Hospital

ADVOCATE ILLINOIS MASONIC MEDICAL CENTER

CCN: 140182 · CHICAGO, IL 60657 · COOK County

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

Overview

Address
836 WEST WELLINGTON AVENUE, CHICAGO, IL 60657
Phone
(773) 975-1600
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 6 of 7 measures reported
1
5
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 9 of 11 measures reported
8
1
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 10 of 12 measures reported
10 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)
0.9983 p48
Heart Failure 275 discharges
1.0870 p90
Pneumonia 172 discharges
0.9928 p47
COPD 45 discharges
1.0710 p93
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 above the national median, suggesting a positive payment adjustment.

31.8 p59
Total Performance Score
National median: 29.5
Clinical Outcomes 25% weight
5.6 p54
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
11.7 p59
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
9.5 p56
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
5.0 p56
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: 1.0870
Value-Based Purchasing
31.8 TPS
Above national median
HAC Reduction
Payment Reduced
HAC Score: 0.6429

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 3.60 No Different Than the National Rate 816
MORT_30_AMI 12.90 No Different Than the National Rate 55
MORT_30_CABG — Number of Cases Too Small —
MORT_30_COPD 8.10 No Different Than the National Rate 36
MORT_30_HF 8.80 No Different Than the National Rate 246
MORT_30_PN 15.20 No Different Than the National Rate 160
MORT_30_STK 10.40 Better Than the National Rate 98
PSI_03 0.65 No Different Than the National Rate 3,096
PSI_04 170.84 No Different Than the National Rate 68
PSI_06 0.29 No Different Than the National Rate 3,801
PSI_08 0.23 No Different Than the National Rate 3,798
PSI_09 2.05 No Different Than the National Rate 865
PSI_10 2.62 No Different Than the National Rate 356
PSI_11 17.29 Worse Than the National Rate 361
PSI_12 3.99 No Different Than the National Rate 938
PSI_13 9.29 Worse Than the National Rate 356
PSI_14 1.64 No Different Than the National Rate 226
PSI_15 1.31 No Different Than the National Rate 746
PSI_90 1.42 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 78% —
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 5% —
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 — 3
H_NURSE_RESPECT_A_P: Nurses "always" treated them with courtesy and respect 85% —
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 12% —
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 76% —
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 5% —
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 19% —
H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand 74% —
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 20% —
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 5% —
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 20% —
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 59% —
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 21% —
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 74% —
H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications 9% —
H_MED_FOR_U_P: Staff "usually" explained new medications 17% —
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 33% —
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 15% —
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge 85% —
H_SYMPTOMS_N_P: No, staff "did not" give patients information about possible symptoms 11% —
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms 89% —
H_CLEAN_HSP_A_P: Room was "always" clean 65% —
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 13% —
H_CLEAN_HSP_U_P: Room was "usually" clean 22% —
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 51% —
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 16% —
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 — 2
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) 23% —
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) 6% —
H_RECMND_DY: "YES", patients would definitely recommend the hospital 70% —
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 0.510 No Different than National Benchmark
HAI_1_CIUPPER 2.309 No Different than National Benchmark
HAI_1_DOPC 5682.000 No Different than National Benchmark
HAI_1_ELIGCASES 5.998 No Different than National Benchmark
HAI_1_NUMERATOR 7.000 No Different than National Benchmark
HAI_1_SIR 1.167 No Different than National Benchmark
HAI_2_CILOWER 0.008 Better than the National Benchmark
HAI_2_CIUPPER 0.753 Better than the National Benchmark
HAI_2_DOPC 4656.000 Better than the National Benchmark
HAI_2_ELIGCASES 6.554 Better than the National Benchmark
HAI_2_NUMERATOR 1.000 Better than the National Benchmark
HAI_2_SIR 0.153 Better than the National Benchmark
HAI_3_CILOWER 0.215 No Different than National Benchmark
HAI_3_CIUPPER 1.634 No Different than National Benchmark
HAI_3_DOPC 216.000 No Different than National Benchmark
HAI_3_ELIGCASES 5.904 No Different than National Benchmark
HAI_3_NUMERATOR 4.000 No Different than National Benchmark
HAI_3_SIR 0.678 No Different than National Benchmark
HAI_4_CILOWER 0.134 No Different than National Benchmark
HAI_4_CIUPPER 2.641 No Different than National Benchmark
HAI_4_DOPC 283.000 No Different than National Benchmark
HAI_4_ELIGCASES 2.502 No Different than National Benchmark
HAI_4_NUMERATOR 2.000 No Different than National Benchmark
HAI_4_SIR 0.799 No Different than National Benchmark
HAI_5_CILOWER 0.075 No Different than National Benchmark
HAI_5_CIUPPER 1.476 No Different than National Benchmark
HAI_5_DOPC 70435.000 No Different than National Benchmark
HAI_5_ELIGCASES 4.477 No Different than National Benchmark
HAI_5_NUMERATOR 2.000 No Different than National Benchmark
HAI_5_SIR 0.447 No Different than National Benchmark
HAI_6_CILOWER 0.242 Better than the National Benchmark
HAI_6_CIUPPER 0.725 Better than the National Benchmark
HAI_6_DOPC 64603.000 Better than the National Benchmark
HAI_6_ELIGCASES 29.883 Better than the National Benchmark
HAI_6_NUMERATOR 13.000 Better than the National Benchmark
HAI_6_SIR 0.435 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 — Electronic Clinical Quality Measure
HH_HYPO — Electronic Clinical Quality Measure
HH_ORAE — Electronic Clinical Quality Measure
IMM_3 84.0 Healthcare Personnel Vaccination
OP_18a 253.0 Emergency Department
OP_18b 243.0 Emergency Department
OP_18c 368.0 Emergency Department
OP_18d — Emergency Department
OP_22 2.0 Emergency Department
OP_23 — Emergency Department
OP_29 97.0 Colonoscopy care
OP_31 — Cataract surgery outcome
OP_40 — Electronic Clinical Quality Measure
SAFE_USE_OF_OPIOIDS 10.0 Electronic Clinical Quality Measure
SEP_1 84.0 Sepsis Care
SEP_SH_3HR 82.0 Sepsis Care
SEP_SH_6HR 96.0 Sepsis Care
SEV_SEP_3HR 94.0 Sepsis Care
SEV_SEP_6HR 97.0 Sepsis Care
STK_02 99.0 Electronic Clinical Quality Measure
STK_03 — Electronic Clinical Quality Measure
STK_05 — Electronic Clinical Quality Measure
VTE_1 98.0 Electronic Clinical Quality Measure
VTE_2 100.0 Electronic Clinical Quality Measure

Unplanned Hospital Visits

Readmission and ED return rates within 30 days of discharge.

Measure Score vs. National
EDAC_30_AMI -16.20 Average Days per 100 Discharges
EDAC_30_HF 7.00 Average Days per 100 Discharges
EDAC_30_PN 6.40 Average Days per 100 Discharges
Hybrid_HWR 16.20 Worse Than the National Rate
OP_32 12.60 No Different Than the National Rate
OP_35_ADM 14.40 Worse Than the National Rate
OP_35_ED 4.10 No Different Than the National Rate
OP_36 0.90 No Different than expected
READM_30_AMI 13.60 No Different Than the National Rate
READM_30_CABG — Number of Cases Too Small
READM_30_COPD 19.50 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 15.80 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
1.01

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 0.20 — metrics.cost_to_charge_ratio
Cost Report Current Ratio 1.11 — metrics.current_ratio
Cost Report Employees per Bed 7.54 — metrics.employees_per_bed
Cost Report fiscal_year 2,023 — fiscal_year
Cost Report Fund Balance ($) $14,259,054,000 — metrics.fund_balance
Cost Report Net Income ($) $196,278,247 — metrics.net_income
Cost Report Net Patient Revenue ($) $786,171,902 — metrics.net_patient_revenue
Cost Report Operating Margin (%) 17.8% — metrics.operating_margin
Cost Report Total Assets ($) $22,997,820,000 — metrics.total_assets
Cost Report Total Costs ($) $538,206,779 — metrics.total_costs
Cost Report Total Liabilities ($) $8,738,766,000 — metrics.total_liabilities
Cost Report Total Margin (%) 23.3% — metrics.total_margin
Cost Report Uncompensated Care (%) 2.0% — metrics.uncompensated_care_pct
General Information Address 836 WEST WELLINGTON AVENUE — 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 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 10 — Count of Facility TE Measures
General Information Count of MORT Measures Better 1 — Count of MORT Measures Better
General Information Count of MORT Measures No Different 5 — 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 8 — Count of READM Measures No Different
General Information Count of READM Measures Worse 1 — 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 COOK — County/Parish
General Information Emergency Services Yes — Emergency Services
General Information Facility ID 140182 — Facility ID
General Information Facility Name ADVOCATE ILLINOIS MASONIC 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 - 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 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 (773) 975-1600 — Telephone Number
General Information ZIP Code 60657 — ZIP Code
HAC Reduction Program fiscal_year 2,026 — fiscal_year
HAC Reduction Program measures — cauti — sir 0.53 — measures.cauti.sir
HAC Reduction Program measures — cdi — sir 0.39 — measures.cdi.sir
HAC Reduction Program measures — clabsi — sir 1.33 — measures.clabsi.sir
HAC Reduction Program measures — mrsa — sir 0.25 — measures.mrsa.sir
HAC Reduction Program measures — ssi — sir 1.21 — measures.ssi.sir
HAC Reduction Program payment_reduction Yes — payment_reduction
HAC Reduction Program total_hac_score 0.64 — 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 1.01 — Value
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Excess readmission ratio 1.00 0.9995 p48 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) — Predicted readmission rate 16.0% — READM-30-AMI-HRRP.predicted_readmission_rate
Readmissions (HRRP) COPD — Excess readmission ratio 1.07 0.9969 p93 READM-30-COPD-HRRP.excess_readmission_ratio
Readmissions (HRRP) COPD — Expected readmission rate 22.0% — READM-30-COPD-HRRP.expected_readmission_rate
Readmissions (HRRP) COPD — Number of discharges 45 — READM-30-COPD-HRRP.num_discharges
Readmissions (HRRP) COPD — Number of readmissions 16 — READM-30-COPD-HRRP.num_readmissions
Readmissions (HRRP) COPD — Predicted readmission rate 23.6% — READM-30-COPD-HRRP.predicted_readmission_rate
Readmissions (HRRP) Heart Failure — Excess readmission ratio 1.09 0.9983 p90 READM-30-HF-HRRP.excess_readmission_ratio
Readmissions (HRRP) Heart Failure — Expected readmission rate 20.3% — READM-30-HF-HRRP.expected_readmission_rate
Readmissions (HRRP) Heart Failure — Number of discharges 275 — READM-30-HF-HRRP.num_discharges
Readmissions (HRRP) Heart Failure — Number of readmissions 67 — READM-30-HF-HRRP.num_readmissions
Readmissions (HRRP) Heart Failure — Predicted readmission rate 22.1% — READM-30-HF-HRRP.predicted_readmission_rate
Readmissions (HRRP) Pneumonia — Excess readmission ratio 0.99 0.9955 p47 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 16.7% — READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Number of discharges 172 — READM-30-PN-HRRP.num_discharges
Readmissions (HRRP) Pneumonia — Number of readmissions 28 — READM-30-PN-HRRP.num_readmissions
Readmissions (HRRP) Pneumonia — Predicted readmission rate 16.6% — READM-30-PN-HRRP.predicted_readmission_rate
Value-Based Purchasing Clinical Outcomes 5.63 5.00 p54 clinical_outcomes_score
Value-Based Purchasing Efficiency & Cost Reduction 5.00 2.50 p56 efficiency_score
Value-Based Purchasing Person & Community Engagement 9.50 8.75 p56 person_community_score
Value-Based Purchasing Safety 11.67 10.00 p59 safety_score
Value-Based Purchasing Total Performance Score 31.79 29.50 p59 total_performance_score
Methodology

Full methodology →