HAC Penalty Risk Auditor
FY2026 · structural fragility of Total HAC Scores
Hospital audit
SSM HEALTH ST MARY'S HOSPITAL - MADISON
WI · Facility ID 520083 · FY2026
Total HAC Score
-0.3199
Percentile
31.1th
Displayed status
No reductionFrom CMS Payment Reduction column (file).
Score vs threshold (0.3792)
Hospital score -0.3199. Penalty threshold 0.3792. Distribution of 2929 scored hospitals.
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 -0.574
- CLABSIz -0.479
- CAUTIz -0.410
- SSIz 0.683
- CDIz -0.761
- MRSAz -0.379
Fragility
Each reported measure moves the score by 0.1667 points.
| Measure | Current Z | Score @ floor | Score @ cap | Abs swing |
|---|---|---|---|---|
| PSI-90controls fate | -0.5736 | -0.4715 | 0.1943 | 0.6658 |
| CAUTI | -0.4099 | -0.4713 | 0.1462 | 0.6175 |
| MRSA | -0.3789 | -0.4996 | 0.1141 | 0.6137 |
| CDI | -0.7613 | -0.4367 | 0.1725 | 0.6092 |
| CLABSI | -0.4786 | -0.4745 | 0.1333 | 0.6078 |
| SSI | 0.6831 | -0.6765 | -0.0718 | 0.6047 |
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
Percentile within WI (62 scored): 23.4th
Hospital score -0.3199. Penalty threshold 0.3792. Distribution of 62 scored hospitals.
Percentile among hospitals with 6 reported measures (1940 scored): 26.5th
Hospital score -0.3199. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.
Plain-language verdict
As scored, the CMS file lists no payment reduction (Total HAC Score -0.3199; threshold 0.3792).
Reported on 6 of 6 measures; each reported measure moves the equal-weighted score by 0.1667 points.
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.