Quality Report


Quality Report

Community Memorial Hospital of Menomonee Falls, Inc.

DBA: Froedtert Menomonee Falls Hospital
HCO ID: 7662
W180 N8085 Town Hall Road
Menomonee Falls, WI, 53051
(262) 257-3700
froedtert.com/locations/hospital/menomonee-falls-hospital
Summary of Quality Information

Accreditation Programs

View Accreditation History
Gold Seal
Hospital
Accreditation Decision
Effective Date
9/22/2022
Last Full Survey Date
9/21/2022
Last On-Site Survey Date
9/21/2022

Advanced Certification Programs

View Certification History
Gold Seal
Acute Heart Attack Ready
Certification Decision
Effective Date
5/5/2023
Last Full Survey Date
3/8/2023
Last On-Site Survey Date
3/8/2023
Gold Seal
Advanced Total Hip and Total Knee Replacement
Certification Decision
Effective Date
1/27/2022
Last Full Survey Date
3/20/2024
Last On-Site Survey Date
3/20/2024
Gold Seal
Primary Stroke Center
Certification Decision
Effective Date
5/4/2022
Last Full Survey Date
5/3/2022
Last On-Site Survey Date
5/3/2022

Sites

Community Memorial Hospital of Menomonee Falls, Inc.
DBA: Froedert Menomonee Falls Hospital
W180 N8085 Town Hall Road
Menomonee Falls, WI, 53051

Available Services

  • Addiction Services
  • Addiction Services (Non-detox - Adult )
  • Behavioral Health (Day Programs - Adult )
  • Behavioral Health (Partial Hospitalization - Adult )
  • Brachytherapy (Imaging/Diagnostic Services )
  • Cardiac Catheterization Lab (Surgical Services )
  • Cardiovascular Unit (Inpatient )
  • Chemical Dependency (Day Programs - Adult )
  • Chemical Dependency (Partial Hospitalization - Adult )
  • Chemical Dependency (Non-detox - Adult )
  • CT Scanner (Imaging/Diagnostic Services )
  • Dialysis Unit (Inpatient )
  • Ear/Nose/Throat Surgery (Surgical Services )
  • EEG/EKG/EMG Lab (Imaging/Diagnostic Services )
  • Family Support (Non 24 Hour Care )
  • Gastroenterology (Surgical Services )
  • GI or Endoscopy Lab (Imaging/Diagnostic Services )
  • Gynecological Surgery (Surgical Services )
  • Gynecology (Inpatient )
  • Hazardous Medication Compounding (Inpatient )
  • Inpatient Unit (Inpatient )
  • Interventional Radiology (Imaging/Diagnostic Services )
  • Labor & Delivery (Inpatient )
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services )
  • Medical /Surgical Unit (Inpatient )
  • Medical ICU (Intensive Care Unit )
  • Neurosurgery (Surgical Services )
  • Non-Sterile Medication Compounding (Inpatient )
  • Normal Newborn Nursery (Inpatient )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Ophthalmology (Surgical Services )
  • Orthopedic Surgery (Surgical Services )
  • Orthopedic/Spine Unit (Inpatient )
  • Outpatient Clinics (Outpatient )
  • Pediatric Unit (Inpatient )
  • Peer Support (Non 24 Hour Care )
  • Plastic Surgery (Surgical Services )
  • Positron Emission Tomography (PET) (Imaging/Diagnostic Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Radiation Oncology (Imaging/Diagnostic Services )
  • Sterile Medication Compounding (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Surgical Unit (Inpatient )
  • Teleradiology (Imaging/Diagnostic Services )
  • Thoracic Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Acute Heart Attack Ready
  • Advanced Total Hip and Total Knee Replacement
  • Primary Stroke Center

Community Memorial Regional Sleep Disorders Center
DBA: FMFH Regional Sleep Disorders Center
W129 N7055 Northfield Drive
Menomonee Falls, WI, 53051

Available Services

  • Outpatient Clinics (Outpatient )

FMFH Family Medicine Residency Clinic
DBA: FMFH Family Medicine Residency Clinic
W180 N8000 Town Hall Road, Fourth Floor
Menomonee Falls, WI, 53051

Available Services

  • Perform Invasive Procedure (Outpatient )
  • Single Specialty Practitioner (Outpatient )

National Patient Safety Goals and National Quality Improvement Goals

Symbol Key

  • starThis organization achieved the best possible results
  • plusThis organization's performance is better than the target range/value
  • checkThis organization's performance is similar to the target range/value
  • minusThis organization's performance is worse than the target range /value
  • naThis measure is not applicable for this organization
  • ndNot displayed

Measures Footnote Key

  1. The measure or measure set was not reported.
  2. The measure set does not have an overall result.
  3. The number is not enough for comparison purposes.
  4. The measure meets the Privacy Disclosure Threshold rule.
  5. The organization scored above 90% but was below most other organizations.
  6. The measure results are not statistically valid.
  7. The measure results are based on a sample of patients.
  8. The number of months with measure data is below the reporting requirement.
  9. The measure results are temporarily suppressed pending resubmission of updated data.
  10. Test Measure: a measure being evaluated for reliability of the individual data elements or awaiting National Quality Forum Endorsement.
  11. There were no eligible patients that met the denominator criteria.
  12. The measure rate is within optimal range.

Symbol Key

  • starThis organization achieved the best possible results
  • plusThis organization's performance is better than the target range/value
  • checkThis organization's performance is similar to the target range/value
  • minusThis organization's performance is worse than the target range/value
  • naThis measure is not applicable for this organization
  • ndNot displayed

Measures Footnote Key

  1. The measure or measure set was not reported.
  2. The measure set does not have an overall result.
  3. The number is not enough for comparison purposes.
  4. The measure meets the Privacy Disclosure Threshold rule.
  5. The organization scored above 90% but was below most other organizations.
  6. The measure results are not statistically valid.
  7. The measure results are based on a sample of patients.
  8. The number of months with measure data is below the reporting requirement.
  9. The measure results are temporarily suppressed pending resubmission of updated data.
  10. Test Measure: a measure being evaluated for reliability of the individual data elements or awaiting National Quality Forum Endorsement.
  11. There were no eligible patients that met the denominator criteria.
  12. The measure rate is within optimal range.

* This information can also be viewed at Hospital Compare.

**      Indicates per 1000 hours of patient care.
***   The measure was not in effect for this quarter.
----   Null value or data not displayed.

Hospital 2022 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Reporting Period: January 2022 - December 2022
Perinatal Care National Comparison: nd 2 Statewide Comparison: nd 2

New Changes to Quarterly Measure

Download Quarterly Measure Results

* State results are not calculated for the National Patient Safety Goals.