Hospital

MEMORIALCARE SADDLEBACK MEDICAL CENTER

CCN: 050603 · LAGUNA HILLS, CA 92653 · ORANGE County

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

Overview

Address
24451 HEALTH CENTER DRIVE, LAGUNA HILLS, CA 92653
Phone
(949) 837-4500
Hospital Type
Acute Care
Ownership
Non-Profit
Emergency Services
Yes
Birthing Friendly
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 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
1
5
Better No different Worse
Healthcare-associated infections and patient safety indicators (PSI-90 composite).
Readmission 7 of 11 measures reported
7
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 10 of 12 measures reported
10 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) 141 discharges
0.9637 p26
Heart Failure 391 discharges
0.9266 p10
Pneumonia 295 discharges
0.9781 p37
COPD 93 discharges
0.9990 p51
Hip/Knee Replacement
— Not reported
CABG Surgery
1.0216 p58
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.

30.6 p54
Total Performance Score
National median: 29.5
Clinical Outcomes 25% weight
7.5 p67
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
13.3 p70
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
9.8 p58
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: 1.0216
Value-Based Purchasing
30.6 TPS
Above national median
HAC Reduction
No Reduction
HAC Score: -0.0013

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 3.90 No Different Than the National Rate 1,134
MORT_30_AMI 11.30 No Different Than the National Rate 121
MORT_30_CABG 2.10 No Different Than the National Rate 30
MORT_30_COPD 10.70 No Different Than the National Rate 82
MORT_30_HF 11.10 No Different Than the National Rate 325
MORT_30_PN 15.60 No Different Than the National Rate 275
MORT_30_STK 15.40 No Different Than the National Rate 172
PSI_03 0.19 No Different Than the National Rate 3,414
PSI_04 150.94 No Different Than the National Rate 56
PSI_06 0.21 No Different Than the National Rate 4,618
PSI_08 0.26 No Different Than the National Rate 4,715
PSI_09 1.86 No Different Than the National Rate 983
PSI_10 1.88 No Different Than the National Rate 374
PSI_11 14.09 No Different Than the National Rate 364
PSI_12 3.39 No Different Than the National Rate 1,071
PSI_13 5.33 No Different Than the National Rate 376
PSI_14 1.67 No Different Than the National Rate 254
PSI_15 0.88 No Different Than the National Rate 787
PSI_90 0.98 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 4% —
H_COMP_1_U_P: Nurses "usually" communicated well 17% —
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 86% —
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 11% —
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 76% —
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 5% —
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 19% —
H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand 75% —
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 20% —
H_COMP_2_A_P: Doctors "always" communicated well 78% —
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 6% —
H_COMP_2_U_P: Doctors "usually" communicated well 16% —
H_COMP_2_LINEAR_SCORE: Doctor communication - linear mean score — —
H_COMP_2_STAR_RATING: Doctor communication - star rating — 3
H_DOCTOR_RESPECT_A_P: Doctors "always" treated them with courtesy and respect 84% —
H_DOCTOR_RESPECT_SN_P: Doctors "sometimes" or "never" treated them with courtesy and respect 4% —
H_DOCTOR_RESPECT_U_P: Doctors "usually" treated them with courtesy and respect 12% —
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 76% —
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 5% —
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 19% —
H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand 73% —
H_DOCTOR_EXPLAIN_SN_P: Doctors "sometimes" or "never" explained things so they could understand 7% —
H_DOCTOR_EXPLAIN_U_P: Doctors "usually" explained things so they could understand 20% —
H_COMP_5_A_P: Staff "always" explained 58% —
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 24% —
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 73% —
H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications 10% —
H_MED_FOR_U_P: Staff "usually" explained new medications 17% —
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 42% —
H_SIDE_EFFECTS_SN_P: Staff "sometimes" or "never" explained possible side effects 37% —
H_SIDE_EFFECTS_U_P: Staff "usually" explained possible side effects 21% —
H_COMP_6_N_P: No, staff "did not" give patients this information 12% —
H_COMP_6_Y_P: Yes, staff "did" give patients this information 88% —
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 11% —
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms 89% —
H_CLEAN_HSP_A_P: Room was "always" clean 75% —
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 6% —
H_CLEAN_HSP_U_P: Room was "usually" clean 19% —
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 44% —
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 19% —
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) 8% —
H_HSP_RATING_7_8: Patients who gave a rating of "7" or "8" (medium) 18% —
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) 5% —
H_RECMND_DY: "YES", patients would definitely recommend the hospital 75% —
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 0.172 No Different than National Benchmark
HAI_1_CIUPPER 1.846 No Different than National Benchmark
HAI_1_DOPC 6157.000 No Different than National Benchmark
HAI_1_ELIGCASES 4.424 No Different than National Benchmark
HAI_1_NUMERATOR 3.000 No Different than National Benchmark
HAI_1_SIR 0.678 No Different than National Benchmark
HAI_2_CILOWER 0.215 No Different than National Benchmark
HAI_2_CIUPPER 2.299 No Different than National Benchmark
HAI_2_DOPC 5139.000 No Different than National Benchmark
HAI_2_ELIGCASES 3.552 No Different than National Benchmark
HAI_2_NUMERATOR 3.000 No Different than National Benchmark
HAI_2_SIR 0.845 No Different than National Benchmark
HAI_3_CILOWER N/A Better than the National Benchmark
HAI_3_CIUPPER 0.967 Better than the National Benchmark
HAI_3_DOPC 141.000 Better than the National Benchmark
HAI_3_ELIGCASES 3.098 Better than the National Benchmark
HAI_3_NUMERATOR 0.000 Better than the National Benchmark
HAI_3_SIR 0.000 Better than the National Benchmark
HAI_4_CILOWER — —
HAI_4_CIUPPER — —
HAI_4_DOPC 81.000 —
HAI_4_ELIGCASES 0.606 —
HAI_4_NUMERATOR 0.000 —
HAI_4_SIR — —
HAI_5_CILOWER N/A No Different than National Benchmark
HAI_5_CIUPPER 1.636 No Different than National Benchmark
HAI_5_DOPC 45659.000 No Different than National Benchmark
HAI_5_ELIGCASES 1.831 No Different than National Benchmark
HAI_5_NUMERATOR 0.000 No Different than National Benchmark
HAI_5_SIR 0.000 No Different than National Benchmark
HAI_6_CILOWER 0.549 No Different than National Benchmark
HAI_6_CIUPPER 1.248 No Different than National Benchmark
HAI_6_DOPC 43709.000 No Different than National Benchmark
HAI_6_ELIGCASES 27.216 No Different than National Benchmark
HAI_6_NUMERATOR 23.000 No Different than National Benchmark
HAI_6_SIR 0.845 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 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 — Electronic Clinical Quality Measure
HH_ORAE — Electronic Clinical Quality Measure
IMM_3 76.0 Healthcare Personnel Vaccination
OP_18a 198.0 Emergency Department
OP_18b 196.0 Emergency Department
OP_18c 252.0 Emergency Department
OP_18d — 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 16.0 Electronic Clinical Quality Measure
SEP_1 73.0 Sepsis Care
SEP_SH_3HR 81.0 Sepsis Care
SEP_SH_6HR 87.0 Sepsis Care
SEV_SEP_3HR 87.0 Sepsis Care
SEV_SEP_6HR 97.0 Sepsis Care
STK_02 97.0 Electronic Clinical Quality Measure
STK_03 — Electronic Clinical Quality Measure
STK_05 97.0 Electronic Clinical Quality Measure
VTE_1 — Electronic Clinical Quality Measure
VTE_2 97.0 Electronic Clinical Quality Measure

Unplanned Hospital Visits

Readmission and ED return rates within 30 days of discharge.

Measure Score vs. National
EDAC_30_AMI -11.50 Average Days per 100 Discharges
EDAC_30_HF -33.50 Fewer Days Than Average per 100 Discharges
EDAC_30_PN 9.70 Average Days per 100 Discharges
Hybrid_HWR 13.60 Better 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 13.10 No Different Than the National Rate
READM_30_CABG 10.80 No Different Than the National Rate
READM_30_COPD 18.10 No Different Than the National Rate
READM_30_HF 18.20 No Different Than the National Rate
READM_30_HIP_KNEE — Number of Cases Too Small
READM_30_PN 15.60 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
1.06

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 0.15 — metrics.cost_to_charge_ratio
Cost Report Current Ratio 11.07 — metrics.current_ratio
Cost Report Employees per Bed 5.65 — metrics.employees_per_bed
Cost Report fiscal_year 2,024 — fiscal_year
Cost Report Fund Balance ($) $724,473,353 — metrics.fund_balance
Cost Report Net Income ($) $35,490,413 — metrics.net_income
Cost Report Net Patient Revenue ($) $390,576,158 — metrics.net_patient_revenue
Cost Report Operating Margin (%) -10.0% — metrics.operating_margin
Cost Report Total Assets ($) $816,460,657 — metrics.total_assets
Cost Report Total Costs ($) $353,259,940 — metrics.total_costs
Cost Report Total Liabilities ($) $91,987,304 — metrics.total_liabilities
Cost Report Total Margin (%) 7.6% — metrics.total_margin
Cost Report Uncompensated Care (%) 1.2% — metrics.uncompensated_care_pct
General Information Address 24451 HEALTH CENTER DRIVE — Address
General Information City/Town LAGUNA HILLS — 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 7 — 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 10 — 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 0 — Count of READM Measures Better
General Information Count of READM Measures No Different 7 — 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 5 — Count of Safety Measures No Different
General Information Count of Safety Measures Worse 0 — Count of Safety Measures Worse
General Information County/Parish ORANGE — County/Parish
General Information Emergency Services Yes — Emergency Services
General Information Facility ID 050603 — Facility ID
General Information Facility Name MEMORIALCARE SADDLEBACK MEDICAL CENTER — 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 - Private — 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 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 (949) 837-4500 — Telephone Number
General Information ZIP Code 92653 — ZIP Code
HAC Reduction Program fiscal_year 2,026 — fiscal_year
HAC Reduction Program measures — cauti — sir 0.89 — measures.cauti.sir
HAC Reduction Program measures — cdi — sir 0.53 — measures.cdi.sir
HAC Reduction Program measures — clabsi — sir 0.46 — measures.clabsi.sir
HAC Reduction Program measures — mrsa — sir 0.51 — measures.mrsa.sir
HAC Reduction Program measures — ssi — sir 0.43 — measures.ssi.sir
HAC Reduction Program payment_reduction No — payment_reduction
HAC Reduction Program total_hac_score -0.00 — 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 1.06 — Value
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Excess readmission ratio 0.96 0.9995 p26 READM-30-AMI-HRRP.excess_readmission_ratio
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Expected readmission rate 12.4% — READM-30-AMI-HRRP.expected_readmission_rate
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of discharges 141 — READM-30-AMI-HRRP.num_discharges
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of readmissions 15 — READM-30-AMI-HRRP.num_readmissions
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Predicted readmission rate 12.0% — READM-30-AMI-HRRP.predicted_readmission_rate
Readmissions (HRRP) CABG Surgery — Excess readmission ratio 1.02 1.0000 p58 READM-30-CABG-HRRP.excess_readmission_ratio
Readmissions (HRRP) CABG Surgery — Expected readmission rate 11.2% — READM-30-CABG-HRRP.expected_readmission_rate
Readmissions (HRRP) CABG Surgery — Predicted readmission rate 11.5% — READM-30-CABG-HRRP.predicted_readmission_rate
Readmissions (HRRP) COPD — Excess readmission ratio 1.00 0.9969 p51 READM-30-COPD-HRRP.excess_readmission_ratio
Readmissions (HRRP) COPD — Expected readmission rate 18.4% — READM-30-COPD-HRRP.expected_readmission_rate
Readmissions (HRRP) COPD — Number of discharges 93 — READM-30-COPD-HRRP.num_discharges
Readmissions (HRRP) COPD — Number of readmissions 17 — READM-30-COPD-HRRP.num_readmissions
Readmissions (HRRP) COPD — Predicted readmission rate 18.4% — READM-30-COPD-HRRP.predicted_readmission_rate
Readmissions (HRRP) Heart Failure — Excess readmission ratio 0.93 0.9983 p10 READM-30-HF-HRRP.excess_readmission_ratio
Readmissions (HRRP) Heart Failure — Expected readmission rate 18.6% — READM-30-HF-HRRP.expected_readmission_rate
Readmissions (HRRP) Heart Failure — Number of discharges 391 — READM-30-HF-HRRP.num_discharges
Readmissions (HRRP) Heart Failure — Number of readmissions 62 — READM-30-HF-HRRP.num_readmissions
Readmissions (HRRP) Heart Failure — Predicted readmission rate 17.2% — READM-30-HF-HRRP.predicted_readmission_rate
Readmissions (HRRP) Pneumonia — Excess readmission ratio 0.98 0.9955 p37 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 15.4% — READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Number of discharges 295 — READM-30-PN-HRRP.num_discharges
Readmissions (HRRP) Pneumonia — Number of readmissions 43 — READM-30-PN-HRRP.num_readmissions
Readmissions (HRRP) Pneumonia — Predicted readmission rate 15.1% — READM-30-PN-HRRP.predicted_readmission_rate
Value-Based Purchasing Clinical Outcomes 7.50 5.00 p67 clinical_outcomes_score
Value-Based Purchasing Efficiency & Cost Reduction 0.00 2.50 p0 efficiency_score
Value-Based Purchasing Person & Community Engagement 9.75 8.75 p58 person_community_score
Value-Based Purchasing Safety 13.33 10.00 p70 safety_score
Value-Based Purchasing Total Performance Score 30.58 29.50 p54 total_performance_score
Methodology

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