ASCENSION COLUMBIA ST MARYS HOSPITAL MILWAUKEE

Data completeness

Reported on 6 of 6. Missing measures show N/A with the CMS footnote; footnote 18 values are imputed worst-case, not measured performance.

• PSI-90z -0.294fn 29: This measure was calculated using partial performance period data due to a CMS-approved exception.
• CLABSIz -0.537fn 29: This measure was calculated using partial performance period data due to a CMS-approved exception.
• CAUTIz -0.644fn 29: This measure was calculated using partial performance period data due to a CMS-approved exception.
• SSIz -0.391fn 29: This measure was calculated using partial performance period data due to a CMS-approved exception.
• CDIz 1.492fn 29: This measure was calculated using partial performance period data due to a CMS-approved exception.
• MRSAz 0.062fn 29: This measure was calculated using partial performance period data due to a CMS-approved exception.

Fragility

Each reported measure moves the score by 0.1667 points.

Swing is a mechanics illustration: replace one reported Z with that measure’s observed floor or cap while holding others fixed. Ranked by absolute swing.

Peer context

Plain-language verdict

Describes scoring mechanics only. Not medical or legal advice. Any “would / would not” language is an illustration against the published threshold, not a CMS prediction.

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