JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Government - Local

Madison Memorial Hospital

Not rated overall

CMS reports safety and quality measures for this hospital but does not assign an overall star rating. See scores below.

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 Limit—Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit—Not available
Central Line Associated Bloodstream Infection: Number of Device Days366Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases0.236Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases1Not available
Central Line Associated Bloodstream Infection (ICU + select Wards)—Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit—Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit—Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days1176Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases0.589Not 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 Limit—Not available
SSI - Colon Surgery: Upper Confidence Limit—Not available
SSI - Colon Surgery: Number of Procedures14Not available
SSI - Colon Surgery: Predicted Cases0.353Not available
SSI - Colon Surgery: Observed Cases0Not available
SSI - Colon Surgery—Not available
SSI - Abdominal Hysterectomy: Lower Confidence Limit—Not available
SSI - Abdominal Hysterectomy: Upper Confidence Limit—Not available
SSI - Abdominal Hysterectomy: Number of Procedures—Not available
SSI - Abdominal Hysterectomy: Predicted Cases—Not available
SSI - Abdominal Hysterectomy: Observed Cases—Not available
SSI - Abdominal Hysterectomy—Not available
MRSA Bacteremia: Lower Confidence Limit—Not available
MRSA Bacteremia: Upper Confidence Limit—Not available
MRSA Bacteremia: Patient Days10876Not available
MRSA Bacteremia: Predicted Cases0.270Not available
MRSA Bacteremia: Observed Cases0Not available
MRSA Bacteremia—Not available
Clostridium Difficile (C.Diff): Lower Confidence Limit0.015Same as national
Clostridium Difficile (C.Diff): Upper Confidence Limit1.502Same as national
Clostridium Difficile (C.Diff): Patient Days7633Same as national
Clostridium Difficile (C.Diff): Predicted Cases3.283Same as national
Clostridium Difficile (C.Diff): Observed Cases1Same as national
Clostridium Difficile (C.Diff)0.305Same 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 patients—Not available—
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4.3Same as national130
Death rate for heart attack patients—Not available—
Death rate for CABG surgery patients—Not available—
Death rate for COPD patients—Not available—
Death rate for heart failure patients—Not available—
Death rate for pneumonia patients14.8Same as national30
Death rate for stroke patients—Not available—
Pressure ulcer rate0.54Same as national312
Death rate among surgical inpatients with serious treatable complications—Not available—
Iatrogenic pneumothorax rate0.21Same as national377
In-hospital fall-associated fracture rate0.27Same as national372
Postoperative hemorrhage or hematoma rate2.63Same as national121
Postoperative acute kidney injury requiring dialysis rate1.66Same as national56
Postoperative respiratory failure rate8.68Same as national54
Perioperative pulmonary embolism or deep vein thrombosis rate3.79Same as national128
Postoperative sepsis rate5.08Same as national40
Postoperative wound dehiscence rate1.74Same as national35
Abdominopelvic accidental puncture or laceration rate1.04Same as national79
CMS Medicare PSI 90: Patient safety and adverse events composite0.96Same 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 patients—Not available—
Hospital return days for heart failure patients21.2Not available26
Hospital return days for pneumonia patients16.9Not available34
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.5Same as national169
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)13.3Same as national372
Rate of inpatient admissions for patients receiving outpatient chemotherapy—Not available—
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy—Not available—
Ratio of unplanned hospital visits after hospital outpatient surgery1.1Same as national105
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate—Not available—
Rate of readmission for CABG—Not available—
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients—Not available—
Heart failure (HF) 30-Day Readmission Rate19.8Same as national26
Rate of readmission after hip/knee replacement—Not available—
Pneumonia (PN) 30-Day Readmission Rate15.9Same as national34

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 rating3272
Doctor communication - star rating4272
Communication about medicines - star rating1272
Discharge information - star rating3272
Cleanliness - star rating3272
Quietness - star rating3272
Overall hospital rating - star rating3272
Recommend hospital - star rating3272
Summary star rating3272

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 Hypoglycemia1149
Hospital Harm - Opioid Related Adverse Events——
Healthcare workers given influenza vaccination651367
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 better135440
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 better132401
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better16833
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 seen010795
Head CT results——
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients100334
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery——
ST-Segment Elevation Myocardial Infarction (STEMI)——
Safe Use of Opioids - Concurrent Prescribing8655
Appropriate care for severe sepsis and septic shock6629
Septic Shock 3-Hour Bundle10012
Septic Shock 6-Hour Bundle——
Severe Sepsis 3-Hour Bundle6929
Severe Sepsis 6-Hour Bundle9213
Discharged on Antithrombotic Therapy——
Anticoagulation Therapy for Atrial Fibrillation/Flutter——
Antithrombotic Therapy by End of Hospital Day 2——
Venous Thromboembolism Prophylaxis74389
Intensive Care Unit Venous Thromboembolism Prophylaxis6896

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 MeasureNo—

Frequently asked questions

How is Madison Memorial Hospital rated?
CMS does not assign an overall star rating to Madison Memorial Hospital, but does publish underlying safety and quality measures shown on this page.
Does Madison Memorial Hospital have emergency services?
Yes. Madison Memorial Hospital operates a 24/7 emergency department.
Where is Madison Memorial Hospital located?
Madison Memorial Hospital is located at 450 East Main Street, Rexburg, ID 83440.
What type of hospital is Madison Memorial Hospital?
Madison Memorial Hospital is classified by CMS as a Acute Care Hospitals facility (Government - Local).

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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