Acute Care Hospitals · Voluntary non-profit - Church
Ascension Columbia St Marys Hospital Milwaukee
- 2323 N Lake Dr, Milwaukee, WI 53211
- (414) 585-1374
- Acute Care Hospitals
- Emergency services available 24/7
At a glance
Ascension Columbia St Marys Hospital Milwaukee carries a 3-star CMS overall rating — in line with the national norm. On healthcare-associated infection measures, it performs better than the national average on 18 and worse on 0.
Healthcare-Associated Infections
lower is better · 36 measures reported
Rates of infections patients can acquire while receiving care, such as central-line and catheter-associated infections, MRSA, and C. difficile.
| Measure | Score | Compared to national |
|---|---|---|
| Central Line Associated Bloodstream Infection (ICU + select Wards): Lower Confidence Limit | 0.120 | Better than national |
| Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit | 0.910 | Better than national |
| Central Line Associated Bloodstream Infection: Number of Device Days | 8652 | Better than national |
| Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases | 10.601 | Better than national |
| Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases | 4 | Better than national |
| Central Line Associated Bloodstream Infection (ICU + select Wards) | 0.377 | Better than national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit | 0.079 | Better than national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit | 0.848 | Better than national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days | 7876 | Better than national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases | 9.625 | Better than national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases | 3 | Better than national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards) | 0.312 | Better than national |
| SSI - Colon Surgery: Lower Confidence Limit | 0.207 | Same as national |
| SSI - Colon Surgery: Upper Confidence Limit | 2.215 | Same as national |
| SSI - Colon Surgery: Number of Procedures | 137 | Same as national |
| SSI - Colon Surgery: Predicted Cases | 3.686 | Same as national |
| SSI - Colon Surgery: Observed Cases | 3 | Same as national |
| SSI - Colon Surgery | 0.814 | Same as national |
| SSI - Abdominal Hysterectomy: Lower Confidence Limit | — | Not available |
| SSI - Abdominal Hysterectomy: Upper Confidence Limit | — | Not available |
| SSI - Abdominal Hysterectomy: Number of Procedures | 79 | Not available |
| SSI - Abdominal Hysterectomy: Predicted Cases | 0.659 | Not available |
| SSI - Abdominal Hysterectomy: Observed Cases | 0 | Not available |
| SSI - Abdominal Hysterectomy | — | Not available |
| MRSA Bacteremia: Lower Confidence Limit | 0.074 | Same as national |
| MRSA Bacteremia: Upper Confidence Limit | 1.451 | Same as national |
| MRSA Bacteremia: Patient Days | 56587 | Same as national |
| MRSA Bacteremia: Predicted Cases | 4.555 | Same as national |
| MRSA Bacteremia: Observed Cases | 2 | Same as national |
| MRSA Bacteremia | 0.439 | Same as national |
| Clostridium Difficile (C.Diff): Lower Confidence Limit | 0.262 | Better than national |
| Clostridium Difficile (C.Diff): Upper Confidence Limit | 0.865 | Better than national |
| Clostridium Difficile (C.Diff): Patient Days | 51334 | Better than national |
| Clostridium Difficile (C.Diff): Predicted Cases | 22.112 | Better than national |
| Clostridium Difficile (C.Diff): Observed Cases | 11 | Better than national |
| Clostridium Difficile (C.Diff) | 0.497 | Better than national |
Complications & Deaths
lower is better · 20 measures reported
Rates of serious complications (like hip/knee replacement problems or accidental cuts during surgery) and 30-day mortality rates for common conditions.
| Measure | Score | Compared to national | Sample |
|---|---|---|---|
| Rate of complications for hip/knee replacement patients | — | Not available | — |
| Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate | 4 | Same as national | 597 |
| Death rate for heart attack patients | 13.4 | Same as national | 93 |
| Death rate for CABG surgery patients | 2.5 | Same as national | 83 |
| Death rate for COPD patients | 8.2 | Same as national | 42 |
| Death rate for heart failure patients | 10.8 | Same as national | 218 |
| Death rate for pneumonia patients | 14.6 | Same as national | 197 |
| Death rate for stroke patients | 11.9 | Same as national | 167 |
| Pressure ulcer rate | 0.49 | Same as national | 2698 |
| Death rate among surgical inpatients with serious treatable complications | 161.13 | Same as national | 64 |
| Iatrogenic pneumothorax rate | 0.22 | Same as national | 3357 |
| In-hospital fall-associated fracture rate | 0.27 | Same as national | 3518 |
| Postoperative hemorrhage or hematoma rate | 2.14 | Same as national | 803 |
| Postoperative acute kidney injury requiring dialysis rate | 1.72 | Same as national | 370 |
| Postoperative respiratory failure rate | 10.04 | Same as national | 357 |
| Perioperative pulmonary embolism or deep vein thrombosis rate | 3.47 | Same as national | 882 |
| Postoperative sepsis rate | 4.34 | Same as national | 363 |
| Postoperative wound dehiscence rate | 1.69 | Same as national | 160 |
| Abdominopelvic accidental puncture or laceration rate | 1.17 | Same as national | 630 |
| CMS Medicare PSI 90: Patient safety and adverse events composite | 0.94 | Same as national | — |
Unplanned Hospital Visits & Readmissions
lower is better · 14 measures reported
How often patients return to the hospital unexpectedly within 30 days of discharge — a marker of care quality and discharge planning.
| Measure | Score | Compared to national | Sample |
|---|---|---|---|
| Hospital return days for heart attack patients | 4.9 | Not available | 131 |
| Hospital return days for heart failure patients | -21.9 | Not available | 253 |
| Hospital return days for pneumonia patients | -3.2 | Not available | 201 |
| Hybrid Hospital-Wide All-Cause Readmission Measure (HWR) | 13.7 | Same as national | 899 |
| Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies) | 14.8 | Same as national | 1926 |
| Rate of inpatient admissions for patients receiving outpatient chemotherapy | 8.4 | Same as national | 78 |
| Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy | 4.9 | Same as national | 78 |
| Ratio of unplanned hospital visits after hospital outpatient surgery | 1 | Same as national | 111 |
| Acute Myocardial Infarction (AMI) 30-Day Readmission Rate | 13.6 | Same as national | 131 |
| Rate of readmission for CABG | 11.4 | Same as national | 80 |
| Rate of readmission for chronic obstructive pulmonary disease (COPD) patients | 17.3 | Same as national | 46 |
| Heart failure (HF) 30-Day Readmission Rate | 19.2 | Same as national | 253 |
| Rate of readmission after hip/knee replacement | — | Not available | — |
| Pneumonia (PN) 30-Day Readmission Rate | 14.2 | Same as national | 201 |
Patient Experience (HCAHPS)
higher is better · 9 measures reported
What patients say about their hospital stay — communication with nurses and doctors, responsiveness, cleanliness, pain management, and whether they would recommend the hospital.
| Measure | Score | Sample |
|---|---|---|
| Nurse communication - star rating | 2 | 352 |
| Doctor communication - star rating | 3 | 352 |
| Communication about medicines - star rating | 2 | 352 |
| Discharge information - star rating | 2 | 352 |
| Cleanliness - star rating | 3 | 352 |
| Quietness - star rating | 3 | 352 |
| Overall hospital rating - star rating | 2 | 352 |
| Recommend hospital - star rating | 3 | 352 |
| Summary star rating | 2 | 352 |
Timely & Effective Care
higher is better (unless a wait time) · 30 measures reported
How consistently hospitals follow recommended care processes — for example, giving heart-attack patients aspirin on arrival, or the average time spent in the emergency department.
| Measure | Score | Sample |
|---|---|---|
| Emergency department volume | — | — |
| Global Malnutrition Composite Score | — | — |
| Global Malnutrition Composite Score: Malnutrition Diagnosis Documented | — | — |
| Global Malnutrition Composite Score: Malnutrition Risk Screening | — | — |
| Global Malnutrition Composite Score: Nutrition Assessment | — | — |
| Global Malnutrition Composite Score: Nutritional Care Plan | — | — |
| Hospital Harm - Severe Hyperglycemia | — | — |
| Hospital Harm - Severe Hypoglycemia | — | — |
| Hospital Harm - Opioid Related Adverse Events | — | — |
| Healthcare workers given influenza vaccination | 85 | 4658 |
| 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 | 169 | 599 |
| 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 | 165 | 549 |
| Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better | 197 | 33 |
| Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better | 265 | 22 |
| Left before being seen | — | — |
| Head CT results | — | — |
| Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients | — | — |
| Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery | — | — |
| ST-Segment Elevation Myocardial Infarction (STEMI) | — | — |
| Safe Use of Opioids - Concurrent Prescribing | — | — |
| Appropriate care for severe sepsis and septic shock | 63 | 117 |
| Septic Shock 3-Hour Bundle | 72 | 39 |
| Septic Shock 6-Hour Bundle | 92 | 24 |
| Severe Sepsis 3-Hour Bundle | 81 | 118 |
| Severe Sepsis 6-Hour Bundle | 92 | 76 |
| Discharged on Antithrombotic Therapy | — | — |
| Anticoagulation Therapy for Atrial Fibrillation/Flutter | — | — |
| Antithrombotic Therapy by End of Hospital Day 2 | — | — |
| Venous Thromboembolism Prophylaxis | — | — |
| Intensive Care Unit Venous Thromboembolism Prophylaxis | — | — |
Maternal Health
lower is better · 4 measures reported
Measures of maternal outcomes and safe delivery practices, including severe complications during childbirth.
| Measure | Score | Sample |
|---|---|---|
| Cesarean Birth | — | — |
| Risk Adjusted Severe Obstetric Complications (All) | — | — |
| Risk Adjusted Severe Obstetric Complications (excluding blood-transfusion-only cases) | — | — |
| Maternal Morbidity Structural Measure | Yes | — |
Frequently asked questions
- How is Ascension Columbia St Marys Hospital Milwaukee rated?
- Ascension Columbia St Marys Hospital Milwaukee has a 3 out of 5 CMS overall star rating as of the latest CMS release.
- Does Ascension Columbia St Marys Hospital Milwaukee have emergency services?
- Yes. Ascension Columbia St Marys Hospital Milwaukee operates a 24/7 emergency department.
- Where is Ascension Columbia St Marys Hospital Milwaukee located?
- Ascension Columbia St Marys Hospital Milwaukee is located at 2323 N Lake Dr, Milwaukee, WI 53211.
- What type of hospital is Ascension Columbia St Marys Hospital Milwaukee?
- Ascension Columbia St Marys Hospital Milwaukee is classified by CMS as a Acute Care Hospitals facility (Voluntary non-profit - Church).
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Data as of 2026-06-14. Source: CMS Provider Data Catalog. This is public data provided for informational purposes only and is not medical advice. See our methodology and editorial policy.