Acute Care Hospital

Madison Memorial Hospital | Madisonhealth

450 East Main Street, Rexburg, ID 83440
24/7 Emergency Services

Quality measures

Mortality

Same as National Average

Measures the rate at which patients die within 30 days of hospital admission for specific conditions. A lower mortality rate indicates better outcomes.

Underlying measures: Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate No Different Than the National Rate Hospital score: 4.30 95% interval: 3.30 – 5.50 Sample size: 130 Reporting period: 07/01/2023 – 06/30/2024 CMS measure id: Hybrid_HWM Death rate for pneumonia patients No Different Than the National Rate Hospital score: 14.80 95% interval: 9.30 – 22.70 Sample size: 30 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_PN Death rate for CABG surgery patients Not Available Hospital score: — Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_CABG Death rate for COPD patients Number of Cases Too Small Hospital score: — Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_COPD Death rate for heart attack patients Not Available Hospital score: — Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_AMI Death rate for heart failure patients Number of Cases Too Small Hospital score: — Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_HF Death rate for stroke patients Number of Cases Too Small Hospital score: — Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_STK

Safety of Care

Same as National Average

Tracks hospital-acquired infections, surgical complications, and other patient safety indicators. Lower rates indicate better safety practices.

Underlying measures: Abdominopelvic accidental puncture or laceration rate No Different Than the National Rate Hospital score: 1.04 95% interval: 0.00 – 2.13 Sample size: 79 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_15 Clostridium Difficile (C.Diff) No Different than National Benchmark Hospital score: 0.30 SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_6_SIR Iatrogenic pneumothorax rate No Different Than the National Rate Hospital score: 0.21 95% interval: 0.00 – 0.44 Sample size: 377 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_06 In-hospital fall-associated fracture rate No Different Than the National Rate Hospital score: 0.27 95% interval: 0.05 – 0.48 Sample size: 372 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_08 Postoperative hemorrhage or hematoma rate No Different Than the National Rate Hospital score: 2.63 95% interval: 0.90 – 4.35 Sample size: 121 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_09 Perioperative pulmonary embolism or deep vein thrombosis rate No Different Than the National Rate Hospital score: 3.79 95% interval: 1.23 – 6.36 Sample size: 128 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_12 Postoperative acute kidney injury requiring dialysis rate No Different Than the National Rate Hospital score: 1.66 95% interval: 0.00 – 3.38 Sample size: 56 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_10 Postoperative respiratory failure rate No Different Than the National Rate Hospital score: 8.68 95% interval: 0.00 – 18.48 Sample size: 54 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_11 Postoperative sepsis rate No Different Than the National Rate Hospital score: 5.08 95% interval: 0.80 – 9.35 Sample size: 40 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_13 Pressure ulcer rate No Different Than the National Rate Hospital score: 0.54 95% interval: 0.00 – 1.79 Sample size: 312 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_03 CMS Medicare PSI 90: Patient safety and adverse events composite No Different Than the National Value Hospital score: 0.96 95% interval: 0.47 – 1.45 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_90 Postoperative wound dehiscence rate No Different Than the National Rate Hospital score: 1.74 95% interval: 0.22 – 3.26 Sample size: 35 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_14 Catheter Associated Urinary Tract Infections (ICU + select Wards) Not Available Hospital score: — SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_2_SIR Central Line Associated Bloodstream Infection (ICU + select Wards) Not Available Hospital score: — SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_1_SIR Rate of complications for hip/knee replacement patients Number of Cases Too Small Hospital score: — Reporting period: 04/01/2021 – 03/31/2024 CMS measure id: COMP_HIP_KNEE MRSA Bacteremia Not Available Hospital score: — SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_5_SIR SSI - Abdominal Hysterectomy Not Available Hospital score: — SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_4_SIR SSI - Colon Surgery Not Available Hospital score: — SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_3_SIR Death rate among surgical inpatients with serious treatable complications Number of Cases Too Small Hospital score: — Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_04

Readmissions

Same as National Average

Measures how often patients return to the hospital within 30 days of discharge. Lower readmission rates suggest effective treatment and discharge planning.

Underlying measures: 30-day Readmission, Heart Failure As expected Hospital score: 1.01 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-HF-HRRP 30-day Readmission, Pneumonia As expected Hospital score: 0.99 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-PN-HRRP 30-day Readmission, Bypass Surgery Hospital score: — Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-CABG-HRRP 30-day Readmission, COPD Hospital score: — Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-COPD-HRRP 30-day Readmission, Heart Attack Hospital score: — Sample size: 0 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-AMI-HRRP 30-day Readmission, Hip/Knee Replacement Hospital score: — Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-HIP-KNEE-HRRP

Patient Experience

Same as National Average

Based on the HCAHPS survey — patient satisfaction with communication, cleanliness, pain management, and discharge information.

Patient survey detail — the questions feeding the Patient Experience domain above expand ↓

CMS computes the Patient Experience domain from the federal HCAHPS survey. Each bar below is one survey question; the percentage is the share of Madison's recent patients who gave the most positive response. HCAHPS percentages aren't directly comparable across all measures — see the methodology page for how CMS weights them.

  • Communication with Nurses 75%
  • Communication with Doctors 80%
  • Hospital Cleanliness 71%
  • Hospital Quietness 54%
  • Staff Responsiveness N/A
  • Discharge Information 86%
  • Overall Hospital Rating (9 or 10) 67%
  • Would Recommend Hospital 63%

Percentages represent patients who gave the most positive response. Survey conducted by CMS through the HCAHPS program.

Timely & Effective Care

Better than National Average

Measures how quickly the hospital provides important treatments such as antibiotics for pneumonia or interventions for heart attacks.

Underlying measures: Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients Better than ~75% of hospitals Hospital score: 100.00 % National median: 97.00 % (higher is better) Sample size: 334 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: OP_29 Safe Use of Opioids - Concurrent Prescribing Better than ~75% of hospitals Hospital score: 8.00 % National median: 15.00 % (lower is better) Sample size: 655 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: SAFE_USE_OF_OPIOIDS Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better Better than ~75% of hospitals Hospital score: 168.00 min National median: 248.00 min (lower is better) Sample size: 33 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: OP_18c Left before being seen Better than ~75% of hospitals Hospital score: 0.00 % National median: 1.00 % (lower is better) Sample size: 10,795 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: OP_22 Septic Shock 3-Hour Bundle Better than ~75% of hospitals Hospital score: 100.00 % National median: 72.00 % (higher is better) Sample size: 12 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: SEP_SH_3HR Average (median) time patients spent in the emergency department before leaving from the visit, excluding patients transferred to another facility or psychiatric care/mental health patients. A lower number of minutes is better Near the national median Hospital score: 132.00 min National median: 148.00 min (lower is better) Sample size: 401 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: OP_18b Average (median) time all patients spent in the emergency department before leaving from the visit, including psychiatric/mental health patients and patients who were transferred to another facility. A lower number of minutes is better Near the national median Hospital score: 135.00 min National median: 154.00 min (lower is better) Sample size: 440 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: OP_18a Appropriate care for severe sepsis and septic shock Near the national median Hospital score: 66.00 % National median: 64.00 % (higher is better) Sample size: 29 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: SEP_1 Hospital Harm - Severe Hypoglycemia Near the national median Hospital score: 1.00 % National median: 1.00 % (lower is better) Sample size: 149 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: HH_HYPO Severe Sepsis 6-Hour Bundle Near the national median Hospital score: 92.00 % National median: 94.00 % (higher is better) Sample size: 13 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: SEV_SEP_6HR Healthcare workers given influenza vaccination Near the national median Hospital score: 65.00 % National median: 79.00 % (higher is better) Sample size: 1,367 Reporting period: 10/01/2024 – 03/31/2025 CMS measure id: IMM_3 Intensive Care Unit Venous Thromboembolism Prophylaxis Worse than ~75% of hospitals Hospital score: 68.00 % National median: 97.00 % (higher is better) Sample size: 96 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: VTE_2 Severe Sepsis 3-Hour Bundle Worse than ~75% of hospitals Hospital score: 69.00 % National median: 81.00 % (higher is better) Sample size: 29 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: SEV_SEP_3HR Venous Thromboembolism Prophylaxis Worse than ~75% of hospitals Hospital score: 74.00 % National median: 90.00 % (higher is better) Sample size: 389 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: VTE_1

Psychiatric Unit Quality (IPFQR)

Madison Memorial Hospital | Madisonhealth operates a Medicare-certified inpatient psychiatric unit that reports under the federal IPFQR program. The measures below are specific to that unit — not the hospital as a whole. They cover restraint and seclusion use, screening for medication side effects, substance-use and tobacco treatment, transitions of care, follow-up after discharge, and readmissions.

Physical Restraint Use 0.0 hours per 1,000 patient-hours
National median: 0.1 hours Near national median

HBIPS-2 — hours of physical restraint use per 1,000 patient-hours. Lower is better; restraints carry physical and psychological risks.

Seclusion Use 0.0 hours per 1,000 patient-hours
National median: 0.0 hours Near national median

HBIPS-3 — hours of seclusion per 1,000 patient-hours. Lower is better; seclusion is used only when no other intervention works.

Metabolic Screening (SMD) 98.0 %
National median: 92.0 % Near national median

SMD — % of patients on antipsychotics screened for metabolic side effects (BMI, blood glucose, cholesterol). Antipsychotics raise metabolic-syndrome risk; screening catches it early.

Substance-Use Treatment Provided 76.0 %
National median: 74.0 % Near national median

SUB-2 — % of patients with alcohol/drug use referred for treatment during admission.

Substance-Use Treatment at Discharge 97.0 %
National median: 77.0 % Better than national median

SUB-3 — % of patients with substance-use disorder offered or referred to treatment at discharge.

Tobacco-Use Treatment at Discharge 96.0 %
National median: 64.0 % Better than national median

TOB-3 — % of patients using tobacco who received counseling and/or medication at discharge.

Transition Record Completed 84.0 %
National median: 77.0 % Near national median

TR-1 — % of discharges with a completed transition record including medications, follow-up plan, and crisis instructions.

30-Day Readmission Rate 16.7 %
National median: 19.1 % Better than national median

READM-30-IPF — risk-standardized 30-day readmission rate. No Different Than the National Rate

Influenza Immunization 92.0 %
National median: 87.0 % Near national median

IMM-2 — % of patients given a flu vaccine during the inpatient stay.

Source: CMS Inpatient Psychiatric Facility Quality Reporting Program. Reporting period ending 12/31/2024.

Clinical Staff

Madison Memorial Hospital | Madisonhealth has 124 CMS-affiliated clinicians on its roster — physicians, advanced practice providers, and other Medicare-enrolled professionals who list this hospital as an affiliated facility.

Top specialties

  • Physician Assistant 22
  • Nurse Practitioner 18
  • Family Practice 14
  • Certified Registered Nurse Anesthetist (Crna) 10
  • Internal Medicine 7
  • Emergency Medicine 7
  • Orthopedic Surgery 6
  • Cardiovascular Disease (Cardiology) 5

Self-reported primary specialty in the CMS Doctors & Clinicians dataset. Many clinicians serve multiple facilities.

Practice characteristics

Accept Medicare assignment
124 (100%)

Bill Medicare directly at the approved rate — patients only owe co-insurance/deductible.

Offer telehealth
21 (17%)

Indicated by the clinician in their CMS profile as routinely providing virtual visits.

Medicare quality scoring (MIPS)

16 of these clinicians have a published Merit-based Incentive Payment System (MIPS) final score. Of those, 5 (31%) score above the national median of 85.5.

MIPS scoring is heavily compressed at the top of the 0–100 range, so individual scores are not a reliable consumer signal. We surface roster-level coverage and the share above the national median instead.

Source: CMS Doctors and Clinicians (Care Compare) national downloadable file and MIPS Performance Year final scores, as of 2026-05-27. Affiliations from the CMS Facility Affiliations dataset. About 16% of small facilities (critical access, rural emergency, freestanding psych, IRF/LTCH) do not appear in the affiliations file and therefore have no panel.

Find a Doctor

Search the 124 clinicians affiliated with Madison Memorial Hospital | Madisonhealth. Each name links to that clinician's official Medicare Care Compare profile, where you can see their credentials, secondary specialties, group affiliations, and (when applicable) MIPS quality scores.

Showing 30 of 124 clinicians (alphabetical)

Roster from CMS Doctors and Clinicians (Care Compare), updated 2026-05-27. A clinician may also practice at other facilities; "affiliated" means this hospital is on their CMS profile, not that they exclusively work here.

Pricing & Costs

Facility Information

Facility type
Acute Care Hospitals
Ownership
Government - Local
Emergency services
Yes — 24/7
About this data

Quality and ratings data are sourced from the U.S. Centers for Medicare & Medicaid Services (CMS) Hospital Compare program. Star ratings are CMS's own calculation; CareRanks does not modify or re-weight them. Facility-level details (address, beds, ownership, teaching status) come from CMS provider files and the CMS Provider of Services file.

Pricing data, where shown, is drawn from the hospital's own Machine-Readable File (MRF) published under the federal Hospital Price Transparency Rule. See our methodology for the full update cadence and limitations.

Report an error on this page →