JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Other

Ssm Health St Mary's Hospital - Janesville

4 / 5

At a glance

Ssm Health St Mary's Hospital - Janesville 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 Days704Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases0.420Not 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 Days1035Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases0.516Not 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 Procedures25Not available
SSI - Colon Surgery: Predicted Cases0.585Not available
SSI - Colon Surgery: Observed Cases1Not available
SSI - Colon SurgeryNot available
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures34Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.253Not available
SSI - Abdominal Hysterectomy: Observed Cases2Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitNot available
MRSA Bacteremia: Upper Confidence LimitNot available
MRSA Bacteremia: Patient Days10713Not available
MRSA Bacteremia: Predicted Cases0.219Not available
MRSA Bacteremia: Observed Cases0Not available
MRSA BacteremiaNot available
Clostridium Difficile (C.Diff): Lower Confidence Limit0.117Same as national
Clostridium Difficile (C.Diff): Upper Confidence Limit2.302Same as national
Clostridium Difficile (C.Diff): Patient Days10037Same as national
Clostridium Difficile (C.Diff): Predicted Cases2.870Same as national
Clostridium Difficile (C.Diff): Observed Cases2Same as national
Clostridium Difficile (C.Diff)0.697Same 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 Rate3.8Same as national262
Death rate for heart attack patientsNot available
Death rate for CABG surgery patientsNot available
Death rate for COPD patients8.6Same as national31
Death rate for heart failure patients12.3Same as national108
Death rate for pneumonia patients18Same as national116
Death rate for stroke patients13.6Same as national32
Pressure ulcer rate0.44Same as national909
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.20Same as national1208
In-hospital fall-associated fracture rate0.26Same as national1165
Postoperative hemorrhage or hematoma rate2.28Same as national115
Postoperative acute kidney injury requiring dialysis rate1.53Same as national47
Postoperative respiratory failure rate7.55Same as national57
Perioperative pulmonary embolism or deep vein thrombosis rate3.76Same as national138
Postoperative sepsis rate4.75Same as national44
Postoperative wound dehiscence rate1.74Same as national46
Abdominopelvic accidental puncture or laceration rate1.02Same as national160
CMS Medicare PSI 90: Patient safety and adverse events composite0.88Same 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 patients1.7Not available106
Hospital return days for pneumonia patients-19.2Not available113
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14Same as national423
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)13.1Same as national789
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 surgery1.2Same as national171
Acute Myocardial Infarction (AMI) 30-Day Readmission RateNot available
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients17.6Same as national35
Heart failure (HF) 30-Day Readmission Rate19.8Same as national106
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate15.9Same as national113

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 rating4480
Doctor communication - star rating4480
Communication about medicines - star rating4480
Discharge information - star rating3480
Cleanliness - star rating2480
Quietness - star rating4480
Overall hospital rating - star rating4480
Recommend hospital - star rating4480
Summary star rating4480

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 volumemedium
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 Hypoglycemia1484
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination78482
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 better144400
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 better140371
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better33612
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better34618
Left before being seen020818
Head CT results
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients9984
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing12497
Appropriate care for severe sepsis and septic shock6487
Septic Shock 3-Hour Bundle5221
Septic Shock 6-Hour Bundle
Severe Sepsis 3-Hour Bundle7987
Severe Sepsis 6-Hour Bundle10049
Discharged on Antithrombotic Therapy9738
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 29732
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 Ssm Health St Mary's Hospital - Janesville rated?
Ssm Health St Mary's Hospital - Janesville has a 4 out of 5 CMS overall star rating as of the latest CMS release.
Does Ssm Health St Mary's Hospital - Janesville have emergency services?
Yes. Ssm Health St Mary's Hospital - Janesville operates a 24/7 emergency department.
Where is Ssm Health St Mary's Hospital - Janesville located?
Ssm Health St Mary's Hospital - Janesville is located at 3400 East Racine Street, Janesville, WI 53546.
What type of hospital is Ssm Health St Mary's Hospital - Janesville?
Ssm Health St Mary's Hospital - Janesville is classified by CMS as a Acute Care Hospitals facility (Voluntary non-profit - Other).

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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