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

Overview

Address
2635 N 7TH ST, GRAND JUNCTION, CO 81501
Phone
(970) 298-2260
Hospital Type
Acute Care
Ownership
Non-Profit (Church)
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 7 of 8 measures reported
1
6
Better No different Worse
Healthcare-associated infections and patient safety indicators (PSI-90 composite).
Readmission 11 of 11 measures reported
3
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 12 of 12 measures reported
12 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) 322 discharges
0.8058 p0
Heart Failure 251 discharges
0.9264 p10
Pneumonia 209 discharges
0.9336 p12
COPD
0.9814 p35
Hip/Knee Replacement
0.9228 p30
CABG Surgery
0.8889 p10
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.

21.1 p19
Total Performance Score
National median: 29.5
Clinical Outcomes 25% weight
7.0 p65
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
7.1 p25
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
7.0 p35
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: 0.9814
Value-Based Purchasing
21.1 TPS
Below national median
HAC Reduction
No Reduction
HAC Score: -0.2306

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 3.30 No Different Than the National Rate 27
Hybrid_HWM 4.00 No Different Than the National Rate 1,386
MORT_30_AMI 12.00 No Different Than the National Rate 291
MORT_30_CABG 2.10 No Different Than the National Rate 110
MORT_30_COPD 9.70 No Different Than the National Rate 60
MORT_30_HF 14.60 No Different Than the National Rate 233
MORT_30_PN 21.40 Worse Than the National Rate 206
MORT_30_STK 13.90 No Different Than the National Rate 282
PSI_03 1.08 No Different Than the National Rate 4,037
PSI_04 184.86 No Different Than the National Rate 122
PSI_06 0.25 No Different Than the National Rate 4,897
PSI_08 0.26 No Different Than the National Rate 5,033
PSI_09 3.23 No Different Than the National Rate 1,781
PSI_10 1.60 No Different Than the National Rate 817
PSI_11 6.23 No Different Than the National Rate 746
PSI_12 3.08 No Different Than the National Rate 1,953
PSI_13 3.86 No Different Than the National Rate 773
PSI_14 1.85 No Different Than the National Rate 418
PSI_15 0.95 No Different Than the National Rate 1,161
PSI_90 0.99 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 3%
H_NURSE_RESPECT_U_P: Nurses "usually" treated them with courtesy and respect 10%
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 75%
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 5%
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 20%
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 5%
H_NURSE_EXPLAIN_U_P: Nurses "usually" explained things so they could understand 22%
H_COMP_2_A_P: Doctors "always" communicated well 77%
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 5%
H_COMP_2_U_P: Doctors "usually" communicated well 18%
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 85%
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 11%
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 76%
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 6%
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 18%
H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand 72%
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 22%
H_COMP_5_A_P: Staff "always" explained 60%
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 20%
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 3
H_MED_FOR_A_P: Staff "always" explained new medications 75%
H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications 8%
H_MED_FOR_U_P: Staff "usually" explained new medications 17%
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 45%
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 24%
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 13%
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge 87%
H_SYMPTOMS_N_P: No, staff "did not" give patients information about possible symptoms 12%
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms 88%
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 57%
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 9%
H_QUIET_HSP_U_P: "Usually" quiet at night 34%
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) 8%
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) 73%
H_HSP_RATING_LINEAR_SCORE: Overall hospital rating - linear mean score
H_HSP_RATING_STAR_RATING: Overall hospital rating - star rating 3
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 71%
H_RECMND_PY: "YES", patients would probably recommend the hospital 24%
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 0.084 Better than the National Benchmark
HAI_1_CIUPPER 0.900 Better than the National Benchmark
HAI_1_DOPC 8724.000 Better than the National Benchmark
HAI_1_ELIGCASES 9.070 Better than the National Benchmark
HAI_1_NUMERATOR 3.000 Better than the National Benchmark
HAI_1_SIR 0.331 Better than the National Benchmark
HAI_2_CILOWER 0.155 Better than the National Benchmark
HAI_2_CIUPPER 0.939 Better than the National Benchmark
HAI_2_DOPC 9379.000 Better than the National Benchmark
HAI_2_ELIGCASES 11.805 Better than the National Benchmark
HAI_2_NUMERATOR 5.000 Better than the National Benchmark
HAI_2_SIR 0.424 Better than the National Benchmark
HAI_3_CILOWER 0.971 No Different than National Benchmark
HAI_3_CIUPPER 3.652 No Different than National Benchmark
HAI_3_DOPC 169.000 No Different than National Benchmark
HAI_3_ELIGCASES 4.522 No Different than National Benchmark
HAI_3_NUMERATOR 9.000 No Different than National Benchmark
HAI_3_SIR 1.990 No Different than National Benchmark
HAI_4_CILOWER
HAI_4_CIUPPER
HAI_4_DOPC 105.000
HAI_4_ELIGCASES 0.792
HAI_4_NUMERATOR 0.000
HAI_4_SIR
HAI_5_CILOWER 0.065 No Different than National Benchmark
HAI_5_CIUPPER 1.285 No Different than National Benchmark
HAI_5_DOPC 75236.000 No Different than National Benchmark
HAI_5_ELIGCASES 5.144 No Different than National Benchmark
HAI_5_NUMERATOR 2.000 No Different than National Benchmark
HAI_5_SIR 0.389 No Different than National Benchmark
HAI_6_CILOWER 0.059 Better than the National Benchmark
HAI_6_CIUPPER 0.359 Better than the National Benchmark
HAI_6_DOPC 69133.000 Better than the National Benchmark
HAI_6_ELIGCASES 30.845 Better than the National Benchmark
HAI_6_NUMERATOR 5.000 Better than the National Benchmark
HAI_6_SIR 0.162 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 6.0 Electronic Clinical Quality Measure
HH_HYPO Electronic Clinical Quality Measure
HH_ORAE Electronic Clinical Quality Measure
IMM_3 88.0 Healthcare Personnel Vaccination
OP_18a 205.0 Emergency Department
OP_18b 198.0 Emergency Department
OP_18c 282.0 Emergency Department
OP_18d Emergency Department
OP_22 2.0 Emergency Department
OP_23 Emergency Department
OP_29 90.0 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 63.0 Sepsis Care
SEP_SH_3HR 62.0 Sepsis Care
SEP_SH_6HR 85.0 Sepsis Care
SEV_SEP_3HR 85.0 Sepsis Care
SEV_SEP_6HR 94.0 Sepsis Care
STK_02 97.0 Electronic Clinical Quality Measure
STK_03 Electronic Clinical Quality Measure
STK_05 93.0 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 -25.10 Fewer Days Than Average per 100 Discharges
EDAC_30_HF -20.00 Fewer Days Than Average per 100 Discharges
EDAC_30_PN -11.30 Average Days per 100 Discharges
Hybrid_HWR 13.90 No Different Than the National Rate
OP_32 13.50 No Different Than the National Rate
OP_35_ADM 10.70 No Different Than the National Rate
OP_35_ED 5.50 No Different Than the National Rate
OP_36 1.10 No Different than expected
READM_30_AMI 11.20 No Different Than the National Rate
READM_30_CABG 9.40 No Different Than the National Rate
READM_30_COPD 17.80 No Different Than the National Rate
READM_30_HF 18.10 No Different Than the National Rate
READM_30_HIP_KNEE 4.50 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
1.04

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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Show 92 rows
Source Metric Value National Median Pctl. Raw key
Cost Report Cost-to-Charge Ratio 0.24 metrics.cost_to_charge_ratio
Cost Report Current Ratio 22.02 metrics.current_ratio
Cost Report Employees per Bed 5.77 metrics.employees_per_bed
Cost Report fiscal_year 2,023 fiscal_year
Cost Report Fund Balance ($) $867,041,641 metrics.fund_balance
Cost Report Net Income ($) $-8,355,104 metrics.net_income
Cost Report Net Patient Revenue ($) $531,450,489 metrics.net_patient_revenue
Cost Report Operating Margin (%) -0.8% metrics.operating_margin
Cost Report Total Assets ($) $893,077,506 metrics.total_assets
Cost Report Total Costs ($) $443,556,467 metrics.total_costs
Cost Report Total Liabilities ($) $26,035,865 metrics.total_liabilities
Cost Report Total Margin (%) -1.5% metrics.total_margin
Cost Report Uncompensated Care (%) 1.9% metrics.uncompensated_care_pct
General Information Address 2635 N 7TH ST Address
General Information City/Town GRAND JUNCTION 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 11 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 12 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 3 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 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 MESA County/Parish
General Information Emergency Services Yes Emergency Services
General Information Facility ID 060023 Facility ID
General Information Facility Name INTERMOUNTAIN HEALTH ST. MARY'S REGIONAL HOSPITAL 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 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) 298-2260 Telephone Number
General Information ZIP Code 81501 ZIP Code
HAC Reduction Program fiscal_year 2,026 fiscal_year
HAC Reduction Program measures — cauti — sir 0.55 measures.cauti.sir
HAC Reduction Program measures — cdi — sir 0.18 measures.cdi.sir
HAC Reduction Program measures — clabsi — sir 0.47 measures.clabsi.sir
HAC Reduction Program measures — mrsa — sir 0.31 measures.mrsa.sir
HAC Reduction Program measures — ssi — sir 1.10 measures.ssi.sir
HAC Reduction Program payment_reduction No payment_reduction
HAC Reduction Program total_hac_score -0.23 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 1.04 Value
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Excess readmission ratio 0.81 0.9995 p0 READM-30-AMI-HRRP.excess_readmission_ratio
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Expected readmission rate 11.0% READM-30-AMI-HRRP.expected_readmission_rate
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of discharges 322 READM-30-AMI-HRRP.num_discharges
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of readmissions 18 READM-30-AMI-HRRP.num_readmissions
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Predicted readmission rate 8.8% READM-30-AMI-HRRP.predicted_readmission_rate
Readmissions (HRRP) CABG Surgery — Excess readmission ratio 0.89 1.0000 p10 READM-30-CABG-HRRP.excess_readmission_ratio
Readmissions (HRRP) CABG Surgery — Expected readmission rate 11.6% READM-30-CABG-HRRP.expected_readmission_rate
Readmissions (HRRP) CABG Surgery — Predicted readmission rate 10.3% READM-30-CABG-HRRP.predicted_readmission_rate
Readmissions (HRRP) COPD — Excess readmission ratio 0.98 0.9969 p35 READM-30-COPD-HRRP.excess_readmission_ratio
Readmissions (HRRP) COPD — Expected readmission rate 15.1% READM-30-COPD-HRRP.expected_readmission_rate
Readmissions (HRRP) COPD — Predicted readmission rate 14.8% 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 18.7% READM-30-HF-HRRP.expected_readmission_rate
Readmissions (HRRP) Heart Failure — Number of discharges 251 READM-30-HF-HRRP.num_discharges
Readmissions (HRRP) Heart Failure — Number of readmissions 38 READM-30-HF-HRRP.num_readmissions
Readmissions (HRRP) Heart Failure — Predicted readmission rate 17.3% READM-30-HF-HRRP.predicted_readmission_rate
Readmissions (HRRP) Hip/Knee Replacement — Excess readmission ratio 0.92 0.9916 p30 READM-30-HIP-KNEE-HRRP.excess_readmission_ratio
Readmissions (HRRP) Hip/Knee Replacement — Expected readmission rate 7.6% READM-30-HIP-KNEE-HRRP.expected_readmission_rate
Readmissions (HRRP) Hip/Knee Replacement — Predicted readmission rate 7.0% READM-30-HIP-KNEE-HRRP.predicted_readmission_rate
Readmissions (HRRP) Pneumonia — Excess readmission ratio 0.93 0.9955 p12 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 15.1% READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Number of discharges 209 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 14.1% READM-30-PN-HRRP.predicted_readmission_rate
Value-Based Purchasing Clinical Outcomes 7.00 5.00 p65 clinical_outcomes_score
Value-Based Purchasing Efficiency & Cost Reduction 0.00 2.50 p0 efficiency_score
Value-Based Purchasing Person & Community Engagement 7.00 8.75 p35 person_community_score
Value-Based Purchasing Safety 7.08 10.00 p25 safety_score
Value-Based Purchasing Total Performance Score 21.08 29.50 p19 total_performance_score
Methodology

Full methodology →