Hospital

FOOTHILL REGIONAL MEDICAL CENTER

CCN: 050780 · TUSTIN, CA 92780 · ORANGE County

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

Overview

Address
14662 NEWPORT AVE, TUSTIN, CA 92780
Phone
(714) 619-7700
Hospital Type
Acute Care
Ownership
For-Profit
Emergency Services
No
—
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.

Mortality 2 of 7 measures reported
2
Better No different Worse
30-day death rates for heart attack, heart failure, pneumonia, COPD, stroke, CABG, and kidney disease.
Safety of Care 2 of 8 measures reported
1
1
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 6 of 12 measures reported
6 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 does not have excess readmissions triggering HRRP penalties.
Acute Myocardial Infarction (Heart Attack)
— Not reported
Heart Failure
0.9771 p35
Pneumonia 179 discharges
0.9750 p35
COPD
— Not reported
Hip/Knee Replacement
— Not reported
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 below the national median, suggesting a negative payment adjustment.

27.0 p40
Total Performance Score
National median: 29.5
Clinical Outcomes 25% weight
13.8 p92
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
12.5 p63
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
0.8 p0
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)
Not Penalized
Worst ERR: 0.9771
Value-Based Purchasing
27.0 TPS
Below national median
HAC Reduction
No Reduction
HAC Score: -1.4044

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 3.50 No Different Than the National Rate 341
MORT_30_AMI — Number of Cases Too Small —
MORT_30_CABG — — —
MORT_30_COPD — Number of Cases Too Small —
MORT_30_HF 10.40 No Different Than the National Rate 38
MORT_30_PN 12.50 Better Than the National Rate 148
MORT_30_STK — Number of Cases Too Small —
PSI_03 0.25 No Different Than the National Rate 1,850
PSI_04 — Number of Cases Too Small —
PSI_06 0.19 No Different Than the National Rate 2,172
PSI_08 0.25 No Different Than the National Rate 2,191
PSI_09 2.21 No Different Than the National Rate 199
PSI_10 1.66 No Different Than the National Rate 59
PSI_11 6.96 No Different Than the National Rate 65
PSI_12 3.08 No Different Than the National Rate 205
PSI_13 5.13 No Different Than the National Rate 54
PSI_14 1.72 No Different Than the National Rate 55
PSI_15 1.00 No Different Than the National Rate 256
PSI_90 0.79 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 66% —
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 10% —
H_COMP_1_U_P: Nurses "usually" communicated well 24% —
H_COMP_1_LINEAR_SCORE: Nurse communication - linear mean score — —
H_COMP_1_STAR_RATING: Nurse communication - star rating — 1
H_NURSE_RESPECT_A_P: Nurses "always" treated them with courtesy and respect 74% —
H_NURSE_RESPECT_SN_P: Nurses "sometimes" or "never" treated them with courtesy and respect 9% —
H_NURSE_RESPECT_U_P: Nurses "usually" treated them with courtesy and respect 17% —
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 63% —
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 11% —
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 26% —
H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand 60% —
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 28% —
H_COMP_2_A_P: Doctors "always" communicated well 64% —
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 14% —
H_COMP_2_U_P: Doctors "usually" communicated well 22% —
H_COMP_2_LINEAR_SCORE: Doctor communication - linear mean score — —
H_COMP_2_STAR_RATING: Doctor communication - star rating — 1
H_DOCTOR_RESPECT_A_P: Doctors "always" treated them with courtesy and respect 71% —
H_DOCTOR_RESPECT_SN_P: Doctors "sometimes" or "never" treated them with courtesy and respect 10% —
H_DOCTOR_RESPECT_U_P: Doctors "usually" treated them with courtesy and respect 19% —
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 61% —
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 13% —
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 26% —
H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand 59% —
H_DOCTOR_EXPLAIN_SN_P: Doctors "sometimes" or "never" explained things so they could understand 18% —
H_DOCTOR_EXPLAIN_U_P: Doctors "usually" explained things so they could understand 23% —
H_COMP_5_A_P: Staff "always" explained 52% —
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 31% —
H_COMP_5_U_P: Staff "usually" explained 17% —
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 62% —
H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications 18% —
H_MED_FOR_U_P: Staff "usually" explained new medications 20% —
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 44% —
H_SIDE_EFFECTS_U_P: Staff "usually" explained possible side effects 14% —
H_COMP_6_N_P: No, staff "did not" give patients this information 24% —
H_COMP_6_Y_P: Yes, staff "did" give patients this information 76% —
H_COMP_6_LINEAR_SCORE: Discharge information - linear mean score — —
H_COMP_6_STAR_RATING: Discharge information - star rating — 1
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 26% —
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms 74% —
H_CLEAN_HSP_A_P: Room was "always" clean 66% —
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 11% —
H_CLEAN_HSP_U_P: Room was "usually" clean 23% —
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 35% —
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 30% —
H_QUIET_HSP_U_P: "Usually" quiet at night 35% —
H_QUIET_LINEAR_SCORE: Quietness - linear mean score — —
H_QUIET_STAR_RATING: Quietness - star rating — 1
H_HSP_RATING_0_6: Patients who gave a rating of "6" or lower (low) 21% —
H_HSP_RATING_7_8: Patients who gave a rating of "7" or "8" (medium) 32% —
H_HSP_RATING_9_10: Patients who gave a rating of "9" or "10" (high) 47% —
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) 20% —
H_RECMND_DY: "YES", patients would definitely recommend the hospital 44% —
H_RECMND_PY: "YES", patients would probably recommend the hospital 36% —
H_RECMND_LINEAR_SCORE: Recommend hospital - linear mean score — —
H_RECMND_STAR_RATING: Recommend hospital - star rating — 1
H_STAR_RATING: Summary star rating — 1

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 824.000 —
HAI_1_ELIGCASES 0.527 —
HAI_1_NUMERATOR 0.000 —
HAI_1_SIR — —
HAI_2_CILOWER — —
HAI_2_CIUPPER — —
HAI_2_DOPC 1229.000 —
HAI_2_ELIGCASES 0.654 —
HAI_2_NUMERATOR 0.000 —
HAI_2_SIR — —
HAI_3_CILOWER — —
HAI_3_CIUPPER — —
HAI_3_DOPC 21.000 —
HAI_3_ELIGCASES 0.583 —
HAI_3_NUMERATOR 0.000 —
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 24739.000 —
HAI_5_ELIGCASES 0.678 —
HAI_5_NUMERATOR 0.000 —
HAI_5_SIR — —
HAI_6_CILOWER N/A Better than the National Benchmark
HAI_6_CIUPPER 0.262 Better than the National Benchmark
HAI_6_DOPC 24739.000 Better than the National Benchmark
HAI_6_ELIGCASES 11.451 Better than the National Benchmark
HAI_6_NUMERATOR 0.000 Better than the National Benchmark
HAI_6_SIR 0.000 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 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 83.0 Healthcare Personnel Vaccination
OP_18a 173.0 Emergency Department
OP_18b 162.0 Emergency Department
OP_18c 487.0 Emergency Department
OP_18d — Emergency Department
OP_22 5.0 Emergency Department
OP_23 — Emergency Department
OP_29 96.0 Colonoscopy care
OP_31 — Cataract surgery outcome
OP_40 — Electronic Clinical Quality Measure
SAFE_USE_OF_OPIOIDS — Electronic Clinical Quality Measure
SEP_1 38.0 Sepsis Care
SEP_SH_3HR — Sepsis Care
SEP_SH_6HR — Sepsis Care
SEV_SEP_3HR 56.0 Sepsis Care
SEV_SEP_6HR — Sepsis Care
STK_02 — Electronic Clinical Quality Measure
STK_03 — Electronic Clinical Quality Measure
STK_05 — Electronic Clinical Quality Measure
VTE_1 — 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 — Number of Cases Too Small
EDAC_30_HF -20.80 Average Days per 100 Discharges
EDAC_30_PN -34.90 Fewer Days Than Average per 100 Discharges
Hybrid_HWR 14.90 No Different Than the National Rate
OP_32 — Number of Cases Too Small
OP_35_ADM — —
OP_35_ED — —
OP_36 — Number of cases too small
READM_30_AMI — Number of Cases Too Small
READM_30_CABG — —
READM_30_COPD — Number of Cases Too Small
READM_30_HF 19.20 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
1.42

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 0.23 — metrics.cost_to_charge_ratio
Cost Report Current Ratio 0.77 — metrics.current_ratio
Cost Report Employees per Bed 2.42 — metrics.employees_per_bed
Cost Report fiscal_year 2,023 — fiscal_year
Cost Report Fund Balance ($) $-9,839,311 — metrics.fund_balance
Cost Report Net Income ($) $4,856,925 — metrics.net_income
Cost Report Net Patient Revenue ($) $85,050,674 — metrics.net_patient_revenue
Cost Report Total Assets ($) $238,572,707 — metrics.total_assets
Cost Report Total Costs ($) $109,368,505 — metrics.total_costs
Cost Report Total Liabilities ($) $248,412,018 — metrics.total_liabilities
Cost Report Total Margin (%) 2.4% — metrics.total_margin
Cost Report Uncompensated Care (%) 1.1% — metrics.uncompensated_care_pct
General Information Address 14662 NEWPORT AVE — Address
General Information City/Town TUSTIN — City/Town
General Information Count of Facility MORT Measures 2 — 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 6 — 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 2 — 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 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 1 — Count of Safety Measures Better
General Information Count of Safety Measures No Different 1 — 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 No — Emergency Services
General Information Facility ID 050780 — Facility ID
General Information Facility Name FOOTHILL REGIONAL MEDICAL CENTER — 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 Proprietary — 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 (714) 619-7700 — Telephone Number
General Information ZIP Code 92780 — ZIP Code
HAC Reduction Program fiscal_year 2,026 — fiscal_year
HAC Reduction Program measures — cauti — sir 0 — measures.cauti.sir
HAC Reduction Program measures — cdi — sir 0 — measures.cdi.sir
HAC Reduction Program measures — mrsa — sir 0 — 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 -1.40 — 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 1.42 — Value
Readmissions (HRRP) Heart Failure — Excess readmission ratio 0.98 0.9983 p35 READM-30-HF-HRRP.excess_readmission_ratio
Readmissions (HRRP) Heart Failure — Expected readmission rate 22.2% — READM-30-HF-HRRP.expected_readmission_rate
Readmissions (HRRP) Heart Failure — Predicted readmission rate 21.7% — READM-30-HF-HRRP.predicted_readmission_rate
Readmissions (HRRP) Pneumonia — Excess readmission ratio 0.97 0.9955 p35 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 19.9% — READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Number of discharges 179 — READM-30-PN-HRRP.num_discharges
Readmissions (HRRP) Pneumonia — Number of readmissions 33 — READM-30-PN-HRRP.num_readmissions
Readmissions (HRRP) Pneumonia — Predicted readmission rate 19.4% — READM-30-PN-HRRP.predicted_readmission_rate
Value-Based Purchasing Clinical Outcomes 13.75 5.00 p92 clinical_outcomes_score
Value-Based Purchasing Efficiency & Cost Reduction 0.00 2.50 p0 efficiency_score
Value-Based Purchasing Person & Community Engagement 0.75 8.75 p0 person_community_score
Value-Based Purchasing Safety 12.50 10.00 p63 safety_score
Value-Based Purchasing Total Performance Score 27.00 29.50 p40 total_performance_score
Methodology

Full methodology →