BELLIN MEMORIAL HOSPITAL

CMS Certification Number

52T049

Ownership Type

Non-profit

Catheter-associated urinary tract infections (CAUTI) - Standardized infection ratio (SIR) 95% confidence interval - lower limit

0.044

-

Other Measure

4.289

-

Catheter-associated urinary tract infections (CAUTI) - Comparative performance category

No Different than the National Benchmark

-

Catheter-associated urinary tract infections (CAUTI) - Catheter days

422

-

Catheter-associated urinary tract infections (CAUTI) - Predicted number of infections (B)

1.150

-

Catheter-associated urinary tract infections (CAUTI) - Number of infections reported (A)

1

-

Catheter-associated urinary tract infections (CAUTI)

0.870

-

Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan - Denominator

154

-

Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan - Numerator

154

-

Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan

100.0

-

Percentage of IRF patients who experience one or more falls with major injury during their IRF stay - Denominator

154

-

Percentage of IRF patients who experience one or more falls with major injury during their IRF stay - Numerator

0

-

Percentage of IRF patients who experience one or more falls with major injury during their IRF stay

0.0

-

Change in patients' ability to care for themselves

9.9

-

Change in patients' ability to care for themselves - Denominator

142

-

Change in patients' ability to care for themselves - Average observed change score

9.8

-

Change in patients' ability to move around

26.0

-

Change in patients' ability to move around - Denominator

142

-

Change in patients' ability to move around - Average observed change score

27.8

-

Percentage of patients who are at or above an expected ability to care for themselves at discharge - Denominator

142

-

Percentage of patients who are at or above an expected ability to care for themselves at discharge - Numerator

60

-

Percentage of patients who are at or above an expected ability to care for themselves at discharge

42.3

-

Percentage of patients who are at or above an expected ability to care for themselves at discharge - Denominator

142

-

Percentage of patients who are at or above an expected ability to care for themselves at discharge - Numerator

62

-

Percentage of patients who are at or above an expected ability to move around at discharge

43.7

-

Clostridium difficile Infection (CDI) - Standardized infection ratio (SIR) 95% confidence interval - lower limit

Not Available

7

Clostridium difficile Infection (CDI) - SIR 95% confidence interval - upper limit

Not Available

7

Clostridium difficile Infection (CDI) - Comparative performance category

Not Available

7

Clostridium difficile Infection (CDI) - Patient days

3,075

-

Clostridium difficile Infection (CDI) - Predicted number of infections (B)

0.952

-

Clostridium difficile Infection (CDI) - Number of infections reported (A)

1

-

Clostridium difficile Infection (CDI)

Not Available

7

Percentage of healthcare personnel who got a flu shot for the current season - Number of health care workers

28

-

Percentage of healthcare personnel who got a flu shot for the current season - Number of health care workers vaccinated

28

-

Percentage of healthcare personnel who got a flu shot for the current season

100.0

-

Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF - Comparative performance category

No Different than the National Rate

-

Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF - Unadjusted potentially preventable readmission rate

4.41

-

Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF - Number of potentially preventable readmissions following discharge

6

-

Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF

8.24

-

Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF - Lower limit of the 95% confidence interval on the RSRR

6.36

-

Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF - Upper limit of the 95% confidence interval on the RSRR

10.72

-

Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF - Number of eligible stays

136

-

Rate of potentially preventable hospital readmissions during the IRF stay - Comparative performance category

No Different than the National Rate

-

Rate of potentially preventable hospital readmissions during the IRF stay - Unadjusted potentially preventable readmission rate

3.45

-

Rate of potentially preventable hospital readmissions during the IRF stay - Number of potentially preventable readmissions

5

-

Rate of potentially preventable hospital readmissions during the IRF stay

4.78

-

Rate of potentially preventable hospital readmissions during the IRF stay - Lower limit of the 95% confidence interval on the RSRR

2.70

-

Rate of potentially preventable hospital readmissions during the IRF stay - Upper limit of the 95% confidence interval on the RSRR

6.60

-

Rate of potentially preventable hospital readmissions during the IRF stay - Number of eligible stays

145

-

Rate of successful return to home or community from an IRF - Comparative performance category

No Different than the National Rate

-

Rate of successful return to home or community from an IRF - Observed number of discharges to community (DTC)

82

-

Rate of successful return to home or community from an IRF - Observed discharge to community rate

71.93

-

Rate of successful return to home or community from an IRF

67.78

-

Rate of successful return to home or community from an IRF - Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate

61.46

-

Rate of successful return to home or community from an IRF - Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate

73.62

-

Rate of successful return to home or community from an IRF - Number of eligible stays

114

-

Medicare Spending Per Beneficiary (MSPB) for patients in IRFs - Number of eligible episodes

142

-

Medicare Spending Per Beneficiary (MSPB) for patients in IRFs

0.83

-

Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified - Denominator

154

-

Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified - Numerator

152

-

Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified

98.7

-

Other Measure

0.8

-

Other Measure

154

-

Other Measure

1

-

Percentage of patients with pressure ulcers/pressure injuries that are new or worsened

0.6

-

Other Measure

38

-

Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series - Number of health care workers vaccinated

35

-

Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series

92.1

-