Hospital

JACK HUGHSTON MEMORIAL HOSPITAL

CCN: 010168 · PHENIX CITY, AL 36867 · RUSSELL County

Bottom quartile Middle Top quartile Percentile badges compare this hospital to all 5,426 hospitals nationally.

Overview

Address
4401 RIVER CHASE DRIVE, PHENIX CITY, AL 36867
Phone
(334) 732-3000
Hospital Type
Acute Care
Ownership
Government (State)
Emergency Services
Yes
—
Star rating not available
Acute Care — General medical and surgical hospital participating in Medicare IPPS. Subject to CMS quality reporting and payment adjustment programs (VBP, HRRP, HAC).

CMS Star Rating — Quality Domain Breakdown

CMS computes the overall star rating from five quality domains. Each domain compares this hospital's measures against national benchmarks.

Safety of Care 2 of 8 measures reported
2
Better No different Worse
Healthcare-associated infections and patient safety indicators (PSI-90 composite).
Readmission 4 of 11 measures reported
4
Better No different Worse
30-day unplanned readmission rates for heart attack, heart failure, pneumonia, COPD, hip/knee replacement, and CABG.
Patient Experience 8 of 8 measures reported
8 measures reported (comparative data not available for this domain)
HCAHPS survey scores — patient-reported experience with communication, responsiveness, cleanliness, and discharge planning.
Timely & Effective Care 8 of 12 measures reported
8 measures reported (comparative data not available for this domain)
Process-of-care measures including flu immunization, blood clot prevention, and appropriate use of imaging.

Readmissions — Hospital Readmissions Reduction Program

The Excess Readmission Ratio (ERR) compares this hospital's 30-day readmission rate to expected, adjusting for patient mix. An ERR of 1.0 means readmissions are as expected; > 1.0 triggers a Medicare payment penalty (up to 3%).

⚠ This hospital has excess readmissions in at least one condition and is subject to HRRP payment reduction.
Acute Myocardial Infarction (Heart Attack)
— Not reported
Heart Failure
— Not reported
Pneumonia
— Not reported
COPD
— Not reported
Hip/Knee Replacement
1.0187 p57
CABG Surgery
— Not reported
Expected (1.0) National median

Value-Based Purchasing

The Hospital VBP Program adjusts Medicare payments based on clinical quality. The Total Performance Score (TPS) is a weighted composite of four domains, each worth 25%. This hospital's TPS is above the national median, suggesting a positive payment adjustment.

54.0 p96
Total Performance Score
National median: 29.5
Safety 25% weight
16.7 p85
Nat'l median: 10.0
Patient safety measures including healthcare-associated infections (CLABSI, CAUTI, SSI, MRSA, C. diff) and perioperative complications.
Person & Community Engagement 25% weight
30.7 p99
Nat'l median: 8.8
Based on HCAHPS patient experience survey results — communication with nurses and doctors, hospital cleanliness, pain management, discharge information.
Efficiency & Cost Reduction 25% weight
6.7 p67
Nat'l median: 2.5
Based on Medicare Spending Per Beneficiary (MSPB). Measures episode-of-care costs from 3 days before admission through 30 days after discharge.

CMS Payment Programs

Three Medicare programs adjust hospital payments based on quality performance. Hospitals can be penalized under multiple programs simultaneously.

Readmissions (HRRP)
Penalized
Worst ERR: 1.0187
Value-Based Purchasing
54.0 TPS
Above national median
HAC Reduction
No Reduction
HAC Score: -0.8869

Complications & Deaths

30-day mortality rates, patient safety indicators, and complication rates. "Better" means statistically significantly better than the national rate.

Measure Score vs. National Denominator
COMP_HIP_KNEE 3.70 No Different Than the National Rate 276
Hybrid_HWM 3.90 No Different Than the National Rate 280
MORT_30_AMI — Number of Cases Too Small —
MORT_30_CABG — — —
MORT_30_COPD — Number of Cases Too Small —
MORT_30_HF — Number of Cases Too Small —
MORT_30_PN — Number of Cases Too Small —
MORT_30_STK — Number of Cases Too Small —
PSI_03 0.54 No Different Than the National Rate 412
PSI_04 — Number of Cases Too Small —
PSI_06 0.27 No Different Than the National Rate 996
PSI_08 0.30 No Different Than the National Rate 904
PSI_09 2.65 No Different Than the National Rate 814
PSI_10 1.60 No Different Than the National Rate 775
PSI_11 5.76 No Different Than the National Rate 777
PSI_12 4.18 No Different Than the National Rate 844
PSI_13 5.96 No Different Than the National Rate 701
PSI_14 1.76 No Different Than the National Rate 126
PSI_15 1.04 No Different Than the National Rate 241
PSI_90 0.95 No Different Than the National Value —

Patient Experience (HCAHPS)

Hospital Consumer Assessment of Healthcare Providers and Systems — standardized patient survey measuring satisfaction with care.

Measure Score Star Rating
H_COMP_1_A_P: Nurses "always" communicated well 86% —
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 4% —
H_COMP_1_U_P: Nurses "usually" communicated well 10% —
H_COMP_1_LINEAR_SCORE: Nurse communication - linear mean score — —
H_COMP_1_STAR_RATING: Nurse communication - star rating — 5
H_NURSE_RESPECT_A_P: Nurses "always" treated them with courtesy and respect 91% —
H_NURSE_RESPECT_SN_P: Nurses "sometimes" or "never" treated them with courtesy and respect 3% —
H_NURSE_RESPECT_U_P: Nurses "usually" treated them with courtesy and respect 6% —
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 84% —
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 4% —
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 12% —
H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand 82% —
H_NURSE_EXPLAIN_SN_P: Nurses "sometimes" or "never" explained things so they could understand 4% —
H_NURSE_EXPLAIN_U_P: Nurses "usually" explained things so they could understand 14% —
H_COMP_2_A_P: Doctors "always" communicated well 84% —
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 3% —
H_COMP_2_U_P: Doctors "usually" communicated well 13% —
H_COMP_2_LINEAR_SCORE: Doctor communication - linear mean score — —
H_COMP_2_STAR_RATING: Doctor communication - star rating — 4
H_DOCTOR_RESPECT_A_P: Doctors "always" treated them with courtesy and respect 89% —
H_DOCTOR_RESPECT_SN_P: Doctors "sometimes" or "never" treated them with courtesy and respect 2% —
H_DOCTOR_RESPECT_U_P: Doctors "usually" treated them with courtesy and respect 9% —
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 83% —
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 3% —
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 14% —
H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand 81% —
H_DOCTOR_EXPLAIN_SN_P: Doctors "sometimes" or "never" explained things so they could understand 4% —
H_DOCTOR_EXPLAIN_U_P: Doctors "usually" explained things so they could understand 15% —
H_COMP_5_A_P: Staff "always" explained 70% —
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 17% —
H_COMP_5_U_P: Staff "usually" explained 13% —
H_COMP_5_LINEAR_SCORE: Communication about medicines - linear mean score — —
H_COMP_5_STAR_RATING: Communication about medicines - star rating — 4
H_MED_FOR_A_P: Staff "always" explained new medications 83% —
H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications 8% —
H_MED_FOR_U_P: Staff "usually" explained new medications 9% —
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 56% —
H_SIDE_EFFECTS_SN_P: Staff "sometimes" or "never" explained possible side effects 25% —
H_SIDE_EFFECTS_U_P: Staff "usually" explained possible side effects 19% —
H_COMP_6_N_P: No, staff "did not" give patients this information 14% —
H_COMP_6_Y_P: Yes, staff "did" give patients this information 86% —
H_COMP_6_LINEAR_SCORE: Discharge information - linear mean score — —
H_COMP_6_STAR_RATING: Discharge information - star rating — 3
H_DISCH_HELP_N_P: No, staff "did not" give patients information about help after discharge 18% —
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge 82% —
H_SYMPTOMS_N_P: No, staff "did not" give patients information about possible symptoms 10% —
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms 90% —
H_CLEAN_HSP_A_P: Room was "always" clean 76% —
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 8% —
H_CLEAN_HSP_U_P: Room was "usually" clean 16% —
H_CLEAN_LINEAR_SCORE: Cleanliness - linear mean score — —
H_CLEAN_STAR_RATING: Cleanliness - star rating — 4
H_QUIET_HSP_A_P: "Always" quiet at night 80% —
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 2% —
H_QUIET_HSP_U_P: "Usually" quiet at night 18% —
H_QUIET_LINEAR_SCORE: Quietness - linear mean score — —
H_QUIET_STAR_RATING: Quietness - star rating — 5
H_HSP_RATING_0_6: Patients who gave a rating of "6" or lower (low) 5% —
H_HSP_RATING_7_8: Patients who gave a rating of "7" or "8" (medium) 8% —
H_HSP_RATING_9_10: Patients who gave a rating of "9" or "10" (high) 87% —
H_HSP_RATING_LINEAR_SCORE: Overall hospital rating - linear mean score — —
H_HSP_RATING_STAR_RATING: Overall hospital rating - star rating — 5
H_RECMND_DN: "NO", patients would not recommend the hospital (they probably would not or definitely would not recommend it) 3% —
H_RECMND_DY: "YES", patients would definitely recommend the hospital 88% —
H_RECMND_PY: "YES", patients would probably recommend the hospital 9% —
H_RECMND_LINEAR_SCORE: Recommend hospital - linear mean score — —
H_RECMND_STAR_RATING: Recommend hospital - star rating — 5
H_STAR_RATING: Summary star rating — 4

Healthcare Associated Infections

Standardized Infection Ratios (SIR). A SIR < 1.0 means fewer infections than predicted based on national baseline data.

Measure Score (SIR) vs. National
HAI_1_CILOWER — —
HAI_1_CIUPPER — —
HAI_1_DOPC — —
HAI_1_ELIGCASES — —
HAI_1_NUMERATOR — —
HAI_1_SIR — —
HAI_2_CILOWER — —
HAI_2_CIUPPER — —
HAI_2_DOPC — —
HAI_2_ELIGCASES — —
HAI_2_NUMERATOR — —
HAI_2_SIR — —
HAI_3_CILOWER — —
HAI_3_CIUPPER — —
HAI_3_DOPC — —
HAI_3_ELIGCASES — —
HAI_3_NUMERATOR — —
HAI_3_SIR — —
HAI_4_CILOWER — —
HAI_4_CIUPPER — —
HAI_4_DOPC — —
HAI_4_ELIGCASES — —
HAI_4_NUMERATOR — —
HAI_4_SIR — —
HAI_5_CILOWER — —
HAI_5_CIUPPER — —
HAI_5_DOPC 5769.000 —
HAI_5_ELIGCASES 0.170 —
HAI_5_NUMERATOR 0.000 —
HAI_5_SIR — —
HAI_6_CILOWER N/A No Different than National Benchmark
HAI_6_CIUPPER 2.751 No Different than National Benchmark
HAI_6_DOPC 5769.000 No Different than National Benchmark
HAI_6_ELIGCASES 1.089 No Different than National Benchmark
HAI_6_NUMERATOR 0.000 No Different than National Benchmark
HAI_6_SIR 0.000 No Different than National Benchmark

Timely & Effective Care

Process-of-care measures including ED wait times, treatment timeliness, and preventive care.

Measure Score Condition
EDV low Emergency Department
GMCS — Electronic Clinical Quality Measure
GMCS_Malnutrition_Diagnosis_Documented — Electronic Clinical Quality Measure
GMCS_Malnutrition_Screening — Electronic Clinical Quality Measure
GMCS_Nutrition_Assessment — Electronic Clinical Quality Measure
GMCS_Nutritional_Care_Plan — Electronic Clinical Quality Measure
HH_HYPER — Electronic Clinical Quality Measure
HH_HYPO — Electronic Clinical Quality Measure
HH_ORAE — Electronic Clinical Quality Measure
IMM_3 41.0 Healthcare Personnel Vaccination
OP_18a 120.0 Emergency Department
OP_18b 116.0 Emergency Department
OP_18c — Emergency Department
OP_18d 324.0 Emergency Department
OP_22 1.0 Emergency Department
OP_23 — Emergency Department
OP_29 — Colonoscopy care
OP_31 — Cataract surgery outcome
OP_40 — Electronic Clinical Quality Measure
SAFE_USE_OF_OPIOIDS 19.0 Electronic Clinical Quality Measure
SEP_1 46.0 Sepsis Care
SEP_SH_3HR — Sepsis Care
SEP_SH_6HR — Sepsis Care
SEV_SEP_3HR 73.0 Sepsis Care
SEV_SEP_6HR 94.0 Sepsis Care
STK_02 — Electronic Clinical Quality Measure
STK_03 — Electronic Clinical Quality Measure
STK_05 — Electronic Clinical Quality Measure
VTE_1 66.0 Electronic Clinical Quality Measure
VTE_2 87.0 Electronic Clinical Quality Measure

Unplanned Hospital Visits

Readmission and ED return rates within 30 days of discharge.

Measure Score vs. National
EDAC_30_AMI — Number of Cases Too Small
EDAC_30_HF — Number of Cases Too Small
EDAC_30_PN — Number of Cases Too Small
Hybrid_HWR 15.20 No Different Than the National Rate
OP_32 12.80 No Different Than the National Rate
OP_35_ADM — —
OP_35_ED — —
OP_36 1.20 No Different than expected
READM_30_AMI — Number of Cases Too Small
READM_30_CABG — —
READM_30_COPD — Number of Cases Too Small
READM_30_HF — Number of Cases Too Small
READM_30_HIP_KNEE 4.90 No Different Than the National Rate
READM_30_PN — Number of Cases Too Small

Medicare Spending Per Beneficiary

MSPB ratio: values > 1.0 mean this hospital's episode spending is higher than the national median hospital.

Value
0.98

Financial Health (Cost Report — FY 2023)

All Data

Every labeled metric surfaced for this hospital, with national medians and percentiles where a benchmark is available.

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Source Metric Value National Median Pctl. Raw key
Cost Report Cost-to-Charge Ratio 0.28 — metrics.cost_to_charge_ratio
Cost Report Current Ratio 1.71 — metrics.current_ratio
Cost Report Employees per Bed 6.36 — metrics.employees_per_bed
Cost Report fiscal_year 2,023 — fiscal_year
Cost Report Fund Balance ($) $15,198,827 — metrics.fund_balance
Cost Report Net Income ($) $4,904,233 — metrics.net_income
Cost Report Net Patient Revenue ($) $79,983,752 — metrics.net_patient_revenue
Cost Report Operating Margin (%) 4.9% — metrics.operating_margin
Cost Report Total Assets ($) $44,678,648 — metrics.total_assets
Cost Report Total Costs ($) $70,132,976 — metrics.total_costs
Cost Report Total Liabilities ($) $29,479,821 — metrics.total_liabilities
Cost Report Total Margin (%) 6.1% — metrics.total_margin
Cost Report Uncompensated Care (%) 3.2% — metrics.uncompensated_care_pct
General Information Address 4401 RIVER CHASE DRIVE — Address
General Information City/Town PHENIX CITY — City/Town
General Information Count of Facility MORT Measures Not Available — Count of Facility MORT Measures
General Information Count of Facility Pt Exp Measures 8 — Count of Facility Pt Exp Measures
General Information Count of Facility READM Measures 4 — Count of Facility READM Measures
General Information Count of Facility Safety Measures 2 — Count of Facility Safety Measures
General Information Count of Facility TE Measures 8 — Count of Facility TE Measures
General Information Count of MORT Measures Better Not Available — Count of MORT Measures Better
General Information Count of MORT Measures No Different Not Available — Count of MORT Measures No Different
General Information Count of MORT Measures Worse Not Available — Count of MORT Measures Worse
General Information Count of READM Measures Better 0 — Count of READM Measures Better
General Information Count of READM Measures No Different 4 — Count of READM Measures No Different
General Information Count of READM Measures Worse 0 — Count of READM Measures Worse
General Information Count of Safety Measures Better 0 — Count of Safety Measures Better
General Information Count of Safety Measures No Different 2 — Count of Safety Measures No Different
General Information Count of Safety Measures Worse 0 — Count of Safety Measures Worse
General Information County/Parish RUSSELL — County/Parish
General Information Emergency Services Yes — Emergency Services
General Information Facility ID 010168 — Facility ID
General Information Facility Name JACK HUGHSTON MEMORIAL HOSPITAL — Facility Name
General Information Hospital overall rating Not Available — Hospital overall rating
General Information Hospital overall rating footnote 16 — Hospital overall rating footnote
General Information Hospital Ownership Government - State — Hospital Ownership
General Information Hospital Type Acute Care Hospitals — Hospital Type
General Information Meets criteria for birthing friendly designation — — Meets criteria for birthing friendly designation
General Information MORT Group Footnote 5 — MORT Group Footnote
General Information MORT Group Measure Count 7 — MORT Group Measure Count
General Information Pt Exp Group Footnote — — Pt Exp Group Footnote
General Information Pt Exp Group Measure Count 8 — Pt Exp Group Measure Count
General Information READM Group Footnote — — READM Group Footnote
General Information READM Group Measure Count 11 — READM Group Measure Count
General Information Safety Group Footnote — — Safety Group Footnote
General Information Safety Group Measure Count 8 — Safety Group Measure Count
General Information State AL — State
General Information TE Group Footnote — — TE Group Footnote
General Information TE Group Measure Count 12 — TE Group Measure Count
General Information Telephone Number (334) 732-3000 — Telephone Number
General Information ZIP Code 36867 — ZIP Code
HAC Reduction Program fiscal_year 2,026 — fiscal_year
HAC Reduction Program measures — cdi — sir 0 — measures.cdi.sir
HAC Reduction Program payment_reduction No — payment_reduction
HAC Reduction Program total_hac_score -0.89 — total_hac_score
Medicare Spending per Beneficiary End Date 12/31/2024 — End Date
Medicare Spending per Beneficiary Measure ID MSPB-1 — Measure ID
Medicare Spending per Beneficiary Start Date 01/01/2024 — Start Date
Medicare Spending per Beneficiary Value 0.98 — Value
Readmissions (HRRP) Hip/Knee Replacement — Excess readmission ratio 1.02 0.9916 p57 READM-30-HIP-KNEE-HRRP.excess_readmission_ratio
Readmissions (HRRP) Hip/Knee Replacement — Expected readmission rate 4.7% — READM-30-HIP-KNEE-HRRP.expected_readmission_rate
Readmissions (HRRP) Hip/Knee Replacement — Predicted readmission rate 4.8% — READM-30-HIP-KNEE-HRRP.predicted_readmission_rate
Value-Based Purchasing Efficiency & Cost Reduction 6.67 2.50 p67 efficiency_score
Value-Based Purchasing Person & Community Engagement 30.67 8.75 p99 person_community_score
Value-Based Purchasing Safety 16.67 10.00 p85 safety_score
Value-Based Purchasing Total Performance Score 54.00 29.50 p96 total_performance_score
Methodology

Full methodology →