Hospital

POUDRE VALLEY HOSPITAL

CCN: 060010 · FORT COLLINS, CO 80524 · LARIMER County

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

Overview

Address
1024 S LEMAY AVE, FORT COLLINS, CO 80524
Phone
(970) 495-7000
Hospital Type
Acute Care
Ownership
Non-Profit
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
1
5
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
4
3
Better No different Worse
Healthcare-associated infections and patient safety indicators (PSI-90 composite).
Readmission 10 of 11 measures reported
2
8
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 does not have excess readmissions triggering HRRP penalties.
Acute Myocardial Infarction (Heart Attack) 152 discharges
0.8896 p4
Heart Failure 345 discharges
0.8923 p4
Pneumonia 363 discharges
0.9410 p15
COPD
0.9385 p6
Hip/Knee Replacement
0.7679 p4
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.

33.3 p64
Total Performance Score
National median: 29.5
Clinical Outcomes 25% weight
8.5 p74
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
10.8 p53
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
11.5 p68
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)
Not Penalized
Worst ERR: 0.9410
Value-Based Purchasing
33.3 TPS
Above national median
HAC Reduction
No Reduction
HAC Score: -0.4561

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 2.60 No Different Than the National Rate 252
Hybrid_HWM 3.80 No Different Than the National Rate 1,360
MORT_30_AMI 11.70 No Different Than the National Rate 144
MORT_30_CABG — — —
MORT_30_COPD 8.60 No Different Than the National Rate 83
MORT_30_HF 13.10 No Different Than the National Rate 330
MORT_30_PN 14.00 No Different Than the National Rate 354
MORT_30_STK 12.00 No Different Than the National Rate 167
PSI_03 0.57 No Different Than the National Rate 4,288
PSI_04 150.10 No Different Than the National Rate 71
PSI_06 0.22 No Different Than the National Rate 5,286
PSI_08 0.26 No Different Than the National Rate 5,303
PSI_09 2.83 No Different Than the National Rate 1,272
PSI_10 1.56 No Different Than the National Rate 491
PSI_11 6.35 No Different Than the National Rate 447
PSI_12 2.89 No Different Than the National Rate 1,373
PSI_13 5.01 No Different Than the National Rate 440
PSI_14 1.52 No Different Than the National Rate 337
PSI_15 1.02 No Different Than the National Rate 1,077
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 80% —
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 3% —
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 — 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 78% —
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 3% —
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 4% —
H_NURSE_EXPLAIN_U_P: Nurses "usually" explained things so they could understand 21% —
H_COMP_2_A_P: Doctors "always" communicated well 79% —
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 4% —
H_COMP_2_U_P: Doctors "usually" communicated well 17% —
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 87% —
H_DOCTOR_RESPECT_SN_P: Doctors "sometimes" or "never" treated them with courtesy and respect 3% —
H_DOCTOR_RESPECT_U_P: Doctors "usually" treated them with courtesy and respect 10% —
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 77% —
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 5% —
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 18% —
H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand 74% —
H_DOCTOR_EXPLAIN_SN_P: Doctors "sometimes" or "never" explained things so they could understand 6% —
H_DOCTOR_EXPLAIN_U_P: Doctors "usually" explained things so they could understand 20% —
H_COMP_5_A_P: Staff "always" explained 62% —
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 20% —
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 — 3
H_MED_FOR_A_P: Staff "always" explained new medications 75% —
H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications 11% —
H_MED_FOR_U_P: Staff "usually" explained new medications 14% —
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 48% —
H_SIDE_EFFECTS_SN_P: Staff "sometimes" or "never" explained possible side effects 30% —
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 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 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 8% —
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms 92% —
H_CLEAN_HSP_A_P: Room was "always" clean 73% —
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 8% —
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 54% —
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 10% —
H_QUIET_HSP_U_P: "Usually" quiet at night 36% —
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) 5% —
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) 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 78% —
H_RECMND_PY: "YES", patients would probably recommend the hospital 19% —
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 0.110 No Different than National Benchmark
HAI_1_CIUPPER 1.181 No Different than National Benchmark
HAI_1_DOPC 7238.000 No Different than National Benchmark
HAI_1_ELIGCASES 6.915 No Different than National Benchmark
HAI_1_NUMERATOR 3.000 No Different than National Benchmark
HAI_1_SIR 0.434 No Different than National Benchmark
HAI_2_CILOWER 0.190 No Different than National Benchmark
HAI_2_CIUPPER 2.029 No Different than National Benchmark
HAI_2_DOPC 3585.000 No Different than National Benchmark
HAI_2_ELIGCASES 4.025 No Different than National Benchmark
HAI_2_NUMERATOR 3.000 No Different than National Benchmark
HAI_2_SIR 0.745 No Different than National Benchmark
HAI_3_CILOWER 0.748 No Different than National Benchmark
HAI_3_CIUPPER 3.385 No Different than National Benchmark
HAI_3_DOPC 159.000 No Different than National Benchmark
HAI_3_ELIGCASES 4.091 No Different than National Benchmark
HAI_3_NUMERATOR 7.000 No Different than National Benchmark
HAI_3_SIR 1.711 No Different than National Benchmark
HAI_4_CILOWER — —
HAI_4_CIUPPER — —
HAI_4_DOPC 39.000 —
HAI_4_ELIGCASES 0.365 —
HAI_4_NUMERATOR 0.000 —
HAI_4_SIR — —
HAI_5_CILOWER N/A Better than the National Benchmark
HAI_5_CIUPPER 0.787 Better than the National Benchmark
HAI_5_DOPC 62377.000 Better than the National Benchmark
HAI_5_ELIGCASES 3.805 Better than the National Benchmark
HAI_5_NUMERATOR 0.000 Better than the National Benchmark
HAI_5_SIR 0.000 Better than the National Benchmark
HAI_6_CILOWER 0.086 Better than the National Benchmark
HAI_6_CIUPPER 0.388 Better than the National Benchmark
HAI_6_DOPC 52654.000 Better than the National Benchmark
HAI_6_ELIGCASES 35.695 Better than the National Benchmark
HAI_6_NUMERATOR 7.000 Better than the National Benchmark
HAI_6_SIR 0.196 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 97.0 Healthcare Personnel Vaccination
OP_18a 131.0 Emergency Department
OP_18b 124.0 Emergency Department
OP_18c 185.0 Emergency Department
OP_18d — Emergency Department
OP_22 0.0 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 77.0 Sepsis Care
SEP_SH_3HR 85.0 Sepsis Care
SEP_SH_6HR 97.0 Sepsis Care
SEV_SEP_3HR 89.0 Sepsis Care
SEV_SEP_6HR 90.0 Sepsis Care
STK_02 99.0 Electronic Clinical Quality Measure
STK_03 — Electronic Clinical Quality Measure
STK_05 96.0 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 -18.00 Fewer Days Than Average per 100 Discharges
EDAC_30_HF -34.30 Fewer Days Than Average per 100 Discharges
EDAC_30_PN 5.90 Average Days per 100 Discharges
Hybrid_HWR 12.80 Better Than the National Rate
OP_32 13.20 No Different Than the National Rate
OP_35_ADM 9.00 No Different Than the National Rate
OP_35_ED 7.70 Worse Than the National Rate
OP_36 1.00 No Different than expected
READM_30_AMI 12.10 No Different Than the National Rate
READM_30_CABG — —
READM_30_COPD 17.00 No Different Than the National Rate
READM_30_HF 17.70 No Different Than the National Rate
READM_30_HIP_KNEE 4.20 No Different Than the National Rate
READM_30_PN 15.00 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 0.20 — metrics.cost_to_charge_ratio
Cost Report Current Ratio 5.34 — metrics.current_ratio
Cost Report Employees per Bed 10.76 — metrics.employees_per_bed
Cost Report fiscal_year 2,024 — fiscal_year
Cost Report Fund Balance ($) $3,032,802,029 — metrics.fund_balance
Cost Report Net Income ($) $355,874,521 — metrics.net_income
Cost Report Net Patient Revenue ($) $753,680,428 — metrics.net_patient_revenue
Cost Report Operating Margin (%) 12.1% — metrics.operating_margin
Cost Report Total Assets ($) $3,414,269,156 — metrics.total_assets
Cost Report Total Costs ($) $526,914,476 — metrics.total_costs
Cost Report Total Liabilities ($) $381,467,127 — metrics.total_liabilities
Cost Report Total Margin (%) 44.6% — metrics.total_margin
Cost Report Uncompensated Care (%) 3.4% — metrics.uncompensated_care_pct
General Information Address 1024 S LEMAY AVE — Address
General Information City/Town FORT COLLINS — 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 7 — 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 1 — Count of MORT Measures Better
General Information Count of MORT Measures No Different 5 — 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 2 — Count of READM Measures Better
General Information Count of READM Measures No Different 8 — 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 4 — Count of Safety Measures Better
General Information Count of Safety Measures No Different 3 — Count of Safety Measures No Different
General Information Count of Safety Measures Worse 0 — Count of Safety Measures Worse
General Information County/Parish LARIMER — County/Parish
General Information Emergency Services Yes — Emergency Services
General Information Facility ID 060010 — Facility ID
General Information Facility Name POUDRE VALLEY HOSPITAL — 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 - 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 CO — State
General Information TE Group Footnote — — TE Group Footnote
General Information TE Group Measure Count 12 — TE Group Measure Count
General Information Telephone Number (970) 495-7000 — Telephone Number
General Information ZIP Code 80524 — ZIP Code
HAC Reduction Program fiscal_year 2,026 — fiscal_year
HAC Reduction Program measures — cauti — sir 0.35 — measures.cauti.sir
HAC Reduction Program measures — cdi — sir 0.20 — measures.cdi.sir
HAC Reduction Program measures — clabsi — sir 0.28 — measures.clabsi.sir
HAC Reduction Program measures — mrsa — sir 0 — measures.mrsa.sir
HAC Reduction Program measures — ssi — sir 1.73 — measures.ssi.sir
HAC Reduction Program payment_reduction No — payment_reduction
HAC Reduction Program total_hac_score -0.46 — 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 0.89 0.9995 p4 READM-30-AMI-HRRP.excess_readmission_ratio
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Expected readmission rate 12.5% — READM-30-AMI-HRRP.expected_readmission_rate
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of discharges 152 — READM-30-AMI-HRRP.num_discharges
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of readmissions 11 — READM-30-AMI-HRRP.num_readmissions
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Predicted readmission rate 11.1% — READM-30-AMI-HRRP.predicted_readmission_rate
Readmissions (HRRP) COPD — Excess readmission ratio 0.94 0.9969 p6 READM-30-COPD-HRRP.excess_readmission_ratio
Readmissions (HRRP) COPD — Expected readmission rate 16.4% — READM-30-COPD-HRRP.expected_readmission_rate
Readmissions (HRRP) COPD — Predicted readmission rate 15.4% — READM-30-COPD-HRRP.predicted_readmission_rate
Readmissions (HRRP) Heart Failure — Excess readmission ratio 0.89 0.9983 p4 READM-30-HF-HRRP.excess_readmission_ratio
Readmissions (HRRP) Heart Failure — Expected readmission rate 18.5% — READM-30-HF-HRRP.expected_readmission_rate
Readmissions (HRRP) Heart Failure — Number of discharges 345 — READM-30-HF-HRRP.num_discharges
Readmissions (HRRP) Heart Failure — Number of readmissions 49 — READM-30-HF-HRRP.num_readmissions
Readmissions (HRRP) Heart Failure — Predicted readmission rate 16.5% — READM-30-HF-HRRP.predicted_readmission_rate
Readmissions (HRRP) Hip/Knee Replacement — Excess readmission ratio 0.77 0.9916 p4 READM-30-HIP-KNEE-HRRP.excess_readmission_ratio
Readmissions (HRRP) Hip/Knee Replacement — Expected readmission rate 4.9% — READM-30-HIP-KNEE-HRRP.expected_readmission_rate
Readmissions (HRRP) Hip/Knee Replacement — Predicted readmission rate 3.7% — READM-30-HIP-KNEE-HRRP.predicted_readmission_rate
Readmissions (HRRP) Pneumonia — Excess readmission ratio 0.94 0.9955 p15 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 14.3% — READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Number of discharges 363 — READM-30-PN-HRRP.num_discharges
Readmissions (HRRP) Pneumonia — Number of readmissions 45 — READM-30-PN-HRRP.num_readmissions
Readmissions (HRRP) Pneumonia — Predicted readmission rate 13.5% — READM-30-PN-HRRP.predicted_readmission_rate
Value-Based Purchasing Clinical Outcomes 8.50 5.00 p74 clinical_outcomes_score
Value-Based Purchasing Efficiency & Cost Reduction 2.50 2.50 p43 efficiency_score
Value-Based Purchasing Person & Community Engagement 11.50 8.75 p68 person_community_score
Value-Based Purchasing Safety 10.83 10.00 p53 safety_score
Value-Based Purchasing Total Performance Score 33.33 29.50 p64 total_performance_score
Methodology

Full methodology →