Hospital

PRESENCE SAINTS MARY AND ELIZABETH MEDICAL CENTER

CCN: 140180 · CHICAGO, IL 60622 · COOK County

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

Overview

Address
2233 W DIVISION ST, CHICAGO, IL 60622
Phone
(312) 770-2000
Hospital Type
Acute Care
Ownership
Non-Profit (Church)
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 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 5 of 8 measures reported
1
4
Better No different Worse
Healthcare-associated infections and patient safety indicators (PSI-90 composite).
Readmission 8 of 11 measures reported
6
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 9 of 12 measures reported
9 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) 32 discharges
1.1225 p95
Heart Failure 161 discharges
1.0714 p86
Pneumonia 124 discharges
0.9422 p16
COPD 53 discharges
1.0481 p84
Hip/Knee Replacement
— Not reported
CABG Surgery
— Not reported
Expected (1.0) National median

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: 1.1225
Value-Based Purchasing
—
HAC Reduction
No Reduction
HAC Score: -0.3731

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 3.80 No Different Than the National Rate 242
MORT_30_AMI 12.20 No Different Than the National Rate 41
MORT_30_CABG — — —
MORT_30_COPD 8.00 No Different Than the National Rate 40
MORT_30_HF 10.90 No Different Than the National Rate 126
MORT_30_PN 13.20 No Different Than the National Rate 125
MORT_30_STK 13.80 No Different Than the National Rate 36
PSI_03 0.28 No Different Than the National Rate 2,345
PSI_04 — Number of Cases Too Small —
PSI_06 0.19 No Different Than the National Rate 2,480
PSI_08 0.25 No Different Than the National Rate 2,566
PSI_09 2.71 No Different Than the National Rate 316
PSI_10 1.65 No Different Than the National Rate 62
PSI_11 13.49 No Different Than the National Rate 68
PSI_12 3.47 No Different Than the National Rate 328
PSI_13 5.90 No Different Than the National Rate 61
PSI_14 1.73 No Different Than the National Rate 91
PSI_15 0.92 No Different Than the National Rate 428
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 72% —
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 7% —
H_COMP_1_U_P: Nurses "usually" communicated well 21% —
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 80% —
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 15% —
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 68% —
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 8% —
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 24% —
H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand 68% —
H_NURSE_EXPLAIN_SN_P: Nurses "sometimes" or "never" explained things so they could understand 8% —
H_NURSE_EXPLAIN_U_P: Nurses "usually" explained things so they could understand 24% —
H_COMP_2_A_P: Doctors "always" communicated well 75% —
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 5% —
H_COMP_2_U_P: Doctors "usually" communicated well 20% —
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 82% —
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 15% —
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 74% —
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 6% —
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 20% —
H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand 69% —
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 24% —
H_COMP_5_A_P: Staff "always" explained 55% —
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 20% —
H_COMP_5_U_P: Staff "usually" explained 25% —
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 71% —
H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications 10% —
H_MED_FOR_U_P: Staff "usually" explained new medications 19% —
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 38% —
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 32% —
H_COMP_6_N_P: No, staff "did not" give patients this information 17% —
H_COMP_6_Y_P: Yes, staff "did" give patients this information 83% —
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 19% —
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge 81% —
H_SYMPTOMS_N_P: No, staff "did not" give patients information about possible symptoms 15% —
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms 85% —
H_CLEAN_HSP_A_P: Room was "always" clean 66% —
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 14% —
H_CLEAN_HSP_U_P: Room was "usually" clean 20% —
H_CLEAN_LINEAR_SCORE: Cleanliness - linear mean score — —
H_CLEAN_STAR_RATING: Cleanliness - star rating — 2
H_QUIET_HSP_A_P: "Always" quiet at night 57% —
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 10% —
H_QUIET_HSP_U_P: "Usually" quiet at night 33% —
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) 9% —
H_HSP_RATING_7_8: Patients who gave a rating of "7" or "8" (medium) 25% —
H_HSP_RATING_9_10: Patients who gave a rating of "9" or "10" (high) 66% —
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) 8% —
H_RECMND_DY: "YES", patients would definitely recommend the hospital 64% —
H_RECMND_PY: "YES", patients would probably recommend the hospital 28% —
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 — —
HAI_1_CIUPPER — —
HAI_1_DOPC 437.000 —
HAI_1_ELIGCASES 0.411 —
HAI_1_NUMERATOR 0.000 —
HAI_1_SIR — —
HAI_2_CILOWER — —
HAI_2_CIUPPER — —
HAI_2_DOPC 384.000 —
HAI_2_ELIGCASES 0.361 —
HAI_2_NUMERATOR 0.000 —
HAI_2_SIR — —
HAI_3_CILOWER 0.025 No Different than National Benchmark
HAI_3_CIUPPER 2.426 No Different than National Benchmark
HAI_3_DOPC 69.000 No Different than National Benchmark
HAI_3_ELIGCASES 2.033 No Different than National Benchmark
HAI_3_NUMERATOR 1.000 No Different than National Benchmark
HAI_3_SIR 0.492 No Different than National Benchmark
HAI_4_CILOWER — —
HAI_4_CIUPPER — —
HAI_4_DOPC 11.000 —
HAI_4_ELIGCASES 0.096 —
HAI_4_NUMERATOR 0.000 —
HAI_4_SIR — —
HAI_5_CILOWER N/A No Different than National Benchmark
HAI_5_CIUPPER 1.482 No Different than National Benchmark
HAI_5_DOPC 34552.000 No Different than National Benchmark
HAI_5_ELIGCASES 2.022 No Different than National Benchmark
HAI_5_NUMERATOR 0.000 No Different than National Benchmark
HAI_5_SIR 0.000 No Different than National Benchmark
HAI_6_CILOWER 0.004 Better than the National Benchmark
HAI_6_CIUPPER 0.356 Better than the National Benchmark
HAI_6_DOPC 33841.000 Better than the National Benchmark
HAI_6_ELIGCASES 13.840 Better than the National Benchmark
HAI_6_NUMERATOR 1.000 Better than the National Benchmark
HAI_6_SIR 0.072 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 — 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 70.0 Healthcare Personnel Vaccination
OP_18a 209.0 Emergency Department
OP_18b 206.0 Emergency Department
OP_18c — Emergency Department
OP_18d — Emergency Department
OP_22 — 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 — Electronic Clinical Quality Measure
SEP_1 48.0 Sepsis Care
SEP_SH_3HR — Sepsis Care
SEP_SH_6HR — Sepsis Care
SEV_SEP_3HR 65.0 Sepsis Care
SEV_SEP_6HR 80.0 Sepsis Care
STK_02 — Electronic Clinical Quality Measure
STK_03 — Electronic Clinical Quality Measure
STK_05 — 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 — Number of Cases Too Small
EDAC_30_HF 13.50 Average Days per 100 Discharges
EDAC_30_PN -6.90 Average Days per 100 Discharges
Hybrid_HWR 14.20 No Different Than the National Rate
OP_32 13.70 No Different Than the National Rate
OP_35_ADM 10.30 No Different Than the National Rate
OP_35_ED 5.00 No Different Than the National Rate
OP_36 — Number of cases too small
READM_30_AMI 15.10 No Different Than the National Rate
READM_30_CABG — —
READM_30_COPD 19.30 No Different Than the National Rate
READM_30_HF 21.00 No Different Than the National Rate
READM_30_HIP_KNEE — Number of Cases Too Small
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
1.03
Footnote
29.00

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 1.26 — metrics.current_ratio
Cost Report Employees per Bed 3.66 — metrics.employees_per_bed
Cost Report fiscal_year 2,024 — fiscal_year
Cost Report Fund Balance ($) $222,759,350 — metrics.fund_balance
Cost Report Net Income ($) $12,840,645 — metrics.net_income
Cost Report Net Patient Revenue ($) $353,428,668 — metrics.net_patient_revenue
Cost Report Operating Margin (%) -4.0% — metrics.operating_margin
Cost Report Total Assets ($) $298,267,179 — metrics.total_assets
Cost Report Total Costs ($) $314,007,936 — metrics.total_costs
Cost Report Total Liabilities ($) $75,507,829 — metrics.total_liabilities
Cost Report Total Margin (%) 3.4% — metrics.total_margin
Cost Report Uncompensated Care (%) 4.2% — metrics.uncompensated_care_pct
General Information Address 2233 W DIVISION ST — Address
General Information City/Town CHICAGO — 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 8 — Count of Facility READM Measures
General Information Count of Facility Safety Measures 5 — Count of Facility Safety Measures
General Information Count of Facility TE Measures 9 — 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 6 — 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 1 — Count of Safety Measures Better
General Information Count of Safety Measures No Different 4 — Count of Safety Measures No Different
General Information Count of Safety Measures Worse 0 — Count of Safety Measures Worse
General Information County/Parish COOK — County/Parish
General Information Emergency Services Yes — Emergency Services
General Information Facility ID 140180 — Facility ID
General Information Facility Name PRESENCE SAINTS MARY AND ELIZABETH MEDICAL CENTER — 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 - 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 IL — State
General Information TE Group Footnote — — TE Group Footnote
General Information TE Group Measure Count 12 — TE Group Measure Count
General Information Telephone Number (312) 770-2000 — Telephone Number
General Information ZIP Code 60622 — ZIP Code
HAC Reduction Program fiscal_year 2,026 — fiscal_year
HAC Reduction Program measures — cauti — sir 0 — measures.cauti.sir
HAC Reduction Program measures — cdi — sir 0.27 — measures.cdi.sir
HAC Reduction Program measures — clabsi — sir 0.71 — measures.clabsi.sir
HAC Reduction Program measures — mrsa — sir 0.43 — measures.mrsa.sir
HAC Reduction Program measures — ssi — sir 0.58 — measures.ssi.sir
HAC Reduction Program payment_reduction No — payment_reduction
HAC Reduction Program total_hac_score -0.37 — total_hac_score
Medicare Spending per Beneficiary End Date 12/31/2024 — End Date
Medicare Spending per Beneficiary Footnote 29 — Footnote
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 1.03 — Value
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Excess readmission ratio 1.12 0.9995 p95 READM-30-AMI-HRRP.excess_readmission_ratio
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Expected readmission rate 16.0% — READM-30-AMI-HRRP.expected_readmission_rate
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of discharges 32 — READM-30-AMI-HRRP.num_discharges
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of readmissions 12 — READM-30-AMI-HRRP.num_readmissions
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Predicted readmission rate 17.9% — READM-30-AMI-HRRP.predicted_readmission_rate
Readmissions (HRRP) COPD — Excess readmission ratio 1.05 0.9969 p84 READM-30-COPD-HRRP.excess_readmission_ratio
Readmissions (HRRP) COPD — Expected readmission rate 18.9% — READM-30-COPD-HRRP.expected_readmission_rate
Readmissions (HRRP) COPD — Number of discharges 53 — READM-30-COPD-HRRP.num_discharges
Readmissions (HRRP) COPD — Number of readmissions 14 — READM-30-COPD-HRRP.num_readmissions
Readmissions (HRRP) COPD — Predicted readmission rate 19.8% — 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 23.6% — READM-30-HF-HRRP.expected_readmission_rate
Readmissions (HRRP) Heart Failure — Number of discharges 161 — READM-30-HF-HRRP.num_discharges
Readmissions (HRRP) Heart Failure — Number of readmissions 46 — READM-30-HF-HRRP.num_readmissions
Readmissions (HRRP) Heart Failure — Predicted readmission rate 25.2% — READM-30-HF-HRRP.predicted_readmission_rate
Readmissions (HRRP) Pneumonia — Excess readmission ratio 0.94 0.9955 p16 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 17.2% — READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Number of discharges 124 — READM-30-PN-HRRP.num_discharges
Readmissions (HRRP) Pneumonia — Number of readmissions 16 — READM-30-PN-HRRP.num_readmissions
Readmissions (HRRP) Pneumonia — Predicted readmission rate 16.2% — READM-30-PN-HRRP.predicted_readmission_rate
Methodology

Full methodology →