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

Overview

Address
655 W 8TH ST, JACKSONVILLE, FL 32209
Phone
(904) 244-4000
Hospital Type
Acute Care
Ownership
Non-Profit
Emergency Services
Yes
Birthing Friendly
Yes
3 /5
CMS Overall Rating
p30
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 10 of 11 measures reported
10
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 11 of 12 measures reported
11 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) 137 discharges
1.0292 p68
Heart Failure 490 discharges
0.9639 p26
Pneumonia 258 discharges
0.9604 p25
COPD 128 discharges
1.0326 p77
Hip/Knee Replacement
— Not reported
CABG Surgery
1.0292 p61
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.

30.4 p53
Total Performance Score
National median: 29.5
Clinical Outcomes 25% weight
13.5 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
9.2 p41
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
5.3 p21
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)
Penalized
Worst ERR: 1.0326
Value-Based Purchasing
30.4 TPS
Above national median
HAC Reduction
No Reduction
HAC Score: 0.1609

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 1,371
MORT_30_AMI 11.70 No Different Than the National Rate 130
MORT_30_CABG 2.00 No Different Than the National Rate 58
MORT_30_COPD 7.40 No Different Than the National Rate 109
MORT_30_HF 8.80 Better Than the National Rate 407
MORT_30_PN 14.80 No Different Than the National Rate 228
MORT_30_STK 13.70 No Different Than the National Rate 149
PSI_03 0.23 No Different Than the National Rate 5,268
PSI_04 156.27 No Different Than the National Rate 103
PSI_06 0.20 No Different Than the National Rate 6,527
PSI_08 0.24 No Different Than the National Rate 6,647
PSI_09 2.36 No Different Than the National Rate 1,428
PSI_10 2.03 No Different Than the National Rate 507
PSI_11 11.43 No Different Than the National Rate 474
PSI_12 3.27 No Different Than the National Rate 1,457
PSI_13 7.77 No Different Than the National Rate 517
PSI_14 1.58 No Different Than the National Rate 302
PSI_15 1.16 No Different Than the National Rate 1,037
PSI_90 1.02 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 75%
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 6%
H_COMP_1_U_P: Nurses "usually" communicated well 19%
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 83%
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 14%
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 71%
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 7%
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 22%
H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand 71%
H_NURSE_EXPLAIN_SN_P: Nurses "sometimes" or "never" explained things so they could understand 6%
H_NURSE_EXPLAIN_U_P: Nurses "usually" explained things so they could understand 23%
H_COMP_2_A_P: Doctors "always" communicated well 77%
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 6%
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 3
H_DOCTOR_RESPECT_A_P: Doctors "always" treated them with courtesy and respect 83%
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 13%
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 74%
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 7%
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 19%
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 7%
H_DOCTOR_EXPLAIN_U_P: Doctors "usually" explained things so they could understand 21%
H_COMP_5_A_P: Staff "always" explained 56%
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 24%
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 2
H_MED_FOR_A_P: Staff "always" explained new medications 71%
H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications 13%
H_MED_FOR_U_P: Staff "usually" explained new medications 16%
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 41%
H_SIDE_EFFECTS_SN_P: Staff "sometimes" or "never" explained possible side effects 35%
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 15%
H_COMP_6_Y_P: Yes, staff "did" give patients this information 85%
H_COMP_6_LINEAR_SCORE: Discharge information - linear mean score
H_COMP_6_STAR_RATING: Discharge information - star rating 3
H_DISCH_HELP_N_P: No, staff "did not" give patients information about help after discharge 17%
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge 83%
H_SYMPTOMS_N_P: No, staff "did not" give patients information about possible symptoms 14%
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms 86%
H_CLEAN_HSP_A_P: Room was "always" clean 69%
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 12%
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 3
H_QUIET_HSP_A_P: "Always" quiet at night 61%
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 9%
H_QUIET_HSP_U_P: "Usually" quiet at night 30%
H_QUIET_LINEAR_SCORE: Quietness - linear mean score
H_QUIET_STAR_RATING: Quietness - star rating 4
H_HSP_RATING_0_6: Patients who gave a rating of "6" or lower (low) 10%
H_HSP_RATING_7_8: Patients who gave a rating of "7" or "8" (medium) 21%
H_HSP_RATING_9_10: Patients who gave a rating of "9" or "10" (high) 69%
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) 7%
H_RECMND_DY: "YES", patients would definitely recommend the hospital 69%
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 0.268 No Different than National Benchmark
HAI_1_CIUPPER 1.008 No Different than National Benchmark
HAI_1_DOPC 14514.000 No Different than National Benchmark
HAI_1_ELIGCASES 16.388 No Different than National Benchmark
HAI_1_NUMERATOR 9.000 No Different than National Benchmark
HAI_1_SIR 0.549 No Different than National Benchmark
HAI_2_CILOWER 0.212 Better than the National Benchmark
HAI_2_CIUPPER 0.961 Better than the National Benchmark
HAI_2_DOPC 8016.000 Better than the National Benchmark
HAI_2_ELIGCASES 14.416 Better than the National Benchmark
HAI_2_NUMERATOR 7.000 Better than the National Benchmark
HAI_2_SIR 0.486 Better than the National Benchmark
HAI_3_CILOWER 0.301 No Different than National Benchmark
HAI_3_CIUPPER 1.544 No Different than National Benchmark
HAI_3_DOPC 256.000 No Different than National Benchmark
HAI_3_ELIGCASES 8.083 No Different than National Benchmark
HAI_3_NUMERATOR 6.000 No Different than National Benchmark
HAI_3_SIR 0.742 No Different than National Benchmark
HAI_4_CILOWER N/A No Different than National Benchmark
HAI_4_CIUPPER 1.245 No Different than National Benchmark
HAI_4_DOPC 260.000 No Different than National Benchmark
HAI_4_ELIGCASES 2.407 No Different than National Benchmark
HAI_4_NUMERATOR 0.000 No Different than National Benchmark
HAI_4_SIR 0.000 No Different than National Benchmark
HAI_5_CILOWER 0.426 No Different than National Benchmark
HAI_5_CIUPPER 1.338 No Different than National Benchmark
HAI_5_DOPC 195015.000 No Different than National Benchmark
HAI_5_ELIGCASES 15.247 No Different than National Benchmark
HAI_5_NUMERATOR 12.000 No Different than National Benchmark
HAI_5_SIR 0.787 No Different than National Benchmark
HAI_6_CILOWER 0.257 Better than the National Benchmark
HAI_6_CIUPPER 0.511 Better than the National Benchmark
HAI_6_DOPC 187056.000 Better than the National Benchmark
HAI_6_ELIGCASES 89.707 Better than the National Benchmark
HAI_6_NUMERATOR 33.000 Better than the National Benchmark
HAI_6_SIR 0.368 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 very 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 68.0 Healthcare Personnel Vaccination
OP_18a 194.0 Emergency Department
OP_18b 194.0 Emergency Department
OP_18c 185.0 Emergency Department
OP_18d Emergency Department
OP_22 4.0 Emergency Department
OP_23 Emergency Department
OP_29 98.0 Colonoscopy care
OP_31 Cataract surgery outcome
OP_40 61.0 Electronic Clinical Quality Measure
SAFE_USE_OF_OPIOIDS 14.0 Electronic Clinical Quality Measure
SEP_1 73.0 Sepsis Care
SEP_SH_3HR 93.0 Sepsis Care
SEP_SH_6HR 96.0 Sepsis Care
SEV_SEP_3HR 83.0 Sepsis Care
SEV_SEP_6HR 91.0 Sepsis Care
STK_02 Electronic Clinical Quality Measure
STK_03 Electronic Clinical Quality Measure
STK_05 87.0 Electronic Clinical Quality Measure
VTE_1 95.0 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 -16.90 Average Days per 100 Discharges
EDAC_30_HF -8.00 Average Days per 100 Discharges
EDAC_30_PN -9.60 Average Days per 100 Discharges
Hybrid_HWR 14.90 No Different Than the National Rate
OP_32 13.60 No Different Than the National Rate
OP_35_ADM 9.80 No Different Than the National Rate
OP_35_ED 6.10 No Different Than the National Rate
OP_36 1.10 No Different than expected
READM_30_AMI 13.90 No Different Than the National Rate
READM_30_CABG 10.90 No Different Than the National Rate
READM_30_COPD 18.80 No Different Than the National Rate
READM_30_HF 18.90 No Different Than the National Rate
READM_30_HIP_KNEE Number of Cases Too Small
READM_30_PN 15.30 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
0.95

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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Show 91 rows
Source Metric Value National Median Pctl. Raw key
Cost Report Cost-to-Charge Ratio 0.17 metrics.cost_to_charge_ratio
Cost Report Current Ratio 1.56 metrics.current_ratio
Cost Report Employees per Bed 9.92 metrics.employees_per_bed
Cost Report fiscal_year 2,024 fiscal_year
Cost Report Fund Balance ($) $264,869,526 metrics.fund_balance
Cost Report Net Income ($) $125,469,716 metrics.net_income
Cost Report Net Patient Revenue ($) $811,984,699 metrics.net_patient_revenue
Cost Report Operating Margin (%) -24.5% metrics.operating_margin
Cost Report Total Assets ($) $1,118,439,800 metrics.total_assets
Cost Report Total Costs ($) $913,264,290 metrics.total_costs
Cost Report Total Liabilities ($) $853,570,274 metrics.total_liabilities
Cost Report Total Margin (%) 11.9% metrics.total_margin
Cost Report Uncompensated Care (%) 9.8% metrics.uncompensated_care_pct
General Information Address 655 W 8TH ST Address
General Information City/Town JACKSONVILLE 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 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 11 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 10 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 DUVAL County/Parish
General Information Emergency Services Yes Emergency Services
General Information Facility ID 100001 Facility ID
General Information Facility Name SHANDS JACKSONVILLE Facility Name
General Information Hospital overall rating 3 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 FL State
General Information TE Group Footnote TE Group Footnote
General Information TE Group Measure Count 12 TE Group Measure Count
General Information Telephone Number (904) 244-4000 Telephone Number
General Information ZIP Code 32209 ZIP Code
HAC Reduction Program fiscal_year 2,026 fiscal_year
HAC Reduction Program measures — cauti — sir 0.61 measures.cauti.sir
HAC Reduction Program measures — cdi — sir 0.40 measures.cdi.sir
HAC Reduction Program measures — clabsi — sir 0.66 measures.clabsi.sir
HAC Reduction Program measures — mrsa — sir 1.02 measures.mrsa.sir
HAC Reduction Program measures — ssi — sir 0.60 measures.ssi.sir
HAC Reduction Program payment_reduction No payment_reduction
HAC Reduction Program total_hac_score 0.16 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 0.95 Value
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Excess readmission ratio 1.03 0.9995 p68 READM-30-AMI-HRRP.excess_readmission_ratio
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Expected readmission rate 14.5% READM-30-AMI-HRRP.expected_readmission_rate
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of discharges 137 READM-30-AMI-HRRP.num_discharges
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of readmissions 22 READM-30-AMI-HRRP.num_readmissions
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Predicted readmission rate 15.0% READM-30-AMI-HRRP.predicted_readmission_rate
Readmissions (HRRP) CABG Surgery — Excess readmission ratio 1.03 1.0000 p61 READM-30-CABG-HRRP.excess_readmission_ratio
Readmissions (HRRP) CABG Surgery — Expected readmission rate 10.5% READM-30-CABG-HRRP.expected_readmission_rate
Readmissions (HRRP) CABG Surgery — Predicted readmission rate 10.8% READM-30-CABG-HRRP.predicted_readmission_rate
Readmissions (HRRP) COPD — Excess readmission ratio 1.03 0.9969 p77 READM-30-COPD-HRRP.excess_readmission_ratio
Readmissions (HRRP) COPD — Expected readmission rate 20.8% READM-30-COPD-HRRP.expected_readmission_rate
Readmissions (HRRP) COPD — Number of discharges 128 READM-30-COPD-HRRP.num_discharges
Readmissions (HRRP) COPD — Number of readmissions 30 READM-30-COPD-HRRP.num_readmissions
Readmissions (HRRP) COPD — Predicted readmission rate 21.5% READM-30-COPD-HRRP.predicted_readmission_rate
Readmissions (HRRP) Heart Failure — Excess readmission ratio 0.96 0.9983 p26 READM-30-HF-HRRP.excess_readmission_ratio
Readmissions (HRRP) Heart Failure — Expected readmission rate 20.9% READM-30-HF-HRRP.expected_readmission_rate
Readmissions (HRRP) Heart Failure — Number of discharges 490 READM-30-HF-HRRP.num_discharges
Readmissions (HRRP) Heart Failure — Number of readmissions 96 READM-30-HF-HRRP.num_readmissions
Readmissions (HRRP) Heart Failure — Predicted readmission rate 20.1% READM-30-HF-HRRP.predicted_readmission_rate
Readmissions (HRRP) Pneumonia — Excess readmission ratio 0.96 0.9955 p25 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 18.1% READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Number of discharges 258 READM-30-PN-HRRP.num_discharges
Readmissions (HRRP) Pneumonia — Number of readmissions 42 READM-30-PN-HRRP.num_readmissions
Readmissions (HRRP) Pneumonia — Predicted readmission rate 17.4% READM-30-PN-HRRP.predicted_readmission_rate
Value-Based Purchasing Clinical Outcomes 13.50 5.00 p92 clinical_outcomes_score
Value-Based Purchasing Efficiency & Cost Reduction 2.50 2.50 p43 efficiency_score
Value-Based Purchasing Person & Community Engagement 5.25 8.75 p21 person_community_score
Value-Based Purchasing Safety 9.17 10.00 p41 safety_score
Value-Based Purchasing Total Performance Score 30.42 29.50 p53 total_performance_score
Methodology

Full methodology →