 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 Critical Access 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 (920) 743-5566 — Telephone Number
General Information ZIP Code 54235 — ZIP Code
Methodology

Full methodology →