JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Fort Memorial Hospital

4 / 5

At a glance

Fort Memorial Hospital carries a 4-star CMS overall rating — above the national norm.

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 LimitNot available
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence LimitNot available
Central Line Associated Bloodstream Infection: Number of Device Days217Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases0.128Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases0Not available
Central Line Associated Bloodstream Infection (ICU + select Wards)Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence LimitNot available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence LimitNot available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days788Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases0.394Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases0Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards)Not available
SSI - Colon Surgery: Lower Confidence LimitNot available
SSI - Colon Surgery: Upper Confidence LimitNot available
SSI - Colon Surgery: Number of Procedures24Not available
SSI - Colon Surgery: Predicted Cases0.581Not available
SSI - Colon Surgery: Observed Cases0Not available
SSI - Colon SurgeryNot available
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures3Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.023Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitNot available
MRSA Bacteremia: Upper Confidence LimitNot available
MRSA Bacteremia: Patient Days6586Not available
MRSA Bacteremia: Predicted Cases0.203Not available
MRSA Bacteremia: Observed Cases0Not available
MRSA BacteremiaNot available
Clostridium Difficile (C.Diff): Lower Confidence Limit0.030Same as national
Clostridium Difficile (C.Diff): Upper Confidence Limit2.936Same as national
Clostridium Difficile (C.Diff): Patient Days5911Same as national
Clostridium Difficile (C.Diff): Predicted Cases1.680Same as national
Clostridium Difficile (C.Diff): Observed Cases1Same as national
Clostridium Difficile (C.Diff)0.595Same as 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 Rate4.7Same as national195
Death rate for heart attack patientsNot available
Death rate for CABG surgery patientsNot available
Death rate for COPD patients8.9Same as national27
Death rate for heart failure patients13.5Same as national67
Death rate for pneumonia patients15.6Same as national63
Death rate for stroke patientsNot available
Pressure ulcer rate0.50Same as national567
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.21Same as national710
In-hospital fall-associated fracture rate0.27Same as national673
Postoperative hemorrhage or hematoma rate2.29Same as national137
Postoperative acute kidney injury requiring dialysis rate1.66Same as national31
Postoperative respiratory failure rate8.98Same as national31
Perioperative pulmonary embolism or deep vein thrombosis rate4.22Same as national146
Postoperative sepsis rate5.12Same as national25
Postoperative wound dehiscence rate1.73Same as national51
Abdominopelvic accidental puncture or laceration rate1.01Same as national95
CMS Medicare PSI 90: Patient safety and adverse events composite0.97Same 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 patientsNot available
Hospital return days for heart failure patients13.5Not available66
Hospital return days for pneumonia patients-34.9Not available62
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.7Same as national262
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)14.7Same as national1071
Rate of inpatient admissions for patients receiving outpatient chemotherapyNot available
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapyNot available
Ratio of unplanned hospital visits after hospital outpatient surgery1.1Same as national342
Acute Myocardial Infarction (AMI) 30-Day Readmission RateNot available
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients17.3Same as national26
Heart failure (HF) 30-Day Readmission Rate18.7Same as national66
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate14.9Same as national62

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 rating4280
Doctor communication - star rating4280
Communication about medicines - star rating4280
Discharge information - star rating4280
Cleanliness - star rating3280
Quietness - star rating3280
Overall hospital rating - star rating4280
Recommend hospital - star rating4280
Summary star rating4280

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 volumelow
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 vaccination961299
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 better174436
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 better165391
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better41019
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better36129
Left before being seen116622
Head CT results5819
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients96223
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing7348
Appropriate care for severe sepsis and septic shock78180
Septic Shock 3-Hour Bundle7854
Septic Shock 6-Hour Bundle8927
Severe Sepsis 3-Hour Bundle88181
Severe Sepsis 6-Hour Bundle98135
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.

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 Fort Memorial Hospital rated?
Fort Memorial Hospital has a 4 out of 5 CMS overall star rating as of the latest CMS release.
Does Fort Memorial Hospital have emergency services?
Yes. Fort Memorial Hospital operates a 24/7 emergency department.
Where is Fort Memorial Hospital located?
Fort Memorial Hospital is located at 611 Sherman Ave E, Fort Atkinson, WI 53538.
What type of hospital is Fort Memorial Hospital?
Fort 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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