Hospital

NORTHSIDE HOSPITAL FORSYTH

CCN: 110005 · CUMMING, GA 30041 · FORSYTH County

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

Overview

Address
1200 NORTHSIDE FORSYTH DRIVE, CUMMING, GA 30041
Phone
(770) 844-3200
Hospital Type
Acute Care
Ownership
Non-Profit
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 6 of 7 measures reported
6
Better No different Worse
30-day death rates for heart attack, heart failure, pneumonia, COPD, stroke, CABG, and kidney disease.
Safety of Care 8 of 8 measures reported
1
7
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 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 has excess readmissions in at least one condition and is subject to HRRP payment reduction.
Acute Myocardial Infarction (Heart Attack)
0.8578 p1
Heart Failure 649 discharges
0.9744 p33
Pneumonia 605 discharges
0.9341 p13
COPD 171 discharges
0.9413 p7
Hip/Knee Replacement
1.0075 p54
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.

22.9 p26
Total Performance Score
National median: 29.5
Clinical Outcomes 25% weight
2.0 p21
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
7.9 p32
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
10.5 p63
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: 1.0075
Value-Based Purchasing
22.9 TPS
Below national median
HAC Reduction
Payment Reduced
HAC Score: 0.4465

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 3.70 No Different Than the National Rate 86
Hybrid_HWM 3.10 Better Than the National Rate 2,297
MORT_30_AMI 14.90 No Different Than the National Rate 188
MORT_30_CABG — Number of Cases Too Small —
MORT_30_COPD 10.40 No Different Than the National Rate 170
MORT_30_HF 9.80 No Different Than the National Rate 588
MORT_30_PN 14.60 No Different Than the National Rate 591
MORT_30_STK 10.50 No Different Than the National Rate 218
PSI_03 0.62 No Different Than the National Rate 7,429
PSI_04 192.16 No Different Than the National Rate 79
PSI_06 0.23 No Different Than the National Rate 8,690
PSI_08 0.30 No Different Than the National Rate 8,862
PSI_09 3.22 No Different Than the National Rate 2,044
PSI_10 2.17 No Different Than the National Rate 990
PSI_11 10.99 No Different Than the National Rate 1,022
PSI_12 3.61 No Different Than the National Rate 2,122
PSI_13 5.87 No Different Than the National Rate 943
PSI_14 1.86 No Different Than the National Rate 491
PSI_15 1.09 No Different Than the National Rate 1,891
PSI_90 1.11 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 84% —
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 14% —
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 76% —
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 4% —
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 84% —
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 13% —
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 75% —
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 6% —
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 19% —
H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand 70% —
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 23% —
H_COMP_5_A_P: Staff "always" explained 58% —
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 22% —
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 72% —
H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications 10% —
H_MED_FOR_U_P: Staff "usually" explained new medications 18% —
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 43% —
H_SIDE_EFFECTS_SN_P: Staff "sometimes" or "never" explained possible side effects 34% —
H_SIDE_EFFECTS_U_P: Staff "usually" explained possible side effects 23% —
H_COMP_6_N_P: No, staff "did not" give patients this information 12% —
H_COMP_6_Y_P: Yes, staff "did" give patients this information 88% —
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 14% —
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge 86% —
H_SYMPTOMS_N_P: No, staff "did not" give patients information about possible symptoms 10% —
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms 90% —
H_CLEAN_HSP_A_P: Room was "always" clean 84% —
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 3% —
H_CLEAN_HSP_U_P: Room was "usually" clean 13% —
H_CLEAN_LINEAR_SCORE: Cleanliness - linear mean score — —
H_CLEAN_STAR_RATING: Cleanliness - star rating — 5
H_QUIET_HSP_A_P: "Always" quiet at night 62% —
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 8% —
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) 5% —
H_HSP_RATING_7_8: Patients who gave a rating of "7" or "8" (medium) 16% —
H_HSP_RATING_9_10: Patients who gave a rating of "9" or "10" (high) 79% —
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 81% —
H_RECMND_PY: "YES", patients would probably recommend the hospital 16% —
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 0.244 No Different than National Benchmark
HAI_1_CIUPPER 1.254 No Different than National Benchmark
HAI_1_DOPC 9502.000 No Different than National Benchmark
HAI_1_ELIGCASES 9.953 No Different than National Benchmark
HAI_1_NUMERATOR 6.000 No Different than National Benchmark
HAI_1_SIR 0.603 No Different than National Benchmark
HAI_2_CILOWER 0.327 No Different than National Benchmark
HAI_2_CIUPPER 1.230 No Different than National Benchmark
HAI_2_DOPC 10729.000 No Different than National Benchmark
HAI_2_ELIGCASES 13.431 No Different than National Benchmark
HAI_2_NUMERATOR 9.000 No Different than National Benchmark
HAI_2_SIR 0.670 No Different than National Benchmark
HAI_3_CILOWER 1.144 Worse than the National Benchmark
HAI_3_CIUPPER 2.980 Worse than the National Benchmark
HAI_3_DOPC 355.000 Worse than the National Benchmark
HAI_3_ELIGCASES 8.948 Worse than the National Benchmark
HAI_3_NUMERATOR 17.000 Worse than the National Benchmark
HAI_3_SIR 1.900 Worse than the National Benchmark
HAI_4_CILOWER 0.237 No Different than National Benchmark
HAI_4_CIUPPER 2.531 No Different than National Benchmark
HAI_4_DOPC 399.000 No Different than National Benchmark
HAI_4_ELIGCASES 3.226 No Different than National Benchmark
HAI_4_NUMERATOR 3.000 No Different than National Benchmark
HAI_4_SIR 0.930 No Different than National Benchmark
HAI_5_CILOWER 0.137 No Different than National Benchmark
HAI_5_CIUPPER 1.043 No Different than National Benchmark
HAI_5_DOPC 129294.000 No Different than National Benchmark
HAI_5_ELIGCASES 9.247 No Different than National Benchmark
HAI_5_NUMERATOR 4.000 No Different than National Benchmark
HAI_5_SIR 0.433 No Different than National Benchmark
HAI_6_CILOWER 0.164 Better than the National Benchmark
HAI_6_CIUPPER 0.426 Better than the National Benchmark
HAI_6_DOPC 114150.000 Better than the National Benchmark
HAI_6_ELIGCASES 62.587 Better than the National Benchmark
HAI_6_NUMERATOR 17.000 Better than the National Benchmark
HAI_6_SIR 0.272 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 80.0 Healthcare Personnel Vaccination
OP_18a 176.0 Emergency Department
OP_18b 174.0 Emergency Department
OP_18c 238.0 Emergency Department
OP_18d — Emergency Department
OP_22 1.0 Emergency Department
OP_23 83.0 Emergency Department
OP_29 97.0 Colonoscopy care
OP_31 — Cataract surgery outcome
OP_40 66.0 Electronic Clinical Quality Measure
SAFE_USE_OF_OPIOIDS 16.0 Electronic Clinical Quality Measure
SEP_1 74.0 Sepsis Care
SEP_SH_3HR 82.0 Sepsis Care
SEP_SH_6HR 94.0 Sepsis Care
SEV_SEP_3HR 83.0 Sepsis Care
SEV_SEP_6HR 97.0 Sepsis Care
STK_02 98.0 Electronic Clinical Quality Measure
STK_03 — Electronic Clinical Quality Measure
STK_05 95.0 Electronic Clinical Quality Measure
VTE_1 — 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 -17.60 Fewer Days Than Average per 100 Discharges
EDAC_30_HF 0.00 Average Days per 100 Discharges
EDAC_30_PN -14.70 Fewer Days Than Average per 100 Discharges
Hybrid_HWR 14.30 No Different Than the National Rate
OP_32 13.10 No Different Than the National Rate
OP_35_ADM 10.00 No Different Than the National Rate
OP_35_ED 4.70 No Different Than the National Rate
OP_36 0.90 No Different than expected
READM_30_AMI 11.80 No Different Than the National Rate
READM_30_CABG — Number of Cases Too Small
READM_30_COPD 17.10 No Different Than the National Rate
READM_30_HF 19.10 No Different Than the National Rate
READM_30_HIP_KNEE 4.90 No Different Than the National Rate
READM_30_PN 14.90 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
0.96

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 0.19 — metrics.cost_to_charge_ratio
Cost Report Employees per Bed 8.50 — metrics.employees_per_bed
Cost Report fiscal_year 2,023 — fiscal_year
Cost Report Fund Balance ($) $480,368,226 — metrics.fund_balance
Cost Report Net Income ($) $-6,469,754 — metrics.net_income
Cost Report Net Patient Revenue ($) $722,920,827 — metrics.net_patient_revenue
Cost Report Operating Margin (%) -3.8% — metrics.operating_margin
Cost Report Total Assets ($) $449,469,130 — metrics.total_assets
Cost Report Total Costs ($) $629,680,285 — metrics.total_costs
Cost Report Total Liabilities ($) $-30,899,096 — metrics.total_liabilities
Cost Report Total Margin (%) -0.8% — metrics.total_margin
Cost Report Uncompensated Care (%) 7.4% — metrics.uncompensated_care_pct
General Information Address 1200 NORTHSIDE FORSYTH DRIVE — Address
General Information City/Town CUMMING — 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 8 — 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 6 — 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 7 — Count of Safety Measures No Different
General Information Count of Safety Measures Worse 0 — Count of Safety Measures Worse
General Information County/Parish FORSYTH — County/Parish
General Information Emergency Services Yes — Emergency Services
General Information Facility ID 110005 — Facility ID
General Information Facility Name NORTHSIDE HOSPITAL FORSYTH — 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 - 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 GA — State
General Information TE Group Footnote — — TE Group Footnote
General Information TE Group Measure Count 12 — TE Group Measure Count
General Information Telephone Number (770) 844-3200 — Telephone Number
General Information ZIP Code 30041 — ZIP Code
HAC Reduction Program fiscal_year 2,026 — fiscal_year
HAC Reduction Program measures — cauti — sir 0.90 — measures.cauti.sir
HAC Reduction Program measures — cdi — sir 0.46 — measures.cdi.sir
HAC Reduction Program measures — clabsi — sir 0.67 — measures.clabsi.sir
HAC Reduction Program measures — mrsa — sir 0.47 — measures.mrsa.sir
HAC Reduction Program measures — ssi — sir 1.50 — measures.ssi.sir
HAC Reduction Program payment_reduction Yes — payment_reduction
HAC Reduction Program total_hac_score 0.45 — 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 0.96 — Value
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Excess readmission ratio 0.86 0.9995 p1 READM-30-AMI-HRRP.excess_readmission_ratio
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Expected readmission rate 13.0% — READM-30-AMI-HRRP.expected_readmission_rate
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Predicted readmission rate 11.2% — READM-30-AMI-HRRP.predicted_readmission_rate
Readmissions (HRRP) COPD — Excess readmission ratio 0.94 0.9969 p7 READM-30-COPD-HRRP.excess_readmission_ratio
Readmissions (HRRP) COPD — Expected readmission rate 18.3% — READM-30-COPD-HRRP.expected_readmission_rate
Readmissions (HRRP) COPD — Number of discharges 171 — READM-30-COPD-HRRP.num_discharges
Readmissions (HRRP) COPD — Number of readmissions 25 — READM-30-COPD-HRRP.num_readmissions
Readmissions (HRRP) COPD — Predicted readmission rate 17.2% — READM-30-COPD-HRRP.predicted_readmission_rate
Readmissions (HRRP) Heart Failure — Excess readmission ratio 0.97 0.9983 p33 READM-30-HF-HRRP.excess_readmission_ratio
Readmissions (HRRP) Heart Failure — Expected readmission rate 19.6% — READM-30-HF-HRRP.expected_readmission_rate
Readmissions (HRRP) Heart Failure — Number of discharges 649 — READM-30-HF-HRRP.num_discharges
Readmissions (HRRP) Heart Failure — Number of readmissions 122 — READM-30-HF-HRRP.num_readmissions
Readmissions (HRRP) Heart Failure — Predicted readmission rate 19.1% — READM-30-HF-HRRP.predicted_readmission_rate
Readmissions (HRRP) Hip/Knee Replacement — Excess readmission ratio 1.01 0.9916 p54 READM-30-HIP-KNEE-HRRP.excess_readmission_ratio
Readmissions (HRRP) Hip/Knee Replacement — Expected readmission rate 5.3% — READM-30-HIP-KNEE-HRRP.expected_readmission_rate
Readmissions (HRRP) Hip/Knee Replacement — Predicted readmission rate 5.4% — READM-30-HIP-KNEE-HRRP.predicted_readmission_rate
Readmissions (HRRP) Pneumonia — Excess readmission ratio 0.93 0.9955 p13 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 605 — READM-30-PN-HRRP.num_discharges
Readmissions (HRRP) Pneumonia — Number of readmissions 81 — 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 2.00 5.00 p21 clinical_outcomes_score
Value-Based Purchasing Efficiency & Cost Reduction 2.50 2.50 p43 efficiency_score
Value-Based Purchasing Person & Community Engagement 10.50 8.75 p63 person_community_score
Value-Based Purchasing Safety 7.92 10.00 p32 safety_score
Value-Based Purchasing Total Performance Score 22.92 29.50 p26 total_performance_score
Methodology

Full methodology →