JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Froedtert Memorial Lutheran Hospital

3 / 5

At a glance

Froedtert Memorial Lutheran Hospital 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. For 30-day readmissions, it beats the national rate on 0 measures and trails on 1.

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 Limit0.390Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit0.923Better than national
Central Line Associated Bloodstream Infection: Number of Device Days32597Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases34.196Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases21Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.614Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.260Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit0.628Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days31551Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases48.351Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases20Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.414Better than national
SSI - Colon Surgery: Lower Confidence Limit0.977Same as national
SSI - Colon Surgery: Upper Confidence Limit2.114Same as national
SSI - Colon Surgery: Number of Procedures578Same as national
SSI - Colon Surgery: Predicted Cases17.760Same as national
SSI - Colon Surgery: Observed Cases26Same as national
SSI - Colon Surgery1.464Same as national
SSI - Abdominal Hysterectomy: Lower Confidence Limit0.488Same as national
SSI - Abdominal Hysterectomy: Upper Confidence Limit3.702Same as national
SSI - Abdominal Hysterectomy: Number of Procedures287Same as national
SSI - Abdominal Hysterectomy: Predicted Cases2.606Same as national
SSI - Abdominal Hysterectomy: Observed Cases4Same as national
SSI - Abdominal Hysterectomy1.535Same as national
MRSA Bacteremia: Lower Confidence Limit0.407Same as national
MRSA Bacteremia: Upper Confidence Limit1.129Same as national
MRSA Bacteremia: Patient Days261061Same as national
MRSA Bacteremia: Predicted Cases21.428Same as national
MRSA Bacteremia: Observed Cases15Same as national
MRSA Bacteremia0.700Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.436Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.681Better than national
Clostridium Difficile (C.Diff): Patient Days254046Better than national
Clostridium Difficile (C.Diff): Predicted Cases140.494Better than national
Clostridium Difficile (C.Diff): Observed Cases77Better than national
Clostridium Difficile (C.Diff)0.548Better 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 Rate3.2Better than national2456
Death rate for heart attack patients11.3Same as national130
Death rate for CABG surgery patients2.1Same as national74
Death rate for COPD patients6.8Same as national157
Death rate for heart failure patients9.4Same as national501
Death rate for pneumonia patients13.2Better than national412
Death rate for stroke patients13.4Same as national310
Pressure ulcer rate0.12Better than national11521
Death rate among surgical inpatients with serious treatable complications186.28Same as national238
Iatrogenic pneumothorax rate0.22Same as national13152
In-hospital fall-associated fracture rate0.17Same as national13985
Postoperative hemorrhage or hematoma rate2.53Same as national2975
Postoperative acute kidney injury requiring dialysis rate1.54Same as national165
Postoperative respiratory failure rate6.29Same as national164
Perioperative pulmonary embolism or deep vein thrombosis rate4.31Same as national3884
Postoperative sepsis rate4.50Same as national164
Postoperative wound dehiscence rate2.17Same as national1016
Abdominopelvic accidental puncture or laceration rate1.73Same as national2798
CMS Medicare PSI 90: Patient safety and adverse events composite0.78Same 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 patients20.1Not available152
Hospital return days for heart failure patients-4.8Not available586
Hospital return days for pneumonia patients10.5Not available436
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)15.4Same as national4569
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)11.1Same as national1074
Rate of inpatient admissions for patients receiving outpatient chemotherapy14.3Worse than national1155
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy5.5Same as national1155
Ratio of unplanned hospital visits after hospital outpatient surgery1.1Same as national1103
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate15.4Same as national152
Rate of readmission for CABG12.3Same as national72
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients19.4Same as national175
Heart failure (HF) 30-Day Readmission Rate18.6Same as national586
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate16.8Same as national436

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 rating42174
Doctor communication - star rating32174
Communication about medicines - star rating32174
Discharge information - star rating42174
Cleanliness - star rating32174
Quietness - star rating32174
Overall hospital rating - star rating42174
Recommend hospital - star rating42174
Summary star rating42174

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 volumevery high
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 Hypoglycemia210219
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination9513567
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 better282514
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 better275493
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better34220
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 seen681316
Head CT results
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients9977
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing1211912
Appropriate care for severe sepsis and septic shock43153
Septic Shock 3-Hour Bundle5246
Septic Shock 6-Hour Bundle8217
Severe Sepsis 3-Hour Bundle67153
Severe Sepsis 6-Hour Bundle8468
Discharged on Antithrombotic Therapy99570
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 2
Venous Thromboembolism Prophylaxis8021482
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 Froedtert Memorial Lutheran Hospital rated?
Froedtert Memorial Lutheran Hospital has a 3 out of 5 CMS overall star rating as of the latest CMS release.
Does Froedtert Memorial Lutheran Hospital have emergency services?
Yes. Froedtert Memorial Lutheran Hospital operates a 24/7 emergency department.
Where is Froedtert Memorial Lutheran Hospital located?
Froedtert Memorial Lutheran Hospital is located at 9200 W Wisconsin Ave, Milwaukee, WI 53226.
What type of hospital is Froedtert Memorial Lutheran Hospital?
Froedtert Memorial Lutheran 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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