Hospital

JACKSON HEALTH SYSTEM

CCN: 100022 · MIAMI, FL 33136 · MIAMI-DADE County

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

Overview

Address
1611 NW 12TH AVE, MIAMI, FL 33136
Phone
(305) 585-1111
Hospital Type
Acute Care
Ownership
Government (District)
Emergency Services
Yes
Birthing Friendly
Yes
1 /5
★★★★★
CMS Overall Rating
p0
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
3
3
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
2
1
Better No different Worse
Healthcare-associated infections and patient safety indicators (PSI-90 composite).
Readmission 9 of 11 measures reported
7
2
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) 174 discharges
0.9945 p45
Heart Failure 439 discharges
1.0750 p86
Pneumonia 442 discharges
0.9971 p51
COPD 130 discharges
0.9952 p48
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.

21.8 p23
Total Performance Score
National median: 29.5
Clinical Outcomes 25% weight
0.0 p0
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
12.1 p62
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: 1.0750
Value-Based Purchasing
21.8 TPS
Below national median
HAC Reduction
No Reduction
HAC Score: -0.0483

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 5.60 Worse Than the National Rate 1,316
MORT_30_AMI 13.40 No Different Than the National Rate 182
MORT_30_CABG — Number of Cases Too Small —
MORT_30_COPD 10.40 No Different Than the National Rate 126
MORT_30_HF 15.70 Worse Than the National Rate 393
MORT_30_PN 19.70 Worse Than the National Rate 463
MORT_30_STK 12.50 No Different Than the National Rate 210
PSI_03 0.56 No Different Than the National Rate 9,317
PSI_04 218.24 Worse Than the National Rate 155
PSI_06 0.37 No Different Than the National Rate 9,446
PSI_08 0.19 No Different Than the National Rate 9,979
PSI_09 1.79 No Different Than the National Rate 2,080
PSI_10 2.09 No Different Than the National Rate 719
PSI_11 16.87 Worse Than the National Rate 766
PSI_12 5.62 Worse Than the National Rate 2,070
PSI_13 5.83 No Different Than the National Rate 726
PSI_14 2.08 No Different Than the National Rate 643
PSI_15 0.70 No Different Than the National Rate 2,368
PSI_90 1.30 Worse 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 76% —
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 7% —
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 — 2
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 5% —
H_NURSE_RESPECT_U_P: Nurses "usually" treated them with courtesy and respect 12% —
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 74% —
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 8% —
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 18% —
H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand 72% —
H_NURSE_EXPLAIN_SN_P: Nurses "sometimes" or "never" explained things so they could understand 9% —
H_NURSE_EXPLAIN_U_P: Nurses "usually" explained things so they could understand 19% —
H_COMP_2_A_P: Doctors "always" communicated well 78% —
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 7% —
H_COMP_2_U_P: Doctors "usually" communicated well 15% —
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 5% —
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 8% —
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 16% —
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 9% —
H_DOCTOR_EXPLAIN_U_P: Doctors "usually" explained things so they could understand 19% —
H_COMP_5_A_P: Staff "always" explained 60% —
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 24% —
H_COMP_5_U_P: Staff "usually" explained 16% —
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 12% —
H_MED_FOR_U_P: Staff "usually" explained new medications 15% —
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 47% —
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 18% —
H_COMP_6_N_P: No, staff "did not" give patients this information 18% —
H_COMP_6_Y_P: Yes, staff "did" give patients this information 82% —
H_COMP_6_LINEAR_SCORE: Discharge information - linear mean score — —
H_COMP_6_STAR_RATING: Discharge information - star rating — 2
H_DISCH_HELP_N_P: No, staff "did not" give patients information about help after discharge 20% —
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge 80% —
H_SYMPTOMS_N_P: No, staff "did not" give patients information about possible symptoms 16% —
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms 84% —
H_CLEAN_HSP_A_P: Room was "always" clean 77% —
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 8% —
H_CLEAN_HSP_U_P: Room was "usually" clean 15% —
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 61% —
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 14% —
H_QUIET_HSP_U_P: "Usually" quiet at night 25% —
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) 11% —
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) 68% —
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) 9% —
H_RECMND_DY: "YES", patients would definitely recommend the hospital 68% —
H_RECMND_PY: "YES", patients would probably recommend the hospital 23% —
H_RECMND_LINEAR_SCORE: Recommend hospital - linear mean score — —
H_RECMND_STAR_RATING: Recommend hospital - star rating — 3
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 0.012 Better than the National Benchmark
HAI_1_CIUPPER 0.126 Better than the National Benchmark
HAI_1_DOPC 52149.000 Better than the National Benchmark
HAI_1_ELIGCASES 64.611 Better than the National Benchmark
HAI_1_NUMERATOR 3.000 Better than the National Benchmark
HAI_1_SIR 0.046 Better than the National Benchmark
HAI_2_CILOWER 0.040 Better than the National Benchmark
HAI_2_CIUPPER 0.207 Better than the National Benchmark
HAI_2_DOPC 35600.000 Better than the National Benchmark
HAI_2_ELIGCASES 60.402 Better than the National Benchmark
HAI_2_NUMERATOR 6.000 Better than the National Benchmark
HAI_2_SIR 0.099 Better than the National Benchmark
HAI_3_CILOWER 0.429 No Different than National Benchmark
HAI_3_CIUPPER 1.153 No Different than National Benchmark
HAI_3_DOPC 751.000 No Different than National Benchmark
HAI_3_ELIGCASES 22.057 No Different than National Benchmark
HAI_3_NUMERATOR 16.000 No Different than National Benchmark
HAI_3_SIR 0.725 No Different than National Benchmark
HAI_4_CILOWER 0.028 No Different than National Benchmark
HAI_4_CIUPPER 2.802 No Different than National Benchmark
HAI_4_DOPC 201.000 No Different than National Benchmark
HAI_4_ELIGCASES 1.760 No Different than National Benchmark
HAI_4_NUMERATOR 1.000 No Different than National Benchmark
HAI_4_SIR 0.568 No Different than National Benchmark
HAI_5_CILOWER 0.744 No Different than National Benchmark
HAI_5_CIUPPER 1.546 No Different than National Benchmark
HAI_5_DOPC 466763.000 No Different than National Benchmark
HAI_5_ELIGCASES 26.590 No Different than National Benchmark
HAI_5_NUMERATOR 29.000 No Different than National Benchmark
HAI_5_SIR 1.091 No Different than National Benchmark
HAI_6_CILOWER 0.077 Better than the National Benchmark
HAI_6_CIUPPER 0.174 Better than the National Benchmark
HAI_6_DOPC 435275.000 Better than the National Benchmark
HAI_6_ELIGCASES 194.798 Better than the National Benchmark
HAI_6_NUMERATOR 23.000 Better than the National Benchmark
HAI_6_SIR 0.118 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 66.0 Healthcare Personnel Vaccination
OP_18a 202.0 Emergency Department
OP_18b 199.0 Emergency Department
OP_18c 278.0 Emergency Department
OP_18d 244.0 Emergency Department
OP_22 1.0 Emergency Department
OP_23 52.0 Emergency Department
OP_29 98.0 Colonoscopy care
OP_31 — Cataract surgery outcome
OP_40 43.0 Electronic Clinical Quality Measure
SAFE_USE_OF_OPIOIDS 11.0 Electronic Clinical Quality Measure
SEP_1 67.0 Sepsis Care
SEP_SH_3HR 76.0 Sepsis Care
SEP_SH_6HR 95.0 Sepsis Care
SEV_SEP_3HR 83.0 Sepsis Care
SEV_SEP_6HR 92.0 Sepsis Care
STK_02 95.0 Electronic Clinical Quality Measure
STK_03 — Electronic Clinical Quality Measure
STK_05 — Electronic Clinical Quality Measure
VTE_1 93.0 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 18.80 More Days Than Average per 100 Discharges
EDAC_30_HF 87.90 More Days Than Average per 100 Discharges
EDAC_30_PN 39.60 More Days Than Average per 100 Discharges
Hybrid_HWR 16.80 Worse Than the National Rate
OP_32 13.90 No Different Than the National Rate
OP_35_ADM 11.70 No Different Than the National Rate
OP_35_ED 5.70 No Different Than the National Rate
OP_36 1.00 No Different than expected
READM_30_AMI 13.40 No Different Than the National Rate
READM_30_CABG — Number of Cases Too Small
READM_30_COPD 18.10 No Different Than the National Rate
READM_30_HF 21.30 No Different Than the National Rate
READM_30_HIP_KNEE — Number of Cases Too Small
READM_30_PN 16.00 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
1.11

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 0.32 — metrics.cost_to_charge_ratio
Cost Report Current Ratio 1.21 — metrics.current_ratio
Cost Report Employees per Bed 8.66 — metrics.employees_per_bed
Cost Report fiscal_year 2,023 — fiscal_year
Cost Report Fund Balance ($) $1,477,916,002 — metrics.fund_balance
Cost Report Net Income ($) $-61,672,298 — metrics.net_income
Cost Report Net Patient Revenue ($) $1,551,114,782 — metrics.net_patient_revenue
Cost Report Operating Margin (%) -86.3% — metrics.operating_margin
Cost Report Total Assets ($) $5,530,237,167 — metrics.total_assets
Cost Report Total Costs ($) $2,225,042,324 — metrics.total_costs
Cost Report Total Liabilities ($) $4,052,321,165 — metrics.total_liabilities
Cost Report Total Margin (%) -2.2% — metrics.total_margin
Cost Report Uncompensated Care (%) 10.5% — metrics.uncompensated_care_pct
General Information Address 1611 NW 12TH AVE — Address
General Information City/Town MIAMI — 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 9 — 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 3 — Count of MORT Measures No Different
General Information Count of MORT Measures Worse 3 — 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 2 — 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 2 — Count of Safety Measures No Different
General Information Count of Safety Measures Worse 1 — Count of Safety Measures Worse
General Information County/Parish MIAMI-DADE — County/Parish
General Information Emergency Services Yes — Emergency Services
General Information Facility ID 100022 — Facility ID
General Information Facility Name JACKSON HEALTH SYSTEM — Facility Name
General Information Hospital overall rating 1 — Hospital overall rating
General Information Hospital overall rating footnote — — Hospital overall rating footnote
General Information Hospital Ownership Government - Hospital District or Authority — 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 (305) 585-1111 — Telephone Number
General Information ZIP Code 33136 — ZIP Code
HAC Reduction Program fiscal_year 2,026 — fiscal_year
HAC Reduction Program measures — cauti — sir 0.22 — measures.cauti.sir
HAC Reduction Program measures — cdi — sir 0.22 — measures.cdi.sir
HAC Reduction Program measures — clabsi — sir 0.18 — measures.clabsi.sir
HAC Reduction Program measures — mrsa — sir 0.96 — measures.mrsa.sir
HAC Reduction Program measures — ssi — sir 0.64 — measures.ssi.sir
HAC Reduction Program payment_reduction No — payment_reduction
HAC Reduction Program total_hac_score -0.05 — 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 1.11 — Value
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Excess readmission ratio 0.99 0.9995 p45 READM-30-AMI-HRRP.excess_readmission_ratio
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Expected readmission rate 16.4% — READM-30-AMI-HRRP.expected_readmission_rate
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of discharges 174 — READM-30-AMI-HRRP.num_discharges
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of readmissions 28 — READM-30-AMI-HRRP.num_readmissions
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Predicted readmission rate 16.3% — READM-30-AMI-HRRP.predicted_readmission_rate
Readmissions (HRRP) COPD — Excess readmission ratio 1.00 0.9969 p48 READM-30-COPD-HRRP.excess_readmission_ratio
Readmissions (HRRP) COPD — Expected readmission rate 21.2% — READM-30-COPD-HRRP.expected_readmission_rate
Readmissions (HRRP) COPD — Number of discharges 130 — READM-30-COPD-HRRP.num_discharges
Readmissions (HRRP) COPD — Number of readmissions 27 — READM-30-COPD-HRRP.num_readmissions
Readmissions (HRRP) COPD — Predicted readmission rate 21.1% — READM-30-COPD-HRRP.predicted_readmission_rate
Readmissions (HRRP) Heart Failure — Excess readmission ratio 1.07 0.9983 p86 READM-30-HF-HRRP.excess_readmission_ratio
Readmissions (HRRP) Heart Failure — Expected readmission rate 21.9% — READM-30-HF-HRRP.expected_readmission_rate
Readmissions (HRRP) Heart Failure — Number of discharges 439 — READM-30-HF-HRRP.num_discharges
Readmissions (HRRP) Heart Failure — Number of readmissions 109 — READM-30-HF-HRRP.num_readmissions
Readmissions (HRRP) Heart Failure — Predicted readmission rate 23.6% — READM-30-HF-HRRP.predicted_readmission_rate
Readmissions (HRRP) Pneumonia — Excess readmission ratio 1.00 0.9955 p51 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 18.7% — READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Number of discharges 442 — READM-30-PN-HRRP.num_discharges
Readmissions (HRRP) Pneumonia — Number of readmissions 82 — READM-30-PN-HRRP.num_readmissions
Readmissions (HRRP) Pneumonia — Predicted readmission rate 18.6% — READM-30-PN-HRRP.predicted_readmission_rate
Value-Based Purchasing Clinical Outcomes 0.00 5.00 p0 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 12.08 10.00 p62 safety_score
Value-Based Purchasing Total Performance Score 21.83 29.50 p23 total_performance_score
Methodology

Full methodology →