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

Overview

Address
3555 SOUTH VAL VISTA DRIVE, GILBERT, AZ 85297
Phone
(480) 728-8000
Hospital Type
Acute Care
Ownership
Non-Profit (Church)
Emergency Services
Yes
Birthing Friendly
Yes
5 /5
CMS Overall Rating
p89
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 6 of 7 measures reported
6
Better No different Worse
30-day death rates for heart attack, heart failure, pneumonia, COPD, stroke, CABG, and kidney disease.
Safety of Care 8 of 8 measures reported
1
7
Better No different Worse
Healthcare-associated infections and patient safety indicators (PSI-90 composite).
Readmission 10 of 11 measures reported
10
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 11 of 12 measures reported
11 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) 146 discharges
1.0629 p83
Heart Failure 459 discharges
1.0685 p85
Pneumonia 502 discharges
0.9960 p50
COPD 152 discharges
0.9860 p40
Hip/Knee Replacement
0.9824 p47
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.

31.2 p56
Total Performance Score
National median: 29.5
Clinical Outcomes 25% weight
10.5 p84
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
10.4 p50
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
10.3 p61
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
0.0 p0
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: 1.0685
Value-Based Purchasing
31.2 TPS
Above national median
HAC Reduction
No Reduction
HAC Score: 0.1207

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 3.10 No Different Than the National Rate 114
Hybrid_HWM 3.50 No Different Than the National Rate 1,930
MORT_30_AMI 13.10 No Different Than the National Rate 171
MORT_30_CABG Number of Cases Too Small
MORT_30_COPD 7.90 No Different Than the National Rate 133
MORT_30_HF 7.80 Better Than the National Rate 397
MORT_30_PN 13.40 No Different Than the National Rate 473
MORT_30_STK 11.60 No Different Than the National Rate 181
PSI_03 0.40 No Different Than the National Rate 5,670
PSI_04 153.46 No Different Than the National Rate 84
PSI_06 0.20 No Different Than the National Rate 6,720
PSI_08 0.26 No Different Than the National Rate 7,055
PSI_09 2.85 No Different Than the National Rate 1,272
PSI_10 1.51 No Different Than the National Rate 437
PSI_11 9.71 No Different Than the National Rate 488
PSI_12 6.65 Worse Than the National Rate 1,315
PSI_13 5.34 No Different Than the National Rate 430
PSI_14 1.64 No Different Than the National Rate 377
PSI_15 0.76 No Different Than the National Rate 1,580
PSI_90 1.07 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 79%
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 3%
H_COMP_1_U_P: Nurses "usually" communicated well 18%
H_COMP_1_LINEAR_SCORE: Nurse communication - linear mean score
H_COMP_1_STAR_RATING: Nurse communication - star rating 4
H_NURSE_RESPECT_A_P: Nurses "always" treated them with courtesy and respect 87%
H_NURSE_RESPECT_SN_P: Nurses "sometimes" or "never" treated them with courtesy and respect 2%
H_NURSE_RESPECT_U_P: Nurses "usually" treated them with courtesy and respect 11%
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 77%
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 4%
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 19%
H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand 73%
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 23%
H_COMP_2_A_P: Doctors "always" communicated well 72%
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 8%
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 82%
H_DOCTOR_RESPECT_SN_P: Doctors "sometimes" or "never" treated them with courtesy and respect 5%
H_DOCTOR_RESPECT_U_P: Doctors "usually" treated them with courtesy and respect 13%
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 68%
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 8%
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 24%
H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand 66%
H_DOCTOR_EXPLAIN_SN_P: Doctors "sometimes" or "never" explained things so they could understand 9%
H_DOCTOR_EXPLAIN_U_P: Doctors "usually" explained things so they could understand 25%
H_COMP_5_A_P: Staff "always" explained 58%
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 22%
H_COMP_5_U_P: Staff "usually" explained 20%
H_COMP_5_LINEAR_SCORE: Communication about medicines - linear mean score
H_COMP_5_STAR_RATING: Communication about medicines - star rating 2
H_MED_FOR_A_P: Staff "always" explained new medications 71%
H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications 11%
H_MED_FOR_U_P: Staff "usually" explained new medications 18%
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 46%
H_SIDE_EFFECTS_SN_P: Staff "sometimes" or "never" explained possible side effects 34%
H_SIDE_EFFECTS_U_P: Staff "usually" explained possible side effects 20%
H_COMP_6_N_P: No, staff "did not" give patients this information 10%
H_COMP_6_Y_P: Yes, staff "did" give patients this information 90%
H_COMP_6_LINEAR_SCORE: Discharge information - linear mean score
H_COMP_6_STAR_RATING: Discharge information - star rating 4
H_DISCH_HELP_N_P: No, staff "did not" give patients information about help after discharge 10%
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge 90%
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 71%
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 9%
H_CLEAN_HSP_U_P: Room was "usually" clean 20%
H_CLEAN_LINEAR_SCORE: Cleanliness - linear mean score
H_CLEAN_STAR_RATING: Cleanliness - star rating 3
H_QUIET_HSP_A_P: "Always" quiet at night 57%
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 10%
H_QUIET_HSP_U_P: "Usually" quiet at night 33%
H_QUIET_LINEAR_SCORE: Quietness - linear mean score
H_QUIET_STAR_RATING: Quietness - star rating 3
H_HSP_RATING_0_6: Patients who gave a rating of "6" or lower (low) 7%
H_HSP_RATING_7_8: Patients who gave a rating of "7" or "8" (medium) 19%
H_HSP_RATING_9_10: Patients who gave a rating of "9" or "10" (high) 74%
H_HSP_RATING_LINEAR_SCORE: Overall hospital rating - linear mean score
H_HSP_RATING_STAR_RATING: Overall hospital rating - star rating 4
H_RECMND_DN: "NO", patients would not recommend the hospital (they probably would not or definitely would not recommend it) 4%
H_RECMND_DY: "YES", patients would definitely recommend the hospital 76%
H_RECMND_PY: "YES", patients would probably recommend the hospital 20%
H_RECMND_LINEAR_SCORE: Recommend hospital - linear mean score
H_RECMND_STAR_RATING: Recommend hospital - star rating 4
H_STAR_RATING: Summary star rating 3

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 0.268 No Different than National Benchmark
HAI_1_CIUPPER 2.032 No Different than National Benchmark
HAI_1_DOPC 5905.000 No Different than National Benchmark
HAI_1_ELIGCASES 4.749 No Different than National Benchmark
HAI_1_NUMERATOR 4.000 No Different than National Benchmark
HAI_1_SIR 0.842 No Different than National Benchmark
HAI_2_CILOWER 0.067 No Different than National Benchmark
HAI_2_CIUPPER 1.321 No Different than National Benchmark
HAI_2_DOPC 5148.000 No Different than National Benchmark
HAI_2_ELIGCASES 5.001 No Different than National Benchmark
HAI_2_NUMERATOR 2.000 No Different than National Benchmark
HAI_2_SIR 0.400 No Different than National Benchmark
HAI_3_CILOWER 0.180 No Different than National Benchmark
HAI_3_CIUPPER 1.923 No Different than National Benchmark
HAI_3_DOPC 156.000 No Different than National Benchmark
HAI_3_ELIGCASES 4.245 No Different than National Benchmark
HAI_3_NUMERATOR 3.000 No Different than National Benchmark
HAI_3_SIR 0.707 No Different than National Benchmark
HAI_4_CILOWER 1.084 Worse than the National Benchmark
HAI_4_CIUPPER 8.226 Worse than the National Benchmark
HAI_4_DOPC 148.000 Worse than the National Benchmark
HAI_4_ELIGCASES 1.173 Worse than the National Benchmark
HAI_4_NUMERATOR 4.000 Worse than the National Benchmark
HAI_4_SIR 3.410 Worse than the National Benchmark
HAI_5_CILOWER 0.102 No Different than National Benchmark
HAI_5_CIUPPER 2.012 No Different than National Benchmark
HAI_5_DOPC 77901.000 No Different than National Benchmark
HAI_5_ELIGCASES 3.284 No Different than National Benchmark
HAI_5_NUMERATOR 2.000 No Different than National Benchmark
HAI_5_SIR 0.609 No Different than National Benchmark
HAI_6_CILOWER 0.294 Better than the National Benchmark
HAI_6_CIUPPER 0.790 Better than the National Benchmark
HAI_6_DOPC 73380.000 Better than the National Benchmark
HAI_6_ELIGCASES 32.206 Better than the National Benchmark
HAI_6_NUMERATOR 16.000 Better than the National Benchmark
HAI_6_SIR 0.497 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 Electronic Clinical Quality Measure
HH_HYPO 1.0 Electronic Clinical Quality Measure
HH_ORAE Electronic Clinical Quality Measure
IMM_3 79.0 Healthcare Personnel Vaccination
OP_18a 229.0 Emergency Department
OP_18b 224.0 Emergency Department
OP_18c 338.0 Emergency Department
OP_18d Emergency Department
OP_22 2.0 Emergency Department
OP_23 79.0 Emergency Department
OP_29 100.0 Colonoscopy care
OP_31 Cataract surgery outcome
OP_40 Electronic Clinical Quality Measure
SAFE_USE_OF_OPIOIDS 10.0 Electronic Clinical Quality Measure
SEP_1 82.0 Sepsis Care
SEP_SH_3HR 83.0 Sepsis Care
SEP_SH_6HR 100.0 Sepsis Care
SEV_SEP_3HR 89.0 Sepsis Care
SEV_SEP_6HR 98.0 Sepsis Care
STK_02 Electronic Clinical Quality Measure
STK_03 Electronic Clinical Quality Measure
STK_05 Electronic Clinical Quality Measure
VTE_1 100.0 Electronic Clinical Quality Measure
VTE_2 100.0 Electronic Clinical Quality Measure

Unplanned Hospital Visits

Readmission and ED return rates within 30 days of discharge.

Measure Score vs. National
EDAC_30_AMI -12.10 Average Days per 100 Discharges
EDAC_30_HF -8.30 Average Days per 100 Discharges
EDAC_30_PN -7.00 Average Days per 100 Discharges
Hybrid_HWR 14.80 No Different Than the National Rate
OP_32 13.10 No Different Than the National Rate
OP_35_ADM 10.70 No Different Than the National Rate
OP_35_ED 5.10 No Different Than the National Rate
OP_36 1.00 No Different than expected
READM_30_AMI 14.30 No Different Than the National Rate
READM_30_CABG Number of Cases Too Small
READM_30_COPD 17.90 No Different Than the National Rate
READM_30_HF 21.20 No Different Than the National Rate
READM_30_HIP_KNEE 4.80 No Different Than the National Rate
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
1.03

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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Show 91 rows
Source Metric Value National Median Pctl. Raw key
Cost Report Cost-to-Charge Ratio 0.13 metrics.cost_to_charge_ratio
Cost Report Current Ratio 3.47 metrics.current_ratio
Cost Report Employees per Bed 6.47 metrics.employees_per_bed
Cost Report fiscal_year 2,024 fiscal_year
Cost Report Fund Balance ($) $391,392,321 metrics.fund_balance
Cost Report Net Income ($) $23,921,685 metrics.net_income
Cost Report Net Patient Revenue ($) $397,372,277 metrics.net_patient_revenue
Cost Report Operating Margin (%) 3.9% metrics.operating_margin
Cost Report Total Assets ($) $730,925,718 metrics.total_assets
Cost Report Total Costs ($) $331,300,601 metrics.total_costs
Cost Report Total Liabilities ($) $339,533,397 metrics.total_liabilities
Cost Report Total Margin (%) 5.9% metrics.total_margin
Cost Report Uncompensated Care (%) 2.9% metrics.uncompensated_care_pct
General Information Address 3555 SOUTH VAL VISTA DRIVE Address
General Information City/Town GILBERT City/Town
General Information Count of Facility MORT Measures 6 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 10 Count of Facility READM Measures
General Information Count of Facility Safety Measures 8 Count of Facility Safety Measures
General Information Count of Facility TE Measures 11 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 6 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 0 Count of READM Measures Better
General Information Count of READM Measures No Different 10 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 1 Count of Safety Measures Better
General Information Count of Safety Measures No Different 7 Count of Safety Measures No Different
General Information Count of Safety Measures Worse 0 Count of Safety Measures Worse
General Information County/Parish MARICOPA County/Parish
General Information Emergency Services Yes Emergency Services
General Information Facility ID 030119 Facility ID
General Information Facility Name MERCY GILBERT MEDICAL CENTER Facility Name
General Information Hospital overall rating 5 Hospital overall rating
General Information Hospital overall rating footnote Hospital overall rating footnote
General Information Hospital Ownership Voluntary non-profit - Church Hospital Ownership
General Information Hospital Type Acute Care Hospitals Hospital Type
General Information Meets criteria for birthing friendly designation Y 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 (480) 728-8000 Telephone Number
General Information ZIP Code 85297 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 0.39 measures.cdi.sir
HAC Reduction Program measures — clabsi — sir 0.93 measures.clabsi.sir
HAC Reduction Program measures — mrsa — sir 0.48 measures.mrsa.sir
HAC Reduction Program measures — ssi — sir 0.96 measures.ssi.sir
HAC Reduction Program payment_reduction No payment_reduction
HAC Reduction Program total_hac_score 0.12 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 1.03 Value
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Excess readmission ratio 1.06 0.9995 p83 READM-30-AMI-HRRP.excess_readmission_ratio
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Expected readmission rate 14.1% READM-30-AMI-HRRP.expected_readmission_rate
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of discharges 146 READM-30-AMI-HRRP.num_discharges
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of readmissions 25 READM-30-AMI-HRRP.num_readmissions
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Predicted readmission rate 14.9% READM-30-AMI-HRRP.predicted_readmission_rate
Readmissions (HRRP) COPD — Excess readmission ratio 0.99 0.9969 p40 READM-30-COPD-HRRP.excess_readmission_ratio
Readmissions (HRRP) COPD — Expected readmission rate 18.7% READM-30-COPD-HRRP.expected_readmission_rate
Readmissions (HRRP) COPD — Number of discharges 152 READM-30-COPD-HRRP.num_discharges
Readmissions (HRRP) COPD — Number of readmissions 27 READM-30-COPD-HRRP.num_readmissions
Readmissions (HRRP) COPD — Predicted readmission rate 18.5% READM-30-COPD-HRRP.predicted_readmission_rate
Readmissions (HRRP) Heart Failure — Excess readmission ratio 1.07 0.9983 p85 READM-30-HF-HRRP.excess_readmission_ratio
Readmissions (HRRP) Heart Failure — Expected readmission rate 20.2% READM-30-HF-HRRP.expected_readmission_rate
Readmissions (HRRP) Heart Failure — Number of discharges 459 READM-30-HF-HRRP.num_discharges
Readmissions (HRRP) Heart Failure — Number of readmissions 104 READM-30-HF-HRRP.num_readmissions
Readmissions (HRRP) Heart Failure — Predicted readmission rate 21.6% READM-30-HF-HRRP.predicted_readmission_rate
Readmissions (HRRP) Hip/Knee Replacement — Excess readmission ratio 0.98 0.9916 p47 READM-30-HIP-KNEE-HRRP.excess_readmission_ratio
Readmissions (HRRP) Hip/Knee Replacement — Expected readmission rate 6.0% READM-30-HIP-KNEE-HRRP.expected_readmission_rate
Readmissions (HRRP) Hip/Knee Replacement — Predicted readmission rate 5.9% READM-30-HIP-KNEE-HRRP.predicted_readmission_rate
Readmissions (HRRP) Pneumonia — Excess readmission ratio 1.00 0.9955 p50 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 15.9% READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Number of discharges 502 READM-30-PN-HRRP.num_discharges
Readmissions (HRRP) Pneumonia — Number of readmissions 79 READM-30-PN-HRRP.num_readmissions
Readmissions (HRRP) Pneumonia — Predicted readmission rate 15.8% READM-30-PN-HRRP.predicted_readmission_rate
Value-Based Purchasing Clinical Outcomes 10.50 5.00 p84 clinical_outcomes_score
Value-Based Purchasing Efficiency & Cost Reduction 0.00 2.50 p0 efficiency_score
Value-Based Purchasing Person & Community Engagement 10.25 8.75 p61 person_community_score
Value-Based Purchasing Safety 10.42 10.00 p50 safety_score
Value-Based Purchasing Total Performance Score 31.17 29.50 p56 total_performance_score
Methodology

Full methodology →