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

Gold Seal
Hospital
Accreditation Decision
Effective Date
5/11/2019
Last Full Survey Date
5/10/2019
Last On-Site Survey Date
5/10/2019

Advanced Certification Programs

Gold Seal
Certification Decision
Effective Date
12/19/2019
Last Full Survey Date
12/18/2019
Last On-Site Survey Date
12/18/2019
Gold Seal
Certification Decision
Effective Date
11/21/2020
Last Full Survey Date
11/20/2020
Last On-Site Survey Date
11/20/2020

Sites

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

Available Services

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

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 (24-hour Acute Care/Crisis Stabilization - Adult )
  • Behavioral Health (Partial Hospitalization - Adult )
  • Brachytherapy (Imaging/Diagnostic Services )
  • Cardiac Catheterization Lab (Surgical Services )
  • Cardiothoracic Surgery (Surgical Services )
  • Cardiovascular Unit (Inpatient )
  • Chemical Dependency (Day Programs - Adult )
  • Chemical Dependency (24-hour Acute Care/Crisis Stabilization - Adult )
  • Chemical Dependency (Partial Hospitalization - Adult )
  • Chemical Dependency (Detox - Adult )
  • Chemical Dependency (Non-detox - Adult )
  • Chemical Dependency (Detox/Non-detox - Adult )
  • Coronary Care Unit (Inpatient )
  • 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 )
  • Hematology/Oncology Unit (Inpatient )
  • Inpatient Unit (Inpatient )
  • Interventional Radiology (Imaging/Diagnostic Services )
  • Labor & Delivery (Inpatient )
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services )
  • Medical /Surgical Unit (Inpatient )
  • Medical Detoxification (Inpatient )
  • Medical ICU (Intensive Care Unit )
  • Neuro/Spine ICU (Intensive Care Unit )
  • Neuro/Spine Unit (Inpatient )
  • 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 )
  • Outpatient Crisis Stabilization
  • 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

  • Advanced Total Hip and Total Knee Replacement
  • Primary Stroke Center

Community Memorial Regional Sleep Disorders Center
DBA: Substitute FMFH for Com. Mem.
W129 N7055 Northfield Drive
Menomonee Falls, WI, 53051

Available Services

  • Outpatient Clinics (Outpatient )

National Patient Safety Goals and National Quality Improvement Goals

Symbol Key

  • starThis organization achieved the best possible results
  • plusThis organization's performance is above the target range/value
  • checkThis organization's performance is similar to the target range/value
  • minusThis organization's performance is below 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.

Symbol Key

  • starThis organization achieved the best possible results
  • plusThis organization's performance is above the target range/value
  • checkThis organization's performance is similar to the target range/value
  • minusThis organization's performance is below 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.

The Joint Commission only reports measures endorsed by the National Quality Forum.
* 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 2019 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Reporting Period: January 2020 - December 2020
Perinatal Care National Comparison: nd 2 Statewide Comparison: nd 2

New Changes to Quarterly Measure

Download Quarterly Measure Results

The Joint Commission only reports measures endorsed by the National Quality Forum.
* State results are not calculated for the National Patient Safety Goals.