Hospital

CALIFORNIA PACIFIC MEDICAL CENTER - MISSION BERNAL

CCN: 050055 · SAN FRANCISCO, CA 94110 · SAN FRANCISCO County

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

Overview

Address
3555 CESAR CHAVEZ, SAN FRANCISCO, CA 94110
Phone
(415) 641-6562
Hospital Type
Acute Care
Ownership
Non-Profit (Church)
Emergency Services
Yes
4 /5
★★★★★
CMS Overall Rating
p63
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 4 of 7 measures reported
1
3
Better No different Worse
30-day death rates for heart attack, heart failure, pneumonia, COPD, stroke, CABG, and kidney disease.
Safety of Care 7 of 8 measures reported
1
6
Better No different Worse
Healthcare-associated infections and patient safety indicators (PSI-90 composite).
Readmission 6 of 11 measures reported
6
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 7 of 12 measures reported
7 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 190 discharges
1.0113 p58
Pneumonia 149 discharges
1.0418 p76
COPD 50 discharges
1.0349 p78
Hip/Knee Replacement
0.8115 p8
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.

41.8 p82
Total Performance Score
National median: 29.5
Clinical Outcomes 25% weight
8.8 p75
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
13.8 p73
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
9.3 p54
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
10.0 p76
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: 1.0418
Value-Based Purchasing
41.8 TPS
Above national median
HAC Reduction
No Reduction
HAC Score: -0.3667

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 2.10 No Different Than the National Rate 372
Hybrid_HWM 3.80 No Different Than the National Rate 651
MORT_30_AMI — Number of Cases Too Small —
MORT_30_CABG — — —
MORT_30_COPD 8.90 No Different Than the National Rate 38
MORT_30_HF 9.90 No Different Than the National Rate 165
MORT_30_PN 13.40 No Different Than the National Rate 132
MORT_30_STK — Number of Cases Too Small —
PSI_03 0.27 No Different Than the National Rate 2,291
PSI_04 163.19 No Different Than the National Rate 28
PSI_06 0.19 No Different Than the National Rate 2,912
PSI_08 0.24 No Different Than the National Rate 2,681
PSI_09 2.46 No Different Than the National Rate 755
PSI_10 1.61 No Different Than the National Rate 425
PSI_11 7.36 No Different Than the National Rate 431
PSI_12 4.07 No Different Than the National Rate 787
PSI_13 5.47 No Different Than the National Rate 401
PSI_14 1.70 No Different Than the National Rate 105
PSI_15 1.24 No Different Than the National Rate 336
PSI_90 0.87 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 78% —
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 4% —
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 — 3
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 74% —
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 4% —
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 22% —
H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand 72% —
H_NURSE_EXPLAIN_SN_P: Nurses "sometimes" or "never" explained things so they could understand 5% —
H_NURSE_EXPLAIN_U_P: Nurses "usually" explained things so they could understand 23% —
H_COMP_2_A_P: Doctors "always" communicated well 82% —
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 4% —
H_COMP_2_U_P: Doctors "usually" communicated well 14% —
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 1% —
H_DOCTOR_RESPECT_U_P: Doctors "usually" treated them with courtesy and respect 10% —
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 80% —
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 4% —
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 16% —
H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand 78% —
H_DOCTOR_EXPLAIN_SN_P: Doctors "sometimes" or "never" explained things so they could understand 5% —
H_DOCTOR_EXPLAIN_U_P: Doctors "usually" explained things so they could understand 17% —
H_COMP_5_A_P: Staff "always" explained 60% —
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 22% —
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 — 2
H_MED_FOR_A_P: Staff "always" explained new medications 72% —
H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications 13% —
H_MED_FOR_U_P: Staff "usually" explained new medications 15% —
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 47% —
H_SIDE_EFFECTS_SN_P: Staff "sometimes" or "never" explained possible side effects 31% —
H_SIDE_EFFECTS_U_P: Staff "usually" explained possible side effects 22% —
H_COMP_6_N_P: No, staff "did not" give patients this information 13% —
H_COMP_6_Y_P: Yes, staff "did" give patients this information 87% —
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 12% —
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge 88% —
H_SYMPTOMS_N_P: No, staff "did not" give patients information about possible symptoms 13% —
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms 87% —
H_CLEAN_HSP_A_P: Room was "always" clean 77% —
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 7% —
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 59% —
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 10% —
H_QUIET_HSP_U_P: "Usually" quiet at night 31% —
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) 6% —
H_HSP_RATING_7_8: Patients who gave a rating of "7" or "8" (medium) 17% —
H_HSP_RATING_9_10: Patients who gave a rating of "9" or "10" (high) 77% —
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) 3% —
H_RECMND_DY: "YES", patients would definitely recommend the hospital 79% —
H_RECMND_PY: "YES", patients would probably recommend the hospital 18% —
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 N/A No Different than National Benchmark
HAI_1_CIUPPER 2.117 No Different than National Benchmark
HAI_1_DOPC 1520.000 No Different than National Benchmark
HAI_1_ELIGCASES 1.415 No Different than National Benchmark
HAI_1_NUMERATOR 0.000 No Different than National Benchmark
HAI_1_SIR 0.000 No Different than National Benchmark
HAI_2_CILOWER 0.031 No Different than National Benchmark
HAI_2_CIUPPER 3.022 No Different than National Benchmark
HAI_2_DOPC 1609.000 No Different than National Benchmark
HAI_2_ELIGCASES 1.632 No Different than National Benchmark
HAI_2_NUMERATOR 1.000 No Different than National Benchmark
HAI_2_SIR 0.613 No Different than National Benchmark
HAI_3_CILOWER N/A No Different than National Benchmark
HAI_3_CIUPPER 2.723 No Different than National Benchmark
HAI_3_DOPC 47.000 No Different than National Benchmark
HAI_3_ELIGCASES 1.100 No Different than National Benchmark
HAI_3_NUMERATOR 0.000 No Different than National Benchmark
HAI_3_SIR 0.000 No Different than National Benchmark
HAI_4_CILOWER — —
HAI_4_CIUPPER — —
HAI_4_DOPC 66.000 —
HAI_4_ELIGCASES 0.486 —
HAI_4_NUMERATOR 0.000 —
HAI_4_SIR — —
HAI_5_CILOWER 0.171 No Different than National Benchmark
HAI_5_CIUPPER 3.371 No Different than National Benchmark
HAI_5_DOPC 24315.000 No Different than National Benchmark
HAI_5_ELIGCASES 1.960 No Different than National Benchmark
HAI_5_NUMERATOR 2.000 No Different than National Benchmark
HAI_5_SIR 1.020 No Different than National Benchmark
HAI_6_CILOWER 0.097 Better than the National Benchmark
HAI_6_CIUPPER 0.497 Better than the National Benchmark
HAI_6_DOPC 24315.000 Better than the National Benchmark
HAI_6_ELIGCASES 25.127 Better than the National Benchmark
HAI_6_NUMERATOR 6.000 Better than the National Benchmark
HAI_6_SIR 0.239 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 medium 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 80.0 Healthcare Personnel Vaccination
OP_18a 218.0 Emergency Department
OP_18b 199.0 Emergency Department
OP_18c 308.0 Emergency Department
OP_18d 525.0 Emergency Department
OP_22 4.0 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 72.0 Sepsis Care
SEP_SH_3HR 71.0 Sepsis Care
SEP_SH_6HR — Sepsis Care
SEV_SEP_3HR 84.0 Sepsis Care
SEV_SEP_6HR 95.0 Sepsis Care
STK_02 — Electronic Clinical Quality Measure
STK_03 — Electronic Clinical Quality Measure
STK_05 — Electronic Clinical Quality Measure
VTE_1 94.0 Electronic Clinical Quality Measure
VTE_2 99.0 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 20.00 More Days Than Average per 100 Discharges
EDAC_30_PN 30.80 More Days Than Average per 100 Discharges
Hybrid_HWR 15.70 No Different Than the National Rate
OP_32 — Number of Cases Too Small
OP_35_ADM — Number of Cases Too Small
OP_35_ED — Number of Cases Too Small
OP_36 1.00 No Different than expected
READM_30_AMI — Number of Cases Too Small
READM_30_CABG — —
READM_30_COPD 18.80 No Different Than the National Rate
READM_30_HF 20.00 No Different Than the National Rate
READM_30_HIP_KNEE 4.00 No Different Than the National Rate
READM_30_PN 16.60 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
0.93

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 0.32 — metrics.cost_to_charge_ratio
Cost Report Current Ratio 4.28 — metrics.current_ratio
Cost Report Employees per Bed 3.47 — metrics.employees_per_bed
Cost Report fiscal_year 2,023 — fiscal_year
Cost Report Fund Balance ($) $2,169,659,958 — metrics.fund_balance
Cost Report Net Income ($) $-35,212,972 — metrics.net_income
Cost Report Net Patient Revenue ($) $192,561,223 — metrics.net_patient_revenue
Cost Report Operating Margin (%) -20.8% — metrics.operating_margin
Cost Report Total Assets ($) $2,959,093,405 — metrics.total_assets
Cost Report Total Costs ($) $208,523,589 — metrics.total_costs
Cost Report Total Liabilities ($) $789,433,447 — metrics.total_liabilities
Cost Report Total Margin (%) -17.8% — metrics.total_margin
Cost Report Uncompensated Care (%) 3.3% — metrics.uncompensated_care_pct
General Information Address 3555 CESAR CHAVEZ — Address
General Information City/Town SAN FRANCISCO — City/Town
General Information Count of Facility MORT Measures 4 — 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 6 — Count of Facility READM Measures
General Information Count of Facility Safety Measures 7 — Count of Facility Safety Measures
General Information Count of Facility TE Measures 7 — Count of Facility TE Measures
General Information Count of MORT Measures Better 1 — Count of MORT Measures Better
General Information Count of MORT Measures No Different 3 — 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 6 — 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 6 — Count of Safety Measures No Different
General Information Count of Safety Measures Worse 0 — Count of Safety Measures Worse
General Information County/Parish SAN FRANCISCO — County/Parish
General Information Emergency Services Yes — Emergency Services
General Information Facility ID 050055 — Facility ID
General Information Facility Name CALIFORNIA PACIFIC MEDICAL CENTER - MISSION BERNAL — Facility Name
General Information Hospital overall rating 4 — 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 — — 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 CA — State
General Information TE Group Footnote — — TE Group Footnote
General Information TE Group Measure Count 12 — TE Group Measure Count
General Information Telephone Number (415) 641-6562 — Telephone Number
General Information ZIP Code 94110 — ZIP Code
HAC Reduction Program fiscal_year 2,026 — fiscal_year
HAC Reduction Program measures — cauti — sir 0.69 — measures.cauti.sir
HAC Reduction Program measures — cdi — sir 0.32 — measures.cdi.sir
HAC Reduction Program measures — clabsi — sir 0 — measures.clabsi.sir
HAC Reduction Program measures — mrsa — sir 0.87 — measures.mrsa.sir
HAC Reduction Program measures — ssi — sir 0.58 — measures.ssi.sir
HAC Reduction Program payment_reduction No — payment_reduction
HAC Reduction Program total_hac_score -0.37 — 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 0.93 — Value
Readmissions (HRRP) COPD — Excess readmission ratio 1.03 0.9969 p78 READM-30-COPD-HRRP.excess_readmission_ratio
Readmissions (HRRP) COPD — Expected readmission rate 20.0% — READM-30-COPD-HRRP.expected_readmission_rate
Readmissions (HRRP) COPD — Number of discharges 50 — READM-30-COPD-HRRP.num_discharges
Readmissions (HRRP) COPD — Number of readmissions 13 — READM-30-COPD-HRRP.num_readmissions
Readmissions (HRRP) COPD — Predicted readmission rate 20.7% — READM-30-COPD-HRRP.predicted_readmission_rate
Readmissions (HRRP) Heart Failure — Excess readmission ratio 1.01 0.9983 p58 READM-30-HF-HRRP.excess_readmission_ratio
Readmissions (HRRP) Heart Failure — Expected readmission rate 18.3% — READM-30-HF-HRRP.expected_readmission_rate
Readmissions (HRRP) Heart Failure — Number of discharges 190 — READM-30-HF-HRRP.num_discharges
Readmissions (HRRP) Heart Failure — Number of readmissions 36 — READM-30-HF-HRRP.num_readmissions
Readmissions (HRRP) Heart Failure — Predicted readmission rate 18.5% — READM-30-HF-HRRP.predicted_readmission_rate
Readmissions (HRRP) Hip/Knee Replacement — Excess readmission ratio 0.81 0.9916 p8 READM-30-HIP-KNEE-HRRP.excess_readmission_ratio
Readmissions (HRRP) Hip/Knee Replacement — Expected readmission rate 4.4% — READM-30-HIP-KNEE-HRRP.expected_readmission_rate
Readmissions (HRRP) Hip/Knee Replacement — Predicted readmission rate 3.6% — READM-30-HIP-KNEE-HRRP.predicted_readmission_rate
Readmissions (HRRP) Pneumonia — Excess readmission ratio 1.04 0.9955 p76 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 14.4% — READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Number of discharges 149 — READM-30-PN-HRRP.num_discharges
Readmissions (HRRP) Pneumonia — Number of readmissions 25 — READM-30-PN-HRRP.num_readmissions
Readmissions (HRRP) Pneumonia — Predicted readmission rate 15.0% — READM-30-PN-HRRP.predicted_readmission_rate
Value-Based Purchasing Clinical Outcomes 8.75 5.00 p75 clinical_outcomes_score
Value-Based Purchasing Efficiency & Cost Reduction 10.00 2.50 p76 efficiency_score
Value-Based Purchasing Person & Community Engagement 9.25 8.75 p54 person_community_score
Value-Based Purchasing Safety 13.75 10.00 p73 safety_score
Value-Based Purchasing Total Performance Score 41.75 29.50 p82 total_performance_score
Methodology

Full methodology →