St Marys Hospital Medical Ctr

Hospital in Green Bay, WI, Medicare certification number 520097. CMS publishes 60 quality measures for it.

Medicare certification

Provider of Services

CCN: 520097The 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 - Other
Control type: Other
Participating since: Jul 1, 1966
Last certification: Sep 29, 2003
Beds: 158
Overall star rating: 3 of 5Care Compare
Address: 1726 Shawano Ave
Green Bay, WI 54303
(920) 498-4200

NPI records for this facility 1

St Mary'S Hospital Medical Center of Green Bay Inc.-Hospital Sisters
- General Acute Care Hospital
- Green Bay, WI
- NPI 1649246877
Medicare enrollment

Patient survey (HCAHPS) 9

Medicare Care Compare

Cleanliness - star rating Worse2 of 5
- State average 4.01 (computed here)
- National average 3.44 (computed here)
- Period from 10/01/2024
Communication about medicines - star rating Worse2 of 5
- State average 3.58 (computed here)
- National average 2.71 (computed here)
- Period from 10/01/2024
Discharge information - star rating Worse3 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 Worse3 of 5
- State average 4.22 (computed here)
- National average 3.43 (computed here)
- Period from 10/01/2024
Overall hospital rating - star rating Worse2 of 5
- State average 3.88 (computed here)
- National average 3.29 (computed here)
- Period from 10/01/2024
Quietness - star rating Worse3 of 5
- State average 3.95 (computed here)
- National average 3.27 (computed here)
- Period from 10/01/2024
Recommend hospital - star rating Worse3 of 5
- State average 4.14 (computed here)
- National average 3.64 (computed here)
- Period from 10/01/2024
Summary star rating Worse3 of 5
- State average 4.04 (computed here)
- National average 3.27 (computed here)
- Period from 10/01/2024

Complications and deaths 17

Medicare Care Compare

Abdominopelvic accidental puncture or laceration rate As expected1.25
- State average 1.12 (computed here)
- National average 1.06
- No different than the national rate
- 368 patients
- Period from 07/01/2022
CMS Medicare PSI 90: Patient safety and adverse events composite As expected1.36
- State average 1.02 (computed here)
- National average 1
- No different than the national value
- Period from 07/01/2022
Death rate for COPD patients As expected10.9
- State average 8.59 (computed here)
- National average 8.6
- No different than the national rate
- 34 patients
- Period from 07/01/2022
Death rate for heart attack patients As expected11.9
- State average 11.65 (computed here)
- National average 11.9
- No different than the national rate
- 79 patients
- Period from 07/01/2022
Death rate for heart failure patients As expected12
- State average 12.02 (computed here)
- National average 11.1
- No different than the national rate
- 87 patients
- Period from 07/01/2022
Death rate for pneumonia patients As expected15.9
- State average 15.15 (computed here)
- National average 15.2
- No different than the national rate
- 78 patients
- Period from 07/01/2022
Death rate for stroke patients As expected13.2
- State average 11.76 (computed here)
- National average 11.9
- No different than the national rate
- 66 patients
- Period from 07/01/2023
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate As expected4
- State average 3.88 (computed here)
- National average 3.9
- No different than the national rate
- 1,284 patients
- Period from 07/01/2024
Iatrogenic pneumothorax rate As expected0.19
- State average 0.21 (computed here)
- National average 0.21
- No different than the national rate
- 1,326 patients
- Period from 07/01/2022
In-hospital fall-associated fracture rate As expected0.26
- State average 0.27 (computed here)
- National average 0.27
- No different than the national rate
- 1,373 patients
- Period from 07/01/2022
Perioperative pulmonary embolism or deep vein thrombosis rate As expected3.17
- State average 3.5 (computed here)
- National average 3.52
- No different than the national rate
- 255 patients
- Period from 07/01/2022
Postoperative acute kidney injury requiring dialysis rate As expected1.63
- State average 1.73 (computed here)
- National average 1.67
- No different than the national rate
- 75 patients
- Period from 07/01/2022
Postoperative hemorrhage or hematoma rate As expected2.88
- State average 2.45 (computed here)
- National average 2.34
- No different than the national rate
- 246 patients
- Period from 07/01/2022
Postoperative respiratory failure rate As expected8.69
- State average 8.39 (computed here)
- National average 9.42
- No different than the national rate
- 76 patients
- Period from 07/01/2022
Postoperative sepsis rate As expected4.98
- State average 4.94 (computed here)
- National average 5.27
- No different than the national rate
- 60 patients
- Period from 07/01/2022
Postoperative wound dehiscence rate As expected1.72
- State average 1.81 (computed here)
- National average 1.77
- No different than the national rate
- 61 patients
- Period from 07/01/2022
Pressure ulcer rate Worse2
- State average 0.76 (computed here)
- National average 0.63
- Worse than the national rate
- 957 patients
- Period from 07/01/2022

Measures CMS does not publish for this facility (3)

Death rate among surgical inpatients with serious treatable complications — 1
Death rate for CABG surgery patients — 5
Rate of complications for hip/knee replacement patients — 1

Infections 3

Medicare Care Compare

Catheter Associated Urinary Tract Infections (ICU + select Wards) As expected0.77
- State average 0.54
- National average 1
- No different than national benchmark
- Period from 10/01/2024
Central Line Associated Bloodstream Infection (ICU + select Wards) As expected1.4
- State average 0.54
- National average 1
- No different than national benchmark
- Period from 10/01/2024
Clostridium Difficile (C.Diff) As expected0.9
- State average 0.53
- National average 1
- No different than national benchmark
- Period from 10/01/2024

Measures CMS does not publish for this facility (3)

MRSA Bacteremia — 13
SSI - Abdominal Hysterectomy — 12
SSI - Colon Surgery — 13

Outpatient imaging 1

Medicare Care Compare

Abdomen CT Use of Contrast Material 3.8
- State average 4.55 (computed here)
- National average 5.83 (computed here)
- Period from 07/01/2024

Measures CMS does not publish for this facility (1)

Breast Cancer Screening Recall Rates — 7

Spending per patient 1

Medicare Care Compare

Medicare hospital spending per patient (Medicare Spending per Beneficiary) 1.04
- State average 0.9
- National average 0.99 (computed here)
- Period from 01/01/2024

Timely and effective care 20

Medicare Care Compare

Antithrombotic Therapy by End of Hospital Day 2 98
- State average 96.09 (computed here)
- National average 92.79 (computed here)
- 44 patients
- Period from 01/01/2024
Appropriate care for severe sepsis and septic shock 69
- State average 72
- National average 65
- 96 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 103
- State average 144
- National average 168
- 380 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 102
- State average 137
- National average 162
- 363 patients
- Period from 10/01/2024
Discharged on Antithrombotic Therapy 98
- State average 98.07 (computed here)
- National average 96.1 (computed here)
- 54 patients
- Period from 01/01/2024
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients 97
- State average 97
- National average 93
- 76 patients
- Period from 01/01/2024
Head CT results 92
- State average 74
- National average 69
- 12 patients
- Period from 10/01/2024
Healthcare workers given influenza vaccination 89
- State average 85
- National average 78
- 1,350 patients
- Period from 10/01/2024
Hospital Harm - Opioid Related Adverse Events 0
- State average 0.14 (computed here)
- National average 0.18 (computed here)
- 1,850 patients
- Period from 01/01/2024
Hospital Harm - Severe Hyperglycemia 12
- State average 9.13 (computed here)
- National average 8.08 (computed here)
- 4,165 patients
- Period from 01/01/2024
Hospital Harm - Severe Hypoglycemia 1
- State average 0.76 (computed here)
- National average 1.09 (computed here)
- 915 patients
- Period from 01/01/2024
Intensive Care Unit Venous Thromboembolism Prophylaxis 97
- State average 95.78 (computed here)
- National average 93.49 (computed here)
- 858 patients
- Period from 01/01/2024
Left before being seen 0
- State average 2
- National average 2
- 22,853 patients
- Period from 01/01/2024
Safe Use of Opioids - Concurrent Prescribing 14
- State average 14
- National average 15
- 882 patients
- Period from 01/01/2024
Septic Shock 3-Hour Bundle 91
- State average 77
- National average 73
- 22 patients
- Period from 10/01/2024
Septic Shock 6-Hour Bundle 86
- State average 88
- National average 87
- 14 patients
- Period from 10/01/2024
Severe Sepsis 3-Hour Bundle 78
- State average 85
- National average 81
- 96 patients
- Period from 10/01/2024
Severe Sepsis 6-Hour Bundle 91
- State average 94
- National average 93
- 58 patients
- Period from 10/01/2024
ST-Segment Elevation Myocardial Infarction (STEMI) 0
- State average 37.33 (computed here)
- National average 46.51 (computed here)
- 33 patients
- Period from 01/01/2024
Venous Thromboembolism Prophylaxis 94
- State average 88.48 (computed here)
- National average 82.23 (computed here)
- 2,027 patients
- Period from 01/01/2024

Measures CMS does not publish for this facility (10)

Anticoagulation Therapy for Atrial Fibrillation/Flutter — 1
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better — 1
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better — 1
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
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery — 5

Unplanned visits 9

Medicare Care Compare

Acute Myocardial Infarction (AMI) 30-Day Readmission Rate As expected12.7
- State average 14.09 (computed here)
- National average 14.4
- No different than the national rate
- 190 patients
- Period from 07/01/2023
Heart failure (HF) 30-Day Readmission Rate As expected19.7
- State average 21.16 (computed here)
- National average 21.3
- No different than the national rate
- 221 patients
- Period from 07/01/2023
Hospital return days for heart attack patients -22
- State average 9.95 (computed here)
- National average 6.71 (computed here)
- Average days per 100 discharges
- 86 patients
- Period from 07/01/2022
Hospital return days for heart failure patients 13.1
- State average -5.03 (computed here)
- National average 4.02 (computed here)
- Average days per 100 discharges
- 89 patients
- Period from 07/01/2022
Hospital return days for pneumonia patients -26.2
- State average -3.39 (computed here)
- National average 5.65 (computed here)
- Fewer days than average per 100 discharges
- 84 patients
- Period from 07/01/2022
Pneumonia (PN) 30-Day Readmission Rate As expected16.4
- State average 17.04 (computed here)
- National average 17.3
- No different than the national rate
- 217 patients
- Period from 07/01/2023
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients As expected19.8
- State average 19.79 (computed here)
- National average 20
- No different than the national rate
- 118 patients
- Period from 07/01/2023
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies) As expected15.3
- State average 13.21 (computed here)
- National average 13
- No different than the national rate
- 735 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
- 367 patients
- Period from 01/01/2024

Measures CMS does not publish for this facility (5)

Hybrid Hospital-Wide All-Cause Readmission Measure (HWR) — 4
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy — 1
Rate of inpatient admissions for patients receiving outpatient chemotherapy — 1
Rate of readmission after hip/knee replacement — 1
Rate of readmission for CABG — 5

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.
NPPES NPI Registry: the NPI records connected to this certification.

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.