JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Bellin Memorial Hospital

4 / 5

At a glance

Bellin Memorial Hospital carries a 4-star CMS overall rating — above the national norm. On healthcare-associated infection measures, it performs better than the national average on 6 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.

MeasureScoreCompared to national
Central Line Associated Bloodstream Infection (ICU + select Wards): Lower Confidence Limit0.017Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit1.652Same as national
Central Line Associated Bloodstream Infection: Number of Device Days4378Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases2.985Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases1Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.335Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.970Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit3.404Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days7594Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases5.237Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases10Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)1.909Same as national
SSI - Colon Surgery: Lower Confidence Limit0.146Same as national
SSI - Colon Surgery: Upper Confidence Limit1.564Same as national
SSI - Colon Surgery: Number of Procedures200Same as national
SSI - Colon Surgery: Predicted Cases5.219Same as national
SSI - Colon Surgery: Observed Cases3Same as national
SSI - Colon Surgery0.575Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures45Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.349Not available
SSI - Abdominal Hysterectomy: Observed Cases2Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence Limit0.204Same as national
MRSA Bacteremia: Upper Confidence Limit4.029Same as national
MRSA Bacteremia: Patient Days43788Same as national
MRSA Bacteremia: Predicted Cases1.640Same as national
MRSA Bacteremia: Observed Cases2Same as national
MRSA Bacteremia1.220Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.211Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.864Better than national
Clostridium Difficile (C.Diff): Patient Days38776Better than national
Clostridium Difficile (C.Diff): Predicted Cases17.573Better than national
Clostridium Difficile (C.Diff): Observed Cases8Better than national
Clostridium Difficile (C.Diff)0.455Better 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.

MeasureScoreCompared to nationalSample
Rate of complications for hip/knee replacement patientsNot available
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4.4Same as national776
Death rate for heart attack patients10.9Same as national141
Death rate for CABG surgery patients2.6Same as national74
Death rate for COPD patients10.4Same as national59
Death rate for heart failure patients16.3Worse than national132
Death rate for pneumonia patients15.1Same as national97
Death rate for stroke patients12.1Same as national59
Pressure ulcer rate2.21Worse than national1872
Death rate among surgical inpatients with serious treatable complications166.72Same as national33
Iatrogenic pneumothorax rate0.18Same as national2444
In-hospital fall-associated fracture rate0.24Same as national2684
Postoperative hemorrhage or hematoma rate2.19Same as national984
Postoperative acute kidney injury requiring dialysis rate1.23Same as national544
Postoperative respiratory failure rate5.50Same as national538
Perioperative pulmonary embolism or deep vein thrombosis rate3.92Same as national1027
Postoperative sepsis rate3.98Same as national534
Postoperative wound dehiscence rate1.62Same as national204
Abdominopelvic accidental puncture or laceration rate1.12Same as national633
CMS Medicare PSI 90: Patient safety and adverse events composite1.30Same 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.

MeasureScoreCompared to nationalSample
Hospital return days for heart attack patients27.1Not available171
Hospital return days for heart failure patients-19.3Not available145
Hospital return days for pneumonia patients-25.2Not available101
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.2Same as national1125
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)12Same as national1499
Rate of inpatient admissions for patients receiving outpatient chemotherapy8.8Same as national121
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy5.7Same as national121
Ratio of unplanned hospital visits after hospital outpatient surgery0.8Same as national778
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate13.7Same as national171
Rate of readmission for CABG9.3Same as national72
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients18.5Same as national63
Heart failure (HF) 30-Day Readmission Rate17.6Same as national145
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate14.8Same as national101

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.

MeasureScoreSample
Nurse communication - star rating4507
Doctor communication - star rating4507
Communication about medicines - star rating3507
Discharge information - star rating4507
Cleanliness - star rating4507
Quietness - star rating3507
Overall hospital rating - star rating4507
Recommend hospital - star rating5507
Summary star rating4507

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.

MeasureScoreSample
Emergency department volumehigh
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 Hypoglycemia12359
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination777099
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 better152441
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 better151412
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better23328
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better
Left before being seen240953
Head CT results5511
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients100208
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing122218
Appropriate care for severe sepsis and septic shock72116
Septic Shock 3-Hour Bundle7360
Septic Shock 6-Hour Bundle7431
Severe Sepsis 3-Hour Bundle96116
Severe Sepsis 6-Hour Bundle9682
Discharged on Antithrombotic Therapy100129
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 2
Venous Thromboembolism Prophylaxis
Intensive Care Unit Venous Thromboembolism Prophylaxis981298

Maternal Health

lower is better · 4 measures reported

Measures of maternal outcomes and safe delivery practices, including severe complications during childbirth.

MeasureScoreSample
Cesarean Birth
Risk Adjusted Severe Obstetric Complications (All)
Risk Adjusted Severe Obstetric Complications (excluding blood-transfusion-only cases)
Maternal Morbidity Structural MeasureYes

Frequently asked questions

How is Bellin Memorial Hospital rated?
Bellin Memorial Hospital has a 4 out of 5 CMS overall star rating as of the latest CMS release.
Does Bellin Memorial Hospital have emergency services?
Yes. Bellin Memorial Hospital operates a 24/7 emergency department.
Where is Bellin Memorial Hospital located?
Bellin Memorial Hospital is located at 744 S Webster Ave, Green Bay, WI 54301.
What type of hospital is Bellin Memorial Hospital?
Bellin Memorial Hospital is classified by CMS as a Acute Care Hospitals facility (Voluntary non-profit - Private).

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.

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