JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Other

St Marys Hospital Medical Ctr

3 / 5

At a glance

St Marys Hospital Medical Ctr carries a 3-star CMS overall rating — in line with 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 Limit0.259Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit5.095Same as national
Central Line Associated Bloodstream Infection: Number of Device Days1846Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases1.297Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases2Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)1.542Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.037Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit3.659Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days2312Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases1.348Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases1Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.742Same as national
SSI - Colon Surgery: Lower Confidence LimitNot available
SSI - Colon Surgery: Upper Confidence LimitNot available
SSI - Colon Surgery: Number of Procedures28Not available
SSI - Colon Surgery: Predicted Cases0.653Not 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 ProceduresNot available
SSI - Abdominal Hysterectomy: Predicted CasesNot available
SSI - Abdominal Hysterectomy: Observed CasesNot available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitNot available
MRSA Bacteremia: Upper Confidence LimitNot available
MRSA Bacteremia: Patient Days18367Not available
MRSA Bacteremia: Predicted Cases0.889Not available
MRSA Bacteremia: Observed Cases1Not available
MRSA BacteremiaNot available
Clostridium Difficile (C.Diff): Lower Confidence Limit0.193Same as national
Clostridium Difficile (C.Diff): Upper Confidence Limit1.468Same as national
Clostridium Difficile (C.Diff): Patient Days18367Same as national
Clostridium Difficile (C.Diff): Predicted Cases6.574Same as national
Clostridium Difficile (C.Diff): Observed Cases4Same as national
Clostridium Difficile (C.Diff)0.608Same 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 Rate4.3Same as national358
Death rate for heart attack patients12Same as national71
Death rate for CABG surgery patientsNot available
Death rate for COPD patients11.3Same as national46
Death rate for heart failure patients12.9Same as national83
Death rate for pneumonia patients16.2Same as national74
Death rate for stroke patients12.3Same as national31
Pressure ulcer rate2.00Worse than national957
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.19Same as national1326
In-hospital fall-associated fracture rate0.26Same as national1373
Postoperative hemorrhage or hematoma rate2.88Same as national246
Postoperative acute kidney injury requiring dialysis rate1.63Same as national75
Postoperative respiratory failure rate8.69Same as national76
Perioperative pulmonary embolism or deep vein thrombosis rate3.17Same as national255
Postoperative sepsis rate4.98Same as national60
Postoperative wound dehiscence rate1.72Same as national61
Abdominopelvic accidental puncture or laceration rate1.25Same as national368
CMS Medicare PSI 90: Patient safety and adverse events composite1.36Same 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-15.8Not available82
Hospital return days for heart failure patients-16.7Not available88
Hospital return days for pneumonia patients-7.9Not available85
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.7Same as national536
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)15.3Same as national735
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 surgery1.1Same as national367
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate12.4Same as national82
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients17.9Same as national48
Heart failure (HF) 30-Day Readmission Rate18.7Same as national88
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate15.2Same as national85

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 rating3552
Doctor communication - star rating3552
Communication about medicines - star rating3552
Discharge information - star rating3552
Cleanliness - star rating2552
Quietness - star rating3552
Overall hospital rating - star rating2552
Recommend hospital - star rating3552
Summary star rating3552

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 Hyperglycemia124165
Hospital Harm - Severe Hypoglycemia1915
Hospital Harm - Opioid Related Adverse Events01850
Healthcare workers given influenza vaccination891350
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 better106381
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 better102358
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better17216
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 seen022853
Head CT results9111
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients9776
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)033
Safe Use of Opioids - Concurrent Prescribing14882
Appropriate care for severe sepsis and septic shock7391
Septic Shock 3-Hour Bundle9021
Septic Shock 6-Hour Bundle8513
Severe Sepsis 3-Hour Bundle8291
Severe Sepsis 6-Hour Bundle9158
Discharged on Antithrombotic Therapy9854
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 29844
Venous Thromboembolism Prophylaxis942027
Intensive Care Unit Venous Thromboembolism Prophylaxis97858

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 MeasureNot Applicable (our hospital does not provide inpatient labor/delivery care)

Frequently asked questions

How is St Marys Hospital Medical Ctr rated?
St Marys Hospital Medical Ctr has a 3 out of 5 CMS overall star rating as of the latest CMS release.
Does St Marys Hospital Medical Ctr have emergency services?
Yes. St Marys Hospital Medical Ctr operates a 24/7 emergency department.
Where is St Marys Hospital Medical Ctr located?
St Marys Hospital Medical Ctr is located at 1726 Shawano Ave, Green Bay, WI 54303.
What type of hospital is St Marys Hospital Medical Ctr?
St Marys Hospital Medical Ctr 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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