JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Government - Local

Witham Health Services

4 / 5

At a glance

Witham Health Services 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 Days395Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases0.241Not 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 Days954Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases0.487Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases2Not 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 Procedures24Not available
SSI - Colon Surgery: Predicted Cases0.627Not 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 Procedures2Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.017Not 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 Days9051Not available
MRSA Bacteremia: Predicted Cases0.334Not available
MRSA Bacteremia: Observed Cases0Not available
MRSA BacteremiaNot available
Clostridium Difficile (C.Diff): Lower Confidence Limit0.287Same as national
Clostridium Difficile (C.Diff): Upper Confidence Limit2.181Same as national
Clostridium Difficile (C.Diff): Patient Days8387Same as national
Clostridium Difficile (C.Diff): Predicted Cases4.424Same as national
Clostridium Difficile (C.Diff): Observed Cases4Same as national
Clostridium Difficile (C.Diff)0.904Same 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 patients3.1Same as national34
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4.6Same as national345
Death rate for heart attack patients12Same as national38
Death rate for CABG surgery patientsNot available
Death rate for COPD patients8.9Same as national54
Death rate for heart failure patients14Same as national92
Death rate for pneumonia patients16.9Same as national130
Death rate for stroke patients13Same as national47
Pressure ulcer rate0.48Same as national915
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.20Same as national1211
In-hospital fall-associated fracture rate0.26Same as national1249
Postoperative hemorrhage or hematoma rate2.28Same as national151
Postoperative acute kidney injury requiring dialysis rate1.64Same as national70
Postoperative respiratory failure rate8.03Same as national65
Perioperative pulmonary embolism or deep vein thrombosis rate3.76Same as national172
Postoperative sepsis rate5.07Same as national53
Postoperative wound dehiscence rateNot available
Abdominopelvic accidental puncture or laceration rate1.04Same as national84
CMS Medicare PSI 90: Patient safety and adverse events composite0.92Same 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-27.2Not available99
Hospital return days for pneumonia patients25.3Not available135
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)13.9Same as national468
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)12.3Same as national413
Rate of inpatient admissions for patients receiving outpatient chemotherapy9.5Same as national67
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy6.7Same as national67
Ratio of unplanned hospital visits after hospital outpatient surgery1Same as national180
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate13.6Same as national36
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients16.9Same as national57
Heart failure (HF) 30-Day Readmission Rate19.2Same as national99
Rate of readmission after hip/knee replacement5.6Same as national40
Pneumonia (PN) 30-Day Readmission Rate16.8Same as national135

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 rating3344
Doctor communication - star rating3344
Communication about medicines - star rating1344
Discharge information - star rating3344
Cleanliness - star rating2344
Quietness - star rating3344
Overall hospital rating - star rating3344
Recommend hospital - star rating3344
Summary star rating3344

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 Hyperglycemia32337
Hospital Harm - Severe Hypoglycemia0491
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination921106
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 better121452
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 better118428
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better31117
Left before being seen122840
Head CT results
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients6375
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing11558
Appropriate care for severe sepsis and septic shock85130
Septic Shock 3-Hour Bundle9354
Septic Shock 6-Hour Bundle9842
Severe Sepsis 3-Hour Bundle89130
Severe Sepsis 6-Hour Bundle10068
Discharged on Antithrombotic Therapy
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 2
Venous Thromboembolism Prophylaxis62779
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 Witham Health Services rated?
Witham Health Services has a 4 out of 5 CMS overall star rating as of the latest CMS release.
Does Witham Health Services have emergency services?
Yes. Witham Health Services operates a 24/7 emergency department.
Where is Witham Health Services located?
Witham Health Services is located at 2605 N Lebanon St, Lebanon, IN 46052.
What type of hospital is Witham Health Services?
Witham Health Services 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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