Acute Care Hospitals · Voluntary non-profit - Private
Ssm Health St Mary's Hospital - Madison
- 700 South Park St, Madison, WI 53715
- (608) 251-6100
- Acute Care Hospitals
- Emergency services available 24/7
At a glance
Ssm Health St Mary's Hospital - Madison carries a 4-star CMS overall rating — above 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 1 measure and trails 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.
| Measure | Score | Compared to national |
|---|---|---|
| Central Line Associated Bloodstream Infection (ICU + select Wards): Lower Confidence Limit | 0.063 | Better than national |
| Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit | 0.679 | Better than national |
| Central Line Associated Bloodstream Infection: Number of Device Days | 12560 | Better than national |
| Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases | 12.025 | Better than national |
| Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases | 3 | Better than national |
| Central Line Associated Bloodstream Infection (ICU + select Wards) | 0.249 | Better than national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit | 0.059 | Better than national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit | 0.632 | Better than national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days | 12074 | Better than national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases | 12.910 | Better than national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases | 3 | Better than national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards) | 0.232 | Better than national |
| SSI - Colon Surgery: Lower Confidence Limit | 0.624 | Same as national |
| SSI - Colon Surgery: Upper Confidence Limit | 2.347 | Same as national |
| SSI - Colon Surgery: Number of Procedures | 284 | Same as national |
| SSI - Colon Surgery: Predicted Cases | 7.038 | Same as national |
| SSI - Colon Surgery: Observed Cases | 9 | Same as national |
| SSI - Colon Surgery | 1.279 | Same as national |
| SSI - Abdominal Hysterectomy: Lower Confidence Limit | — | Same as national |
| SSI - Abdominal Hysterectomy: Upper Confidence Limit | 2.651 | Same as national |
| SSI - Abdominal Hysterectomy: Number of Procedures | 138 | Same as national |
| SSI - Abdominal Hysterectomy: Predicted Cases | 1.130 | Same as national |
| SSI - Abdominal Hysterectomy: Observed Cases | 0 | Same as national |
| SSI - Abdominal Hysterectomy | 0.000 | Same as national |
| MRSA Bacteremia: Lower Confidence Limit | 0.164 | Same as national |
| MRSA Bacteremia: Upper Confidence Limit | 1.758 | Same as national |
| MRSA Bacteremia: Patient Days | 97258 | Same as national |
| MRSA Bacteremia: Predicted Cases | 4.644 | Same as national |
| MRSA Bacteremia: Observed Cases | 3 | Same as national |
| MRSA Bacteremia | 0.646 | Same as national |
| Clostridium Difficile (C.Diff): Lower Confidence Limit | 0.142 | Better than national |
| Clostridium Difficile (C.Diff): Upper Confidence Limit | 0.410 | Better than national |
| Clostridium Difficile (C.Diff): Patient Days | 87880 | Better than national |
| Clostridium Difficile (C.Diff): Predicted Cases | 55.957 | Better than national |
| Clostridium Difficile (C.Diff): Observed Cases | 14 | Better than national |
| Clostridium Difficile (C.Diff) | 0.250 | Better 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.
| Measure | Score | Compared to national | Sample |
|---|---|---|---|
| Rate of complications for hip/knee replacement patients | 3 | Same as national | 119 |
| Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate | 3.7 | Same as national | 2180 |
| Death rate for heart attack patients | 10.9 | Same as national | 344 |
| Death rate for CABG surgery patients | 1.5 | Same as national | 240 |
| Death rate for COPD patients | 9.8 | Same as national | 117 |
| Death rate for heart failure patients | 13.6 | Same as national | 512 |
| Death rate for pneumonia patients | 17.2 | Same as national | 400 |
| Death rate for stroke patients | 12.5 | Same as national | 395 |
| Pressure ulcer rate | 0.52 | Same as national | 6700 |
| Death rate among surgical inpatients with serious treatable complications | 176.10 | Same as national | 146 |
| Iatrogenic pneumothorax rate | 0.19 | Same as national | 8016 |
| In-hospital fall-associated fracture rate | 0.30 | Same as national | 8243 |
| Postoperative hemorrhage or hematoma rate | 2.40 | Same as national | 2315 |
| Postoperative acute kidney injury requiring dialysis rate | 1.93 | Same as national | 1302 |
| Postoperative respiratory failure rate | 8.65 | Same as national | 1315 |
| Perioperative pulmonary embolism or deep vein thrombosis rate | 2.37 | Same as national | 2802 |
| Postoperative sepsis rate | 5.22 | Same as national | 1238 |
| Postoperative wound dehiscence rate | 1.54 | Same as national | 549 |
| Abdominopelvic accidental puncture or laceration rate | 0.91 | Same as national | 1686 |
| CMS Medicare PSI 90: Patient safety and adverse events composite | 0.90 | Same 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.
| Measure | Score | Compared to national | Sample |
|---|---|---|---|
| Hospital return days for heart attack patients | -0.3 | Not available | 394 |
| Hospital return days for heart failure patients | -22.1 | Not available | 557 |
| Hospital return days for pneumonia patients | 16.3 | Not available | 405 |
| Hybrid Hospital-Wide All-Cause Readmission Measure (HWR) | 14.4 | Same as national | 3467 |
| Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies) | 13.5 | Same as national | 129 |
| Rate of inpatient admissions for patients receiving outpatient chemotherapy | 8.6 | Same as national | 137 |
| Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy | 6 | Same as national | 137 |
| Ratio of unplanned hospital visits after hospital outpatient surgery | 1.2 | Same as national | 754 |
| Acute Myocardial Infarction (AMI) 30-Day Readmission Rate | 13.6 | Same as national | 394 |
| Rate of readmission for CABG | 10.6 | Same as national | 238 |
| Rate of readmission for chronic obstructive pulmonary disease (COPD) patients | 18.1 | Same as national | 131 |
| Heart failure (HF) 30-Day Readmission Rate | 17 | Better than national | 557 |
| Rate of readmission after hip/knee replacement | 4.6 | Same as national | 112 |
| Pneumonia (PN) 30-Day Readmission Rate | 16.3 | Same as national | 405 |
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.
| Measure | Score | Sample |
|---|---|---|
| Nurse communication - star rating | 4 | 1112 |
| Doctor communication - star rating | 4 | 1112 |
| Communication about medicines - star rating | 3 | 1112 |
| Discharge information - star rating | 3 | 1112 |
| Cleanliness - star rating | 4 | 1112 |
| Quietness - star rating | 4 | 1112 |
| Overall hospital rating - star rating | 4 | 1112 |
| Recommend hospital - star rating | 4 | 1112 |
| Summary star rating | 4 | 1112 |
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.
| Measure | Score | Sample |
|---|---|---|
| Emergency department volume | medium | — |
| 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 | 1 | 4074 |
| Hospital Harm - Opioid Related Adverse Events | — | — |
| Healthcare workers given influenza vaccination | 74 | 3398 |
| 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 better | 194 | 401 |
| 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 better | 192 | 381 |
| Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better | 238 | 19 |
| 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 seen | 3 | 38529 |
| Head CT results | 84 | 19 |
| Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients | 100 | 22 |
| Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery | — | — |
| ST-Segment Elevation Myocardial Infarction (STEMI) | — | — |
| Safe Use of Opioids - Concurrent Prescribing | 15 | 3927 |
| Appropriate care for severe sepsis and septic shock | 50 | 98 |
| Septic Shock 3-Hour Bundle | 53 | 38 |
| Septic Shock 6-Hour Bundle | 89 | 19 |
| Severe Sepsis 3-Hour Bundle | 76 | 99 |
| Severe Sepsis 6-Hour Bundle | 90 | 50 |
| Discharged on Antithrombotic Therapy | 99 | 389 |
| Anticoagulation Therapy for Atrial Fibrillation/Flutter | — | — |
| Antithrombotic Therapy by End of Hospital Day 2 | 97 | 388 |
| 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.
| Measure | Score | Sample |
|---|---|---|
| Cesarean Birth | — | — |
| Risk Adjusted Severe Obstetric Complications (All) | — | — |
| Risk Adjusted Severe Obstetric Complications (excluding blood-transfusion-only cases) | — | — |
| Maternal Morbidity Structural Measure | Yes | — |
Frequently asked questions
- How is Ssm Health St Mary's Hospital - Madison rated?
- Ssm Health St Mary's Hospital - Madison has a 4 out of 5 CMS overall star rating as of the latest CMS release.
- Does Ssm Health St Mary's Hospital - Madison have emergency services?
- Yes. Ssm Health St Mary's Hospital - Madison operates a 24/7 emergency department.
- Where is Ssm Health St Mary's Hospital - Madison located?
- Ssm Health St Mary's Hospital - Madison is located at 700 South Park St, Madison, WI 53715.
- What type of hospital is Ssm Health St Mary's Hospital - Madison?
- Ssm Health St Mary's Hospital - Madison is classified by CMS as a Acute Care Hospitals facility (Voluntary non-profit - Private).
Compare with nearby hospitals
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.