Quality Report


Quality Report

Froedtert Memorial Lutheran Hospital, Inc

DBA: Froedtert Memorial Lutheran Hospital
HCO ID: 7718
9200 West Wisconsin Avenue
Milwaukee, WI, 53226
(414) 805-3000
www.froedtert.com
Summary of Quality Information

Accreditation Programs

View Accreditation History
Gold Seal
Hospital
Accreditation Decision
Effective Date
12/2/2023
Last Full Survey Date
10/28/2022
Last On-Site Survey Date
12/1/2023

Advanced Certification Programs

View Certification History
Gold Seal
Advanced Comprehensive Stroke Center
Certification Decision
Effective Date
2/3/2022
Last Full Survey Date
3/13/2024
Last On-Site Survey Date
3/13/2024
Gold Seal
Primary Heart Attack Center
Certification Decision
Effective Date
5/9/2023
Last Full Survey Date
3/10/2023
Last On-Site Survey Date
3/10/2023
Gold Seal
Ventricular Assist Device
Certification Decision
Effective Date
9/14/2022
Last Full Survey Date
9/13/2022
Last On-Site Survey Date
9/13/2022

Sites

Froedtert Memorial Lutheran Hospital Inc
DBA: DBA Froedtert &Medical College Reproductive Medicine Center
W129 N7055 Northfield Drive, Building A, Suite 101
Menomonee Falls, WI, 53051

Available Services

  • Anesthesia (Outpatient )
  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Froedtert Memorial Lutheran Hospital, Inc
DBA: Froedtert Hospital RAYUS Radiology
2445 North Mayfair Road
Milwaukee, WI, 53226

Available Services

  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Froedtert Memorial Lutheran Hospital, Inc
DBA: Sports Medicine Clinic-Diagnostic Radiology
8700 Watertown Plank Rd
Milwaukee, WI, 53226

Available Services

  • Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

  • Rehab

Froedtert Memorial Lutheran Hospital, Inc
DBA: Froedtert Hospital RAYUS Radiology
2315 East Moreland Blvd., Suite 1500
Waukesha, WI, 53186

Available Services

  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Froedtert Memorial Lutheran Hospital, Inc
DBA: Froedtert Hospital RAYUS Radiology
4455 S 108th Street, Suite 140
Greenfield, WI, 53228-2504

Available Services

  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Froedtert Memorial Lutheran Hospital, Inc
DBA: Froedtert Hospital RAYUS Radiology
1240 West Town Square Road
Mequon, WI, 53092

Available Services

  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Froedtert Memorial Lutheran Hospital, Inc
DBA: Plank Road Clinic
1155 N. Mayfair Rd.
Milwaukee, WI, 53226

Available Services

  • Outpatient Clinics (Outpatient )

Froedtert Memorial Lutheran Hospital, Inc
DBA: Froedtert Memorial Lutheran Hospital
9200 West Wisconsin Avenue
Milwaukee, WI, 53226

Available Services

  • Brachytherapy (Imaging/Diagnostic Services )
  • Cardiac Catheterization Lab (Surgical Services )
  • Cardiac Surgery (Surgical Services )
  • Cardiothoracic Surgery (Surgical Services )
  • Cardiovascular Unit (Inpatient )
  • CT Scanner (Imaging/Diagnostic Services )
  • Dialysis Unit (Inpatient )
  • Ear/Nose/Throat Surgery (Surgical Services )
  • EEG/EKG/EMG Lab (Imaging/Diagnostic Services )
  • 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 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 )
  • Nuclear Pharmacy (Inpatient )
  • Ophthalmology (Surgical Services )
  • Orthopedic Surgery (Surgical Services )
  • Orthopedic/Spine Unit (Inpatient )
  • Outpatient Clinics (Outpatient )
  • Plastic Surgery (Surgical Services )
  • Positron Emission Tomography (PET) (Imaging/Diagnostic Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Radiation Oncology (Imaging/Diagnostic Services )
  • Rehabilitation Unit (Inpatient )
  • Rehabilitation Unit (24-hour Acute Care/Crisis Stabilization )
  • Sleep Laboratory (Sleep Laboratory )
  • Sterile Medication Compounding (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Surgical Unit (Inpatient )
  • Teleradiology (Imaging/Diagnostic Services )
  • Thoracic Surgery (Surgical Services )
  • Transplant Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Advanced Comprehensive Stroke Center
  • Primary Heart Attack Center
  • Ventricular Assist Device

Froedtert Memorial Lutheran Hospital, Inc
DBA: FMLH Cancer Center Menomonee Falls
W180 N8085 Town Hall Road Suite A
Menomonee Falls, WI, 53051

Available Services

  • Administration of Blood Product (Outpatient )
  • Administration of High Risk Medications (Outpatient )
  • Hazardous Medication Compounding (Outpatient )
  • Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

  • Infusion Services
  • Medical Oncology
  • Radiation Oncology
  • Surgical Oncology

Froedtert Memorial Lutheran Hospital, Inc
DBA: Moorland Reserve Health Center
4805 S. Moorland Rd
New Berlin, WI, 53151

Available Services

  • Administration of Blood Product (Outpatient )
  • Administration of High Risk Medications (Outpatient )
  • Hazardous Medication Compounding (Outpatient )
  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Other Clinics/Practices Located at This Site:

  • Cancer Center
  • Infusion Center
  • Pharmacy

Froedtert Memorial Lutheran Hospital, Inc
DBA: Springdale Health Center
21800 Intertech Drive
Brookfield, WI, 53045

Available Services

  • Outpatient Clinics (Outpatient )

Froedtert Memorial Lutheran Hospital, Inc
DBA: FMLH Cancer Center West Bend
3200 Pleasant Valley Road Suite A
West Bend, WI, 53095

Available Services

  • Administration of Blood Product (Outpatient )
  • Administration of High Risk Medications (Outpatient )
  • High Risk Sterile Medication Compounding (Outpatient )
  • Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

  • Infusion Services
  • Medical Oncology
  • Radiation Oncology
  • Surgical Oncology

Froedtert Memorial Lutheran Hospital, Inc
DBA: Froedtert Hospital RAYUS Radiology
W129 N7055 Northfield Drive, Suite 101, Building A
Menomonee Falls, WI, 53051

Available Services

  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Other Clinics/Practices Located at This Site:

  • Reproductive Medicine Center, Suite 500, Building B

Froedtert Memorial Lutheran Hospital, Inc.
DBA: Drexel Town Square Health Center
7901 S. 6th Street
Oak Creek, WI, 53154

Available Services

  • Administration of Blood Product (Outpatient )
  • Administration of High Risk Medications (Outpatient )
  • Hazardous Medication Compounding (Outpatient )
  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Other Clinics/Practices Located at This Site:

  • Cancer Center
  • Compunding Pharmacy
  • Infusion Center
  • Radiation Oncology

Froedtert Memorial Lutheran Hospital. Inc
DBA: DBA Froedtert Hospital RAYUS Radiology
10050 S. 27th Street
Oak Creek, WI, 53154

Available Services

  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Froedtert Memorial Lutheran Hospital. Inc
DBA: Froedtert Bluemound Rehabilitation Hospital
10000 West Bluemound Rd
Wauwatosa, WI, 53226

Available Services

  • Inpatient Unit (Inpatient )
  • Non-Sterile Medication Compounding (Inpatient )
  • Outpatient Clinics (Outpatient )
  • Rehabilitation Unit (Inpatient )
  • Rehabilitation Unit (24-hour Acute Care/Crisis Stabilization )
  • Ultrasound (Imaging/Diagnostic Services )

Other Clinics/Practices Located at This Site:

  • Dermatology

Froedtert Memorial Lutheran Hospital. Inc
DBA: Froedtert Hospital RAYUS Radiology
1709 S. 18th Ave Suite 102
West Bend, WI, 53095

Available Services

  • Outpatient Clinics (Outpatient )

Cooperative Agreements

Hospital - Accredited by American College of Surgeons-Commission on Cancer (ACoS-COC)

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 2023 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.