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Theda Clark Med Ctr - Profile, Major Services, Health Measures, and Patient Experience

The following tables show the profile, major inpatient hospital services, 30-day mortality measures, and patient hospital experience survey at Theda Clark Med Ctr.

Basic Information

Address: 130 2nd St, Neenah, WI 54956         Phone: 920-729-3100
Hospital Type: Acute Care Hospitals         Emergency Services: Yes
Hospital Owner: Voluntary non-profit - Private

Major Inpatient Hospital Services

The information in this table reflects inpatient hospital services provided by Theda Clark Med Ctr to Medicare beneficiaries.

Service Name Number of Cases Treated i
Major joint replacement or reattachment of lower extremity without MCC97
Spinal fusion except cervical without MCC51
Heart failure and shock with CC40
Back and neck proc exc spinal fusion without CC/MCC30
Perc cardiovasc proc with drug-eluting stent without MCC18
Chronic obstructive pulmonary disease with CC16
Major small and large bowel procedures with CC16
Cervical spinal fusion without CC/MCC15
Chronic obstructive pulmonary disease with MCC14
Simple pneumonia and pleurisy with MCC13
Heart failure and shock without CC/MCC12
Chronic obstructive pulmonary disease without CC/MCC11
Acute myocardial infarction, discharged alive without CC/MCC<11 (*)
Acute myocardial infarction, discharged alive with MCC<11 (*)
Acute myocardial infarction, discharged alive with CC<11 (*)
Heart failure and shock with MCC<11 (*)
Diabetes with MCC<11 (*)
Chest Pain<11 (*)
Major cardiovasc procedures with MCC or thoracic aortic aneurysm repair<11 (*)
Extracranial procedures without CC/MCC<11 (*)
Permanent cardiac pacemaker implant with CC<11 (*)
Laparoscopic cholecystectomy without c.d.e. without CC/MCC<11 (*)
Laparoscopic cholecystectomy without c.d.e. with MCC<11 (*)
Laparoscopic cholecystectomy without c.d.e. with CC<11 (*)
Hernia procedures except inguinal and femoral with CC<11 (*)
Major small and large bowel procedures without CC/MCC<11 (*)
Major small and large bowel procedures with MCC<11 (*)
Stomach, esophageal duodenal proc without CC/MCC<11 (*)
Cervical spinal fusion with MCC<11 (*)
Cervical spinal fusion with CC<11 (*)
Spinal fusion except cervical with MCC<11 (*)
Back and neck proc exc spinal fusion with CC/MCC or disc device/neurostim<11 (*)
Major joint replacement or reattachment of lower extremity with MCC<11 (*)
Revision of hip or knee replacement without CC/MCC<11 (*)
Revision of hip or knee replacement with CC<11 (*)
Biopsies of musculoskeletal system and connective tissue without CC/MCC<11 (*)
Biopsies of musculoskeletal system and connective tissue with CC<11 (*)
Other musculoskelet sys and conn tiss O.R. proc with MCC<11 (*)
Kidney and ureter procedures for neoplasm without CC/MCC<11 (*)
Kidney and ureter procedures for neoplasm with MCC<11 (*)
Kidney and ureter procedures for neoplasm with CC<11 (*)
Kidney and ureter procedures for non-neoplasm with MCC<11 (*)
Other kidney and urinary tract procedures with MCC<11 (*)
Other kidney and urinary tract procedures with CC<11 (*)
Female reproductive system reconstructive procedures<11 (*)
Uterine and adnexa proc for non-malignancy without CC/MCC<11 (*)

Note: (*) indicates data cannot be disclosed to protect personal health information due to the small number of Medicare patients.
CC: Complicating or Comorbid condition; MCC: Major Complicating or Comorbid Condition.

30-Day Mortality Measures

The 30-day mortality rate at Theda Clark Med Ctr was calculated by CMS (Centers for Medicare & Medicaid Services) using Medicare claims and eligibility information as well as VA administrative information.

Measure Name Result
Hospital 30-Day Death (Mortality) Rates from Heart Attack 15.9
Comparison to U S Rate - Hospital 30-Day Death (Mortality) Rates from Heart Attack No Different than U.S. National Rate
Lower Mortality Estimate - Hospital 30-Day Death (Mortality) Rates from Heart Attack 12.3
Upper Mortality Estimate - Hospital 30-Day Death (Mortality) Rates from Heart Attack 20.4
Number of Patients - Hospital 30-Day Death (Mortality) Rates from Heart Attack 57
Footnote - Hospital 30-Day Death (Mortality) Rates from Heart Attack
Hospital 30-Day Death (Mortality) Rates from Heart Failure 15.9
Comparison to U S Rate - Hospital 30-Day Death (Mortality) Rates from Heart Failure Worse than U.S. National Rate
Lower Mortality Estimate - Hospital 30-Day Death (Mortality) Rates from Heart Failure 12.4
Upper Mortality Estimate - Hospital 30-Day Death (Mortality) Rates from Heart Failure 20.3
Number of Patients - Hospital 30-Day Death (Mortality) Rates from Heart Failure 160
Footnote - Hospital 30-Day Death (Mortality) Rates from Heart Failure
Hospital 30-Day Death (Mortality) Rates from Pneumonia 11.5
Comparison to U S Rate - Hospital 30-Day Death (Mortality) Rates from Pneumonia No Different than U.S. National Rate
Lower Mortality Estimate - Hospital 30-Day Death (Mortality) Rates from Pneumonia 8.4
Upper Mortality Estimate - Hospital 30-Day Death (Mortality) Rates from Pneumonia 15.7
Number of Patients - Hospital 30-Day Death (Mortality) Rates from Pneumonia 106
Footnote - Hospital 30-Day Death (Mortality) Rates from Pneumonia

Patient Hospital Experience Survey

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Patient Survey is a 32-item survey instrument and data collection methodology for measuring patients’ perceptions of their hospital experience. This survey at Theda Clark Med Ctr is administered to a random sample of adult inpatients between 48 hours and six weeks after discharge.

Survey Question Result
Percent of patients who reported that their nurses "Sometimes" or "Never" communicated well. 4%
Percent of patients who reported that their nurses "Usually" communicated well. 21%
Percent of patients who reported that their nurses "Always" communicated well. 75%
Percent of patients who reported that their doctors "Sometimes" or "Never" communicated well. 5%
Percent of patients who reported that their doctors "Usually" communicated well. 16%
Percent of patients who reported that their doctors "Always" communicated well. 79%
Percent of patients who reported that they "Sometimes" or "Never" received help as soon as they wanted. 8%
Percent of patients who reported that they "Usually" received help as soon as they wanted. 27%
Percent of patients who reported that they "Always" received help as soon as they wanted. 65%
Percent of patients who reported that their pain was "Sometimes" or "Never" well controlled. 6%
Percent of patients who reported that their pain was "Usually" well controlled. 25%
Percent of patients who reported that their pain was "Always" well controlled. 69%
Percent of patients who reported that staff "Sometimes" or "Never" explained about medicines before giving it to them. 20%
Percent of patients who reported that staff "Usually" explained about medicines before giving it to them. 18%
Percent of patients who reported that staff "Always" explained about medicines before giving it to them. 62%
Percent of patients who reported that their room and bathroom were "Sometimes" or "Never" clean. 9%
Percent of patients who reported that their room and bathroom were "Usually" clean. 19%
Percent of patients who reported that their room and bathroom were "Always" clean. 72%
Percent of patients who reported that the area around their room was "Sometimes" or "Never" quiet at night. 12%
Percent of patients who reported that the area around their room was "Usually" quiet at night. 35%
Percent of patients who reported that the area around their room was "Always" quiet at night. 53%
Percent of patients who reported that YES,they were given information about what to do during their recovery at home. 87%
Percent of patients who reported that they were not given information about what to do during their recovery at home. 13%
Percent of patients who gave their hospital a rating of 6 or lower on a scale from 0 (lowest) to 10 (highest). 5%
Percent of patients who gave their hospital a rating of 7 or 8 on a scale from 0 (lowest) to 10 (highest). 22%
Percent of patients who gave their hospital a rating of 9 or 10 on a scale from 0 (lowest) to 10 (highest). 73%
Percent of patients who reported NO,they would not recommend the hospital. 2%
Percent of patients who reported YES,they would probably recommend the hospital. 20%
Percent of patients who reported YES,they would definitely recommend the hospital. 78%
Number of Completed Surveys 300 or more
Survey Response Rate Percent 44%
Hospital Footnote