Hospital

ST. MARY'S HOSPITAL

CCN: 030010 · TUCSON, AZ 85745 · PIMA County

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

Overview

Address
1601 WEST ST MARY'S ROAD, TUCSON, AZ 85745
Phone
(520) 872-3000
Hospital Type
Acute Care
Ownership
Non-Profit
Emergency Services
Yes
3 /5
★★★★★
CMS Overall Rating
p30
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.

Mortality 7 of 7 measures reported
7
Better No different Worse
30-day death rates for heart attack, heart failure, pneumonia, COPD, stroke, CABG, and kidney disease.
Safety of Care 6 of 8 measures reported
6
Better No different Worse
Healthcare-associated infections and patient safety indicators (PSI-90 composite).
Readmission 8 of 11 measures reported
1
6
1
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 9 of 12 measures reported
9 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) 184 discharges
1.0230 p64
Heart Failure 169 discharges
0.9997 p50
Pneumonia 195 discharges
0.9930 p47
COPD
1.0287 p75
Hip/Knee Replacement
— Not reported
CABG Surgery
0.9939 p47
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 below the national median, suggesting a negative payment adjustment.

15.3 p5
Total Performance Score
National median: 29.5
Clinical Outcomes 25% weight
6.5 p60
Nat'l median: 5.0
Measures mortality rates for conditions like heart attack, heart failure, pneumonia, and COPD. Based on 30-day risk-standardized mortality.
Safety 25% weight
3.5 p7
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
2.8 p3
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
2.5 p43
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: 1.0287
Value-Based Purchasing
15.3 TPS
Below national median
HAC Reduction
No Reduction
HAC Score: -0.2762

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 — Number of Cases Too Small —
Hybrid_HWM 4.00 No Different Than the National Rate 806
MORT_30_AMI 13.20 No Different Than the National Rate 164
MORT_30_CABG 2.40 No Different Than the National Rate 47
MORT_30_COPD 8.20 No Different Than the National Rate 35
MORT_30_HF 11.90 No Different Than the National Rate 145
MORT_30_PN 15.20 No Different Than the National Rate 189
MORT_30_STK 15.10 No Different Than the National Rate 151
PSI_03 0.56 No Different Than the National Rate 2,184
PSI_04 181.12 No Different Than the National Rate 57
PSI_06 0.24 No Different Than the National Rate 2,822
PSI_08 0.28 No Different Than the National Rate 2,969
PSI_09 2.20 No Different Than the National Rate 750
PSI_10 1.60 No Different Than the National Rate 60
PSI_11 7.37 No Different Than the National Rate 57
PSI_12 3.83 No Different Than the National Rate 862
PSI_13 5.84 No Different Than the National Rate 61
PSI_14 1.69 No Different Than the National Rate 135
PSI_15 1.50 No Different Than the National Rate 411
PSI_90 0.97 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 70% —
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 9% —
H_COMP_1_U_P: Nurses "usually" communicated well 21% —
H_COMP_1_LINEAR_SCORE: Nurse communication - linear mean score — —
H_COMP_1_STAR_RATING: Nurse communication - star rating — 2
H_NURSE_RESPECT_A_P: Nurses "always" treated them with courtesy and respect 78% —
H_NURSE_RESPECT_SN_P: Nurses "sometimes" or "never" treated them with courtesy and respect 6% —
H_NURSE_RESPECT_U_P: Nurses "usually" treated them with courtesy and respect 16% —
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 66% —
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 10% —
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 24% —
H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand 65% —
H_NURSE_EXPLAIN_SN_P: Nurses "sometimes" or "never" explained things so they could understand 12% —
H_NURSE_EXPLAIN_U_P: Nurses "usually" explained things so they could understand 23% —
H_COMP_2_A_P: Doctors "always" communicated well 70% —
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 10% —
H_COMP_2_U_P: Doctors "usually" communicated well 20% —
H_COMP_2_LINEAR_SCORE: Doctor communication - linear mean score — —
H_COMP_2_STAR_RATING: Doctor communication - star rating — 2
H_DOCTOR_RESPECT_A_P: Doctors "always" treated them with courtesy and respect 77% —
H_DOCTOR_RESPECT_SN_P: Doctors "sometimes" or "never" treated them with courtesy and respect 7% —
H_DOCTOR_RESPECT_U_P: Doctors "usually" treated them with courtesy and respect 16% —
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 69% —
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 11% —
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 20% —
H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand 63% —
H_DOCTOR_EXPLAIN_SN_P: Doctors "sometimes" or "never" explained things so they could understand 12% —
H_DOCTOR_EXPLAIN_U_P: Doctors "usually" explained things so they could understand 25% —
H_COMP_5_A_P: Staff "always" explained 52% —
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 30% —
H_COMP_5_U_P: Staff "usually" explained 18% —
H_COMP_5_LINEAR_SCORE: Communication about medicines - linear mean score — —
H_COMP_5_STAR_RATING: Communication about medicines - star rating — 1
H_MED_FOR_A_P: Staff "always" explained new medications 65% —
H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications 16% —
H_MED_FOR_U_P: Staff "usually" explained new medications 19% —
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 39% —
H_SIDE_EFFECTS_SN_P: Staff "sometimes" or "never" explained possible side effects 44% —
H_SIDE_EFFECTS_U_P: Staff "usually" explained possible side effects 17% —
H_COMP_6_N_P: No, staff "did not" give patients this information 20% —
H_COMP_6_Y_P: Yes, staff "did" give patients this information 80% —
H_COMP_6_LINEAR_SCORE: Discharge information - linear mean score — —
H_COMP_6_STAR_RATING: Discharge information - star rating — 2
H_DISCH_HELP_N_P: No, staff "did not" give patients information about help after discharge 23% —
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge 77% —
H_SYMPTOMS_N_P: No, staff "did not" give patients information about possible symptoms 16% —
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms 84% —
H_CLEAN_HSP_A_P: Room was "always" clean 63% —
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 16% —
H_CLEAN_HSP_U_P: Room was "usually" clean 21% —
H_CLEAN_LINEAR_SCORE: Cleanliness - linear mean score — —
H_CLEAN_STAR_RATING: Cleanliness - star rating — 2
H_QUIET_HSP_A_P: "Always" quiet at night 45% —
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 18% —
H_QUIET_HSP_U_P: "Usually" quiet at night 37% —
H_QUIET_LINEAR_SCORE: Quietness - linear mean score — —
H_QUIET_STAR_RATING: Quietness - star rating — 2
H_HSP_RATING_0_6: Patients who gave a rating of "6" or lower (low) 18% —
H_HSP_RATING_7_8: Patients who gave a rating of "7" or "8" (medium) 27% —
H_HSP_RATING_9_10: Patients who gave a rating of "9" or "10" (high) 55% —
H_HSP_RATING_LINEAR_SCORE: Overall hospital rating - linear mean score — —
H_HSP_RATING_STAR_RATING: Overall hospital rating - star rating — 1
H_RECMND_DN: "NO", patients would not recommend the hospital (they probably would not or definitely would not recommend it) 15% —
H_RECMND_DY: "YES", patients would definitely recommend the hospital 51% —
H_RECMND_PY: "YES", patients would probably recommend the hospital 34% —
H_RECMND_LINEAR_SCORE: Recommend hospital - linear mean score — —
H_RECMND_STAR_RATING: Recommend hospital - star rating — 1
H_STAR_RATING: Summary star rating — 2

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 0.017 No Different than National Benchmark
HAI_1_CIUPPER 1.710 No Different than National Benchmark
HAI_1_DOPC 3490.000 No Different than National Benchmark
HAI_1_ELIGCASES 2.884 No Different than National Benchmark
HAI_1_NUMERATOR 1.000 No Different than National Benchmark
HAI_1_SIR 0.347 No Different than National Benchmark
HAI_2_CILOWER 0.015 No Different than National Benchmark
HAI_2_CIUPPER 1.452 No Different than National Benchmark
HAI_2_DOPC 3937.000 No Different than National Benchmark
HAI_2_ELIGCASES 3.397 No Different than National Benchmark
HAI_2_NUMERATOR 1.000 No Different than National Benchmark
HAI_2_SIR 0.294 No Different than National Benchmark
HAI_3_CILOWER 0.045 No Different than National Benchmark
HAI_3_CIUPPER 4.419 No Different than National Benchmark
HAI_3_DOPC 40.000 No Different than National Benchmark
HAI_3_ELIGCASES 1.116 No Different than National Benchmark
HAI_3_NUMERATOR 1.000 No Different than National Benchmark
HAI_3_SIR 0.896 No Different than National Benchmark
HAI_4_CILOWER — —
HAI_4_CIUPPER — —
HAI_4_DOPC — —
HAI_4_ELIGCASES — —
HAI_4_NUMERATOR — —
HAI_4_SIR — —
HAI_5_CILOWER 0.244 No Different than National Benchmark
HAI_5_CIUPPER 2.612 No Different than National Benchmark
HAI_5_DOPC 41313.000 No Different than National Benchmark
HAI_5_ELIGCASES 3.126 No Different than National Benchmark
HAI_5_NUMERATOR 3.000 No Different than National Benchmark
HAI_5_SIR 0.960 No Different than National Benchmark
HAI_6_CILOWER 0.168 Better than the National Benchmark
HAI_6_CIUPPER 0.630 Better than the National Benchmark
HAI_6_DOPC 41313.000 Better than the National Benchmark
HAI_6_ELIGCASES 26.200 Better than the National Benchmark
HAI_6_NUMERATOR 9.000 Better than the National Benchmark
HAI_6_SIR 0.344 Better than the National Benchmark

Timely & Effective Care

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

Measure Score Condition
EDV high 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 2.0 Electronic Clinical Quality Measure
HH_HYPO 0.0 Electronic Clinical Quality Measure
HH_ORAE — Electronic Clinical Quality Measure
IMM_3 90.0 Healthcare Personnel Vaccination
OP_18a 198.0 Emergency Department
OP_18b 192.0 Emergency Department
OP_18c 320.0 Emergency Department
OP_18d 425.0 Emergency Department
OP_22 5.0 Emergency Department
OP_23 83.0 Emergency Department
OP_29 99.0 Colonoscopy care
OP_31 — Cataract surgery outcome
OP_40 — Electronic Clinical Quality Measure
SAFE_USE_OF_OPIOIDS 11.0 Electronic Clinical Quality Measure
SEP_1 39.0 Sepsis Care
SEP_SH_3HR 55.0 Sepsis Care
SEP_SH_6HR 64.0 Sepsis Care
SEV_SEP_3HR 63.0 Sepsis Care
SEV_SEP_6HR 79.0 Sepsis Care
STK_02 — Electronic Clinical Quality Measure
STK_03 — Electronic Clinical Quality Measure
STK_05 — Electronic Clinical Quality Measure
VTE_1 76.0 Electronic Clinical Quality Measure
VTE_2 — Electronic Clinical Quality Measure

Unplanned Hospital Visits

Readmission and ED return rates within 30 days of discharge.

Measure Score vs. National
EDAC_30_AMI -2.30 Average Days per 100 Discharges
EDAC_30_HF 14.60 Average Days per 100 Discharges
EDAC_30_PN 18.80 More Days Than Average per 100 Discharges
Hybrid_HWR 14.30 No Different Than the National Rate
OP_32 13.00 No Different Than the National Rate
OP_35_ADM — Number of Cases Too Small
OP_35_ED — Number of Cases Too Small
OP_36 1.50 Worse than expected
READM_30_AMI 13.80 No Different Than the National Rate
READM_30_CABG 10.50 No Different Than the National Rate
READM_30_COPD 18.70 No Different Than the National Rate
READM_30_HF 19.80 No Different Than the National Rate
READM_30_HIP_KNEE — Number of Cases Too Small
READM_30_PN 16.00 No Different Than the National Rate

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 2024)

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 0.08 — metrics.cost_to_charge_ratio
Cost Report Current Ratio 2.64 — metrics.current_ratio
Cost Report Employees per Bed 1.80 — metrics.employees_per_bed
Cost Report fiscal_year 2,024 — fiscal_year
Cost Report Fund Balance ($) $88,497,942 — metrics.fund_balance
Cost Report Net Income ($) $9,764,048 — metrics.net_income
Cost Report Net Patient Revenue ($) $206,249,472 — metrics.net_patient_revenue
Cost Report Operating Margin (%) 4.4% — metrics.operating_margin
Cost Report Total Assets ($) $122,882,016 — metrics.total_assets
Cost Report Total Costs ($) $174,347,140 — metrics.total_costs
Cost Report Total Liabilities ($) $34,384,074 — metrics.total_liabilities
Cost Report Total Margin (%) 4.7% — metrics.total_margin
Cost Report Uncompensated Care (%) 2.4% — metrics.uncompensated_care_pct
General Information Address 1601 WEST ST MARY'S ROAD — Address
General Information City/Town TUCSON — City/Town
General Information Count of Facility MORT Measures 7 — 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 8 — Count of Facility READM Measures
General Information Count of Facility Safety Measures 6 — Count of Facility Safety Measures
General Information Count of Facility TE Measures 9 — Count of Facility TE Measures
General Information Count of MORT Measures Better 0 — Count of MORT Measures Better
General Information Count of MORT Measures No Different 7 — Count of MORT Measures No Different
General Information Count of MORT Measures Worse 0 — Count of MORT Measures Worse
General Information Count of READM Measures Better 1 — Count of READM Measures Better
General Information Count of READM Measures No Different 6 — Count of READM Measures No Different
General Information Count of READM Measures Worse 1 — 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 6 — Count of Safety Measures No Different
General Information Count of Safety Measures Worse 0 — Count of Safety Measures Worse
General Information County/Parish PIMA — County/Parish
General Information Emergency Services Yes — Emergency Services
General Information Facility ID 030010 — Facility ID
General Information Facility Name ST. MARY'S HOSPITAL — Facility Name
General Information Hospital overall rating 3 — Hospital overall rating
General Information Hospital overall rating footnote — — Hospital overall rating footnote
General Information Hospital Ownership Voluntary non-profit - Private — 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 — — 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 AZ — State
General Information TE Group Footnote — — TE Group Footnote
General Information TE Group Measure Count 12 — TE Group Measure Count
General Information Telephone Number (520) 872-3000 — Telephone Number
General Information ZIP Code 85745 — ZIP Code
HAC Reduction Program fiscal_year 2,026 — fiscal_year
HAC Reduction Program measures — cauti — sir 0.43 — measures.cauti.sir
HAC Reduction Program measures — cdi — sir 0.55 — measures.cdi.sir
HAC Reduction Program measures — clabsi — sir 0.38 — measures.clabsi.sir
HAC Reduction Program measures — mrsa — sir 0.70 — measures.mrsa.sir
HAC Reduction Program measures — ssi — sir 0 — measures.ssi.sir
HAC Reduction Program payment_reduction No — payment_reduction
HAC Reduction Program total_hac_score -0.28 — 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) Acute Myocardial Infarction (Heart Attack) — Excess readmission ratio 1.02 0.9995 p64 READM-30-AMI-HRRP.excess_readmission_ratio
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Expected readmission rate 13.2% — READM-30-AMI-HRRP.expected_readmission_rate
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of discharges 184 — READM-30-AMI-HRRP.num_discharges
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of readmissions 26 — READM-30-AMI-HRRP.num_readmissions
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Predicted readmission rate 13.5% — READM-30-AMI-HRRP.predicted_readmission_rate
Readmissions (HRRP) CABG Surgery — Excess readmission ratio 0.99 1.0000 p47 READM-30-CABG-HRRP.excess_readmission_ratio
Readmissions (HRRP) CABG Surgery — Expected readmission rate 11.0% — READM-30-CABG-HRRP.expected_readmission_rate
Readmissions (HRRP) CABG Surgery — Predicted readmission rate 11.0% — READM-30-CABG-HRRP.predicted_readmission_rate
Readmissions (HRRP) COPD — Excess readmission ratio 1.03 0.9969 p75 READM-30-COPD-HRRP.excess_readmission_ratio
Readmissions (HRRP) COPD — Expected readmission rate 14.6% — READM-30-COPD-HRRP.expected_readmission_rate
Readmissions (HRRP) COPD — Predicted readmission rate 15.0% — READM-30-COPD-HRRP.predicted_readmission_rate
Readmissions (HRRP) Heart Failure — Excess readmission ratio 1.00 0.9983 p50 READM-30-HF-HRRP.excess_readmission_ratio
Readmissions (HRRP) Heart Failure — Expected readmission rate 18.4% — READM-30-HF-HRRP.expected_readmission_rate
Readmissions (HRRP) Heart Failure — Number of discharges 169 — READM-30-HF-HRRP.num_discharges
Readmissions (HRRP) Heart Failure — Number of readmissions 31 — READM-30-HF-HRRP.num_readmissions
Readmissions (HRRP) Heart Failure — Predicted readmission rate 18.4% — READM-30-HF-HRRP.predicted_readmission_rate
Readmissions (HRRP) Pneumonia — Excess readmission ratio 0.99 0.9955 p47 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 14.7% — READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Number of discharges 195 — READM-30-PN-HRRP.num_discharges
Readmissions (HRRP) Pneumonia — Number of readmissions 28 — READM-30-PN-HRRP.num_readmissions
Readmissions (HRRP) Pneumonia — Predicted readmission rate 14.6% — READM-30-PN-HRRP.predicted_readmission_rate
Value-Based Purchasing Clinical Outcomes 6.50 5.00 p60 clinical_outcomes_score
Value-Based Purchasing Efficiency & Cost Reduction 2.50 2.50 p43 efficiency_score
Value-Based Purchasing Person & Community Engagement 2.75 8.75 p3 person_community_score
Value-Based Purchasing Safety 3.50 10.00 p7 safety_score
Value-Based Purchasing Total Performance Score 15.25 29.50 p5 total_performance_score
Methodology

Full methodology →