JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

St Josephs Community Hospital West Bend

4 / 5

At a glance

St Josephs Community Hospital West Bend carries a 4-star CMS overall rating — above the national norm. On healthcare-associated infection measures, it performs better than the national average on 6 and worse 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.

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 Days1461Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases0.883Not 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 Limit0.038Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit3.779Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days1932Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases1.305Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases1Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.766Same as national
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 Cases0.566Not 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 Procedures6Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.065Not 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 Days20425Not available
MRSA Bacteremia: Predicted Cases0.540Not available
MRSA Bacteremia: Observed Cases0Not available
MRSA BacteremiaNot available
Clostridium Difficile (C.Diff): Lower Confidence LimitBetter than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.514Better than national
Clostridium Difficile (C.Diff): Patient Days18794Better than national
Clostridium Difficile (C.Diff): Predicted Cases5.824Better than national
Clostridium Difficile (C.Diff): Observed Cases0Better than national
Clostridium Difficile (C.Diff)0.000Better 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 patients4.5Same as national64
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate3.8Same as national445
Death rate for heart attack patientsNot available
Death rate for CABG surgery patientsNot available
Death rate for COPD patients7.7Same as national59
Death rate for heart failure patients13.2Same as national208
Death rate for pneumonia patients15.2Same as national133
Death rate for stroke patients13.6Same as national77
Pressure ulcer rate1.14Same as national1562
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.20Same as national1927
In-hospital fall-associated fracture rate0.25Same as national1936
Postoperative hemorrhage or hematoma rate2.24Same as national240
Postoperative acute kidney injury requiring dialysis rateNot available
Postoperative respiratory failure rateNot available
Perioperative pulmonary embolism or deep vein thrombosis rate3.96Same as national274
Postoperative sepsis rateNot available
Postoperative wound dehiscence rate1.72Same as national55
Abdominopelvic accidental puncture or laceration rate1.27Same as national284
CMS Medicare PSI 90: Patient safety and adverse events composite1.16Same 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 patients-14.5Not available232
Hospital return days for pneumonia patients-3.6Not available133
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.1Same as national731
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)14Same as national188
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 surgery0.9Same as national216
Acute Myocardial Infarction (AMI) 30-Day Readmission RateNot available
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients17.2Same as national68
Heart failure (HF) 30-Day Readmission Rate18.4Same as national232
Rate of readmission after hip/knee replacement5.4Same as national61
Pneumonia (PN) 30-Day Readmission Rate15.8Same as national133

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 rating4517
Doctor communication - star rating3517
Communication about medicines - star rating3517
Discharge information - star rating4517
Cleanliness - star rating3517
Quietness - star rating3517
Overall hospital rating - star rating3517
Recommend hospital - star rating4517
Summary star rating3517

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 Hypoglycemia0999
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination914321
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 better205407
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 better201378
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better30315
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better36016
Left before being seen222590
Head CT results10013
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients10048
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing13965
Appropriate care for severe sepsis and septic shock4892
Septic Shock 3-Hour Bundle5319
Septic Shock 6-Hour Bundle
Severe Sepsis 3-Hour Bundle7392
Severe Sepsis 6-Hour Bundle8249
Discharged on Antithrombotic Therapy9777
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 2
Venous Thromboembolism Prophylaxis872156
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 St Josephs Community Hospital West Bend rated?
St Josephs Community Hospital West Bend has a 4 out of 5 CMS overall star rating as of the latest CMS release.
Does St Josephs Community Hospital West Bend have emergency services?
Yes. St Josephs Community Hospital West Bend operates a 24/7 emergency department.
Where is St Josephs Community Hospital West Bend located?
St Josephs Community Hospital West Bend is located at 3200 Pleasant Valley Road, West Bend, WI 53095.
What type of hospital is St Josephs Community Hospital West Bend?
St Josephs Community Hospital West Bend 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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