Prohealth Waukesha Memorial Hospital, Inc.

Doing business as Waukesha Memorial Hospital

Hospital in Waukesha, WI, Medicare certification number 520008. CMS publishes 65 quality measures for it.

Medicare certification

Provider of Services

CCN: 520008The number CMS certifies the facility under, not a provider identifier
Status: Active
Provider type: Hospital – Short-term
Listed by Care Compare as: Acute Care Hospitals
Ownership: Voluntary non-profit - Private
Control type: Private (not for profit)
Participating since: Jul 1, 1966
Last certification: Aug 9, 2012
Beds: 400
Overall star rating: 4 of 5Care Compare
Address: 725 American Ave
Waukesha, WI 53188
(262) 928-1000

NPI records for this facility (CCN to NPI Mapping) 1

Prohealth Waukesha Memorial Hospital, Inc.
- General Acute Care Hospital
- Waukesha, WI
- NPI 1629056890
Medicare enrollment

Patient survey (HCAHPS) 9

Medicare Care Compare

Cleanliness - star rating Worse3 of 5
- State average 4.01 (computed here)
- National average 3.44 (computed here)
- Period from 10/01/2024
Communication about medicines - star rating Better3 of 5
- State average 3.58 (computed here)
- National average 2.71 (computed here)
- Period from 10/01/2024
Discharge information - star rating Better4 of 5
- State average 4.14 (computed here)
- National average 3.31 (computed here)
- Period from 10/01/2024
Doctor communication - star rating As expected3 of 5
- State average 3.68 (computed here)
- National average 3.12 (computed here)
- Period from 10/01/2024
Nurse communication - star rating Better4 of 5
- State average 4.22 (computed here)
- National average 3.43 (computed here)
- Period from 10/01/2024
Overall hospital rating - star rating Better4 of 5
- State average 3.88 (computed here)
- National average 3.29 (computed here)
- Period from 10/01/2024
Quietness - star rating Better4 of 5
- State average 3.95 (computed here)
- National average 3.27 (computed here)
- Period from 10/01/2024
Recommend hospital - star rating Better4 of 5
- State average 4.14 (computed here)
- National average 3.64 (computed here)
- Period from 10/01/2024
Summary star rating Better4 of 5
- State average 4.04 (computed here)
- National average 3.27 (computed here)
- Period from 10/01/2024

Affiliated providers 871

Page 1 of 35Medicare Care Compare

Clinicians who list this facility as a hospital or facility affiliation in Care Compare.

Amrou Abdelkader, MD
- Anatomic Pathology & Clinical Pathology Physician
- West Allis, WI
- NPI 1316364698
Alan Michael Abdulla, D.O.
- Emergency Medicine Physician
- Waukesha, WI
- NPI 1508164419
Krystyna L Abdulla, DO
- Emergency Medicine Physician
- New Berlin, WI
- NPI 1205146578
Emily Marie Abeyta, MD
- Family Medicine Physician
- Waukesha, WI
- NPI 1386905107
Andrew Ackell, MD
- Neurology Physician
- Quincy, IL
- NPI 1942793237
Rachel Addis, PA-C
- Physician Assistant
- Waterford, WI
- NPI 1629812649
Jennifer Oluyemisi Adeghate, MD, PHD
- Retina Specialist (Ophthalmology) Physician
- Milwaukee, WI
- NPI 1437655891
Adekunle Adesokan, M.D.
- Anatomic Pathology & Clinical Pathology Physician
- West Allis, WI
- NPI 1790777043
Kayla Elizabeth Adkins, MD
- Plastic and Reconstructive Surgery Physician
- Waukesha, WI
- NPI 1164927802
Michelle M Agnew, M.D.
- Internal Medicine Physician
- Brookfield, WI
- NPI 1720051550
Baseer Ul-Anwar Ahmad, MD
- Ophthalmology Physician
- Milwaukee, WI
- NPI 1114160918
Muhammad Erfan Ahmad, M.D.
- Family Medicine Physician
- Mukwonago, WI
- NPI 1164731923
Kabir Ahmed, M.D.
- Sleep Medicine (Internal Medicine) Physician
- Fond Du Lac, WI
- NPI 1528325891
Janine Marie Ahrens, APNP
- Nurse Practitioner
- Waukesha, WI
- NPI 1659390896
Muhammad T Akbar, M.D.
- Pulmonary Disease Physician
- Milwaukee, WI
- NPI 1093767899
Saima T Akbar, M.D
- Geriatric Medicine (Internal Medicine) Physician
- West Allis, WI
- NPI 1407011497
Dana Joy Akiya, MD
- Obstetrics & Gynecology Physician
- Waukesha, WI
- NPI 1407915796
Younus Dheyaa Younus Al-Midfai, MD
- Nephrology Physician
- Waukesha, WI
- NPI 1821626979
Laith Mutasem Al-Shihabi, M.D.
- Orthopaedic Hand Surgery Physician
- Pewaukee, WI
- NPI 1861713265
John Moore Albert V, M.D.
- Anesthesiology Physician
- Cleveland, OH
- NPI 1417212085
Rebecca Lee Aldridge, M.D.
- Internal Medicine Physician
- Dallas, TX
- NPI 1548421811
Zuber Sherefa Ali, M.D.
- Cardiovascular Disease Physician
- Waukesha, WI
- NPI 1548536204
Nina M Alioto, NP
- Nurse Practitioner
- Milwaukee, WI
- NPI 1932878923
Charles Edward Allen Jr., M.D.
- Family Medicine Physician
- Oconomowoc, WI
- NPI 1871804336
Stephanie Allen
- Family Medicine Physician
- Menomonee Falls, WI
- NPI 1386224764

Complications and deaths 19

Medicare Care Compare

Abdominopelvic accidental puncture or laceration rate As expected1.3
- State average 1.12 (computed here)
- National average 1.06
- No different than the national rate
- 1,042 patients
- Period from 07/01/2022
CMS Medicare PSI 90: Patient safety and adverse events composite As expected0.9
- State average 1.02 (computed here)
- National average 1
- No different than the national value
- Period from 07/01/2022
Death rate among surgical inpatients with serious treatable complications As expected148.65
- State average 168.21 (computed here)
- National average 173.3
- No different than the national rate
- 59 patients
- Period from 07/01/2022
Death rate for CABG surgery patients As expected2
- State average 2.37 (computed here)
- National average 2.4
- No different than the national rate
- 50 patients
- Period from 07/01/2022
Death rate for COPD patients As expected8.1
- State average 8.59 (computed here)
- National average 8.6
- No different than the national rate
- 105 patients
- Period from 07/01/2022
Death rate for heart attack patients As expected12.4
- State average 11.65 (computed here)
- National average 11.9
- No different than the national rate
- 161 patients
- Period from 07/01/2022
Death rate for heart failure patients As expected10.6
- State average 12.02 (computed here)
- National average 11.1
- No different than the national rate
- 519 patients
- Period from 07/01/2022
Death rate for pneumonia patients As expected17.1
- State average 15.15 (computed here)
- National average 15.2
- No different than the national rate
- 435 patients
- Period from 07/01/2022
Death rate for stroke patients As expected11
- State average 11.76 (computed here)
- National average 11.9
- No different than the national rate
- 315 patients
- Period from 07/01/2023
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate As expected3.7
- State average 3.88 (computed here)
- National average 3.9
- No different than the national rate
- 4,479 patients
- Period from 07/01/2024
Iatrogenic pneumothorax rate As expected0.2
- State average 0.21 (computed here)
- National average 0.21
- No different than the national rate
- 5,800 patients
- Period from 07/01/2022
In-hospital fall-associated fracture rate As expected0.33
- State average 0.27 (computed here)
- National average 0.27
- No different than the national rate
- 5,931 patients
- Period from 07/01/2022
Perioperative pulmonary embolism or deep vein thrombosis rate As expected4.23
- State average 3.5 (computed here)
- National average 3.52
- No different than the national rate
- 1,236 patients
- Period from 07/01/2022
Postoperative acute kidney injury requiring dialysis rate As expected1.33
- State average 1.73 (computed here)
- National average 1.67
- No different than the national rate
- 521 patients
- Period from 07/01/2022
Postoperative hemorrhage or hematoma rate As expected2.22
- State average 2.45 (computed here)
- National average 2.34
- No different than the national rate
- 1,159 patients
- Period from 07/01/2022
Postoperative respiratory failure rate As expected7.64
- State average 8.39 (computed here)
- National average 9.42
- No different than the national rate
- 524 patients
- Period from 07/01/2022
Postoperative sepsis rate As expected6.42
- State average 4.94 (computed here)
- National average 5.27
- No different than the national rate
- 501 patients
- Period from 07/01/2022
Postoperative wound dehiscence rate As expected1.67
- State average 1.81 (computed here)
- National average 1.77
- No different than the national rate
- 321 patients
- Period from 07/01/2022
Pressure ulcer rate As expected0.19
- State average 0.76 (computed here)
- National average 0.63
- No different than the national rate
- 4,643 patients
- Period from 07/01/2022

Measures CMS does not publish for this facility (1)

Rate of complications for hip/knee replacement patients — 1

Infections 5

Medicare Care Compare

Catheter Associated Urinary Tract Infections (ICU + select Wards) Better0.16
- State average 0.54
- National average 1
- Better than the national benchmark
- Period from 10/01/2024
Central Line Associated Bloodstream Infection (ICU + select Wards) Better0
- State average 0.54
- National average 1
- Better than the national benchmark
- Period from 10/01/2024
Clostridium Difficile (C.Diff) Better0.31
- State average 0.53
- National average 1
- Better than the national benchmark
- Period from 10/01/2024
MRSA Bacteremia As expected0.45
- State average 0.58
- National average 1
- No different than national benchmark
- Period from 10/01/2024
SSI - Colon Surgery As expected1.22
- State average 0.98
- National average 1
- No different than national benchmark
- Period from 10/01/2024

Measures CMS does not publish for this facility (1)

SSI - Abdominal Hysterectomy — 13

Outpatient imaging 2

Medicare Care Compare

Abdomen CT Use of Contrast Material 4
- State average 4.55 (computed here)
- National average 5.83 (computed here)
- Period from 07/01/2024
Breast Cancer Screening Recall Rates 2.7
- State average 5.62 (computed here)
- National average 8.08 (computed here)
- Period from 07/01/2024

Spending per patient 1

Medicare Care Compare

Medicare hospital spending per patient (Medicare Spending per Beneficiary) 1.05
- State average 0.9
- National average 0.99 (computed here)
- Period from 01/01/2024

Timely and effective care 17

Medicare Care Compare

Appropriate care for severe sepsis and septic shock 75
- State average 72
- National average 65
- 140 patients
- Period from 10/01/2024
Average (median) time all patients spent in the emergency department before leaving from the visit, including psychiatric/mental health patients and patients who were transferred to another facility. A lower number of minutes is better 142
- State average 144
- National average 168
- 405 patients
- Period from 10/01/2024
Average (median) time patients spent in the emergency department before leaving from the visit, excluding patients transferred to another facility or psychiatric care/mental health patients. A lower number of minutes is better 140
- State average 137
- National average 162
- 380 patients
- Period from 10/01/2024
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better 153
- State average 203
- National average 257
- 23 patients
- Period from 10/01/2024
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients 99
- State average 97
- National average 93
- 96 patients
- Period from 01/01/2024
Head CT results 78
- State average 74
- National average 69
- 18 patients
- Period from 10/01/2024
Healthcare workers given influenza vaccination 97
- State average 85
- National average 78
- 5,603 patients
- Period from 10/01/2024
Hospital Harm - Severe Hypoglycemia 1
- State average 0.76 (computed here)
- National average 1.09 (computed here)
- 3,371 patients
- Period from 01/01/2024
Intensive Care Unit Venous Thromboembolism Prophylaxis 100
- State average 95.78 (computed here)
- National average 93.49 (computed here)
- 1,275 patients
- Period from 01/01/2024
Left before being seen 0
- State average 2
- National average 2
- 39,368 patients
- Period from 01/01/2024
Safe Use of Opioids - Concurrent Prescribing 17
- State average 14
- National average 15
- 3,068 patients
- Period from 01/01/2024
Septic Shock 3-Hour Bundle 92
- State average 77
- National average 73
- 38 patients
- Period from 10/01/2024
Septic Shock 6-Hour Bundle 87
- State average 88
- National average 87
- 30 patients
- Period from 10/01/2024
Severe Sepsis 3-Hour Bundle 86
- State average 85
- National average 81
- 140 patients
- Period from 10/01/2024
Severe Sepsis 6-Hour Bundle 90
- State average 94
- National average 93
- 94 patients
- Period from 10/01/2024
ST-Segment Elevation Myocardial Infarction (STEMI) 43
- State average 37.33 (computed here)
- National average 46.51 (computed here)
- 58 patients
- Period from 01/01/2024
Venous Thromboembolism Prophylaxis 99
- State average 88.48 (computed here)
- National average 82.23 (computed here)
- 5,958 patients
- Period from 01/01/2024

Measures CMS does not publish for this facility (13)

Anticoagulation Therapy for Atrial Fibrillation/Flutter — 5
Antithrombotic Therapy by End of Hospital Day 2 — 5
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better — 1
Discharged on Antithrombotic Therapy — 5
Emergency department volume — medium
Global Malnutrition Composite Score — 5
Global Malnutrition Composite Score: Malnutrition Diagnosis Documented — 5
Global Malnutrition Composite Score: Malnutrition Risk Screening — 5
Global Malnutrition Composite Score: Nutrition Assessment — 5
Global Malnutrition Composite Score: Nutritional Care Plan — 5
Hospital Harm - Opioid Related Adverse Events — 5
Hospital Harm - Severe Hyperglycemia — 5
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery — 5

Unplanned visits 12

Medicare Care Compare

Acute Myocardial Infarction (AMI) 30-Day Readmission Rate As expected15.1
- State average 14.09 (computed here)
- National average 14.4
- No different than the national rate
- 325 patients
- Period from 07/01/2023
Heart failure (HF) 30-Day Readmission Rate As expected21
- State average 21.16 (computed here)
- National average 21.3
- No different than the national rate
- 1,000 patients
- Period from 07/01/2023
Hospital return days for heart attack patients 14.8
- State average 9.95 (computed here)
- National average 6.71 (computed here)
- Average days per 100 discharges
- 170 patients
- Period from 07/01/2022
Hospital return days for heart failure patients -7.3
- State average -5.03 (computed here)
- National average 4.02 (computed here)
- Average days per 100 discharges
- 584 patients
- Period from 07/01/2022
Hospital return days for pneumonia patients 1.9
- State average -3.39 (computed here)
- National average 5.65 (computed here)
- Average days per 100 discharges
- 469 patients
- Period from 07/01/2022
Pneumonia (PN) 30-Day Readmission Rate As expected17.7
- State average 17.04 (computed here)
- National average 17.3
- No different than the national rate
- 867 patients
- Period from 07/01/2023
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy As expected4.8
- State average 5.66 (computed here)
- National average 5.4
- No different than the national rate
- 281 patients
- Period from 01/01/2024
Rate of inpatient admissions for patients receiving outpatient chemotherapy As expected9.2
- State average 10.67 (computed here)
- National average 10.7
- No different than the national rate
- 281 patients
- Period from 01/01/2024
Rate of readmission for CABG As expected9.2
- State average 10.61 (computed here)
- National average 11
- No different than the national rate
- 108 patients
- Period from 07/01/2023
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients As expected21.1
- State average 19.79 (computed here)
- National average 20
- No different than the national rate
- 251 patients
- Period from 07/01/2023
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies) As expected14.6
- State average 13.21 (computed here)
- National average 13
- No different than the national rate
- 1,182 patients
- Period from 01/01/2022
Ratio of unplanned hospital visits after hospital outpatient surgery As expected1.1
- State average 1.03 (computed here)
- National average 1.01 (computed here)
- No different than expected
- 571 patients
- Period from 01/01/2024

Measures CMS does not publish for this facility (2)

Hybrid Hospital-Wide All-Cause Readmission Measure (HWR) — 4
Rate of readmission after hip/knee replacement — 1

Other hospitals in Waukesha, WI

Waukesha County Mental Health Ctr

Sources for this page

Provider of Services: the certification, provider type, beds and status.
Medicare Care Compare: the star rating and every measure on this page, with the state and national rates CMS publishes beside them, and the clinicians who list this facility as an affiliation.
NPPES NPI Registry: the NPI records connected to this certification and the names of the providers listed above.

Better and worse are CMS's own comparison with the national rate, not ours: for most measures a low score is the good one (deaths, infections) and for others a high one is, so measures where CMS states no comparison are left uncoloured. The exception is star ratings, which are read against the national average here. Quality measures are published by CMS and are not adjusted or re-scored here. Averages marked “computed here” are the mean of every facility reporting that measure, worked out by NPIMap because CMS publishes no comparison for it. Confirm anything you rely on at Medicare Care Compare.