Hospital

SUSAN B ALLEN MEMORIAL HOSPITAL

CCN: 170017 · EL DORADO, KS 67042 · BUTLER County

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

Overview

Address
720 W CENTRAL ST, EL DORADO, KS 67042
Phone
(316) 321-3300
Hospital Type
Acute Care
Ownership
Non-Profit
Emergency Services
Yes
Birthing Friendly
Yes
2 /5
★★★★★
CMS Overall Rating
p7
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 3 of 7 measures reported
3
Better No different Worse
30-day death rates for heart attack, heart failure, pneumonia, COPD, stroke, CABG, and kidney disease.
Safety of Care 2 of 8 measures reported
2
Better No different Worse
Healthcare-associated infections and patient safety indicators (PSI-90 composite).
Readmission 5 of 11 measures reported
5
Better No different Worse
30-day unplanned readmission rates for heart attack, heart failure, pneumonia, COPD, hip/knee replacement, and CABG.
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)
— Not reported
Heart Failure
— Not reported
Pneumonia
1.0112 p59
COPD
— Not reported
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.

57.0 p97
Total Performance Score
National median: 29.5
Safety 25% weight
8.3 p35
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
15.3 p86
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
33.3 p99
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: 1.0112
Value-Based Purchasing
57.0 TPS
Above national median
HAC Reduction
Payment Reduced
HAC Score: 0.9890

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 4.00 No Different Than the National Rate 95
MORT_30_AMI — Number of Cases Too Small —
MORT_30_CABG — — —
MORT_30_COPD — Number of Cases Too Small —
MORT_30_HF — Number of Cases Too Small —
MORT_30_PN 16.40 No Different Than the National Rate 46
MORT_30_STK — Number of Cases Too Small —
PSI_03 0.57 No Different Than the National Rate 242
PSI_04 — — —
PSI_06 0.21 No Different Than the National Rate 367
PSI_08 0.27 No Different Than the National Rate 352
PSI_09 2.31 No Different Than the National Rate 76
PSI_10 1.63 No Different Than the National Rate 55
PSI_11 8.95 No Different Than the National Rate 53
PSI_12 3.38 No Different Than the National Rate 80
PSI_13 5.13 No Different Than the National Rate 49
PSI_14 — Number of Cases Too Small —
PSI_15 1.05 No Different Than the National Rate 50
PSI_90 0.96 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 79% —
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 2% —
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 — 4
H_NURSE_RESPECT_A_P: Nurses "always" treated them with courtesy and respect 87% —
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 11% —
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 80% —
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 1% —
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 19% —
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 4% —
H_NURSE_EXPLAIN_U_P: Nurses "usually" explained things so they could understand 25% —
H_COMP_2_A_P: Doctors "always" communicated well 80% —
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 5% —
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 — 4
H_DOCTOR_RESPECT_A_P: Doctors "always" treated them with courtesy and respect 85% —
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 11% —
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 77% —
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 6% —
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 17% —
H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand 79% —
H_DOCTOR_EXPLAIN_SN_P: Doctors "sometimes" or "never" explained things so they could understand 5% —
H_DOCTOR_EXPLAIN_U_P: Doctors "usually" explained things so they could understand 16% —
H_COMP_5_A_P: Staff "always" explained 62% —
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 18% —
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 — 3
H_MED_FOR_A_P: Staff "always" explained new medications 75% —
H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications 3% —
H_MED_FOR_U_P: Staff "usually" explained new medications 22% —
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 49% —
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 17% —
H_COMP_6_N_P: No, staff "did not" give patients this information 14% —
H_COMP_6_Y_P: Yes, staff "did" give patients this information 86% —
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 18% —
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge 82% —
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 59% —
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 23% —
H_CLEAN_HSP_U_P: Room was "usually" clean 18% —
H_CLEAN_LINEAR_SCORE: Cleanliness - linear mean score — —
H_CLEAN_STAR_RATING: Cleanliness - star rating — 1
H_QUIET_HSP_A_P: "Always" quiet at night 69% —
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 6% —
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 — 4
H_HSP_RATING_0_6: Patients who gave a rating of "6" or lower (low) 6% —
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) 71% —
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) 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 — —
HAI_1_CIUPPER — —
HAI_1_DOPC 104.000 —
HAI_1_ELIGCASES 0.060 —
HAI_1_NUMERATOR 0.000 —
HAI_1_SIR — —
HAI_2_CILOWER — —
HAI_2_CIUPPER — —
HAI_2_DOPC 227.000 —
HAI_2_ELIGCASES 0.111 —
HAI_2_NUMERATOR 0.000 —
HAI_2_SIR — —
HAI_3_CILOWER — —
HAI_3_CIUPPER — —
HAI_3_DOPC 4.000 —
HAI_3_ELIGCASES 0.094 —
HAI_3_NUMERATOR 0.000 —
HAI_3_SIR — —
HAI_4_CILOWER — —
HAI_4_CIUPPER — —
HAI_4_DOPC — —
HAI_4_ELIGCASES — —
HAI_4_NUMERATOR — —
HAI_4_SIR — —
HAI_5_CILOWER — —
HAI_5_CIUPPER — —
HAI_5_DOPC 2017.000 —
HAI_5_ELIGCASES 0.051 —
HAI_5_NUMERATOR 0.000 —
HAI_5_SIR — —
HAI_6_CILOWER 1.132 Worse than the National Benchmark
HAI_6_CIUPPER 8.592 Worse than the National Benchmark
HAI_6_DOPC 1784.000 Worse than the National Benchmark
HAI_6_ELIGCASES 1.123 Worse than the National Benchmark
HAI_6_NUMERATOR 4.000 Worse than the National Benchmark
HAI_6_SIR 3.562 Worse than the National Benchmark

Timely & Effective Care

Process-of-care measures including ED wait times, treatment timeliness, and preventive care.

Measure Score Condition
EDV low 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 9.0 Electronic Clinical Quality Measure
HH_HYPO 0.0 Electronic Clinical Quality Measure
HH_ORAE — Electronic Clinical Quality Measure
IMM_3 92.0 Healthcare Personnel Vaccination
OP_18a 107.0 Emergency Department
OP_18b 102.0 Emergency Department
OP_18c — Emergency Department
OP_18d 269.0 Emergency Department
OP_22 1.0 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 12.0 Electronic Clinical Quality Measure
SEP_1 83.0 Sepsis Care
SEP_SH_3HR 71.0 Sepsis Care
SEP_SH_6HR — Sepsis Care
SEV_SEP_3HR 98.0 Sepsis Care
SEV_SEP_6HR 96.0 Sepsis Care
STK_02 — Electronic Clinical Quality Measure
STK_03 — Electronic Clinical Quality Measure
STK_05 — Electronic Clinical Quality Measure
VTE_1 94.0 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 — Number of Cases Too Small
EDAC_30_PN -5.30 Average Days per 100 Discharges
Hybrid_HWR 15.10 No Different Than the National Rate
OP_32 13.80 No Different Than the National Rate
OP_35_ADM — Number of Cases Too Small
OP_35_ED — Number of Cases Too Small
OP_36 1.00 No Different than expected
READM_30_AMI — Number of Cases Too Small
READM_30_CABG — —
READM_30_COPD — Number of Cases Too Small
READM_30_HF — Number of Cases Too Small
READM_30_HIP_KNEE — Number of Cases Too Small
READM_30_PN 16.10 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
0.84

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 0.34 — metrics.cost_to_charge_ratio
Cost Report Current Ratio 2.08 — metrics.current_ratio
Cost Report Employees per Bed 9.32 — metrics.employees_per_bed
Cost Report fiscal_year 2,023 — fiscal_year
Cost Report Fund Balance ($) $39,291,360 — metrics.fund_balance
Cost Report Net Income ($) $-849,226 — metrics.net_income
Cost Report Net Patient Revenue ($) $31,300,497 — metrics.net_patient_revenue
Cost Report Operating Margin (%) -22.1% — metrics.operating_margin
Cost Report Total Assets ($) $44,457,867 — metrics.total_assets
Cost Report Total Costs ($) $29,134,794 — metrics.total_costs
Cost Report Total Liabilities ($) $5,166,507 — metrics.total_liabilities
Cost Report Total Margin (%) -2.3% — metrics.total_margin
Cost Report Uncompensated Care (%) 21.5% — metrics.uncompensated_care_pct
General Information Address 720 W CENTRAL ST — Address
General Information City/Town EL DORADO — City/Town
General Information Count of Facility MORT Measures 3 — Count of Facility MORT Measures
General Information Count of Facility Pt Exp Measures Not Available — Count of Facility Pt Exp Measures
General Information Count of Facility READM Measures 5 — Count of Facility READM Measures
General Information Count of Facility Safety Measures 2 — 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 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 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 5 — 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 0 — 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 0 — Count of Safety Measures Worse
General Information County/Parish BUTLER — County/Parish
General Information Emergency Services Yes — Emergency Services
General Information Facility ID 170017 — Facility ID
General Information Facility Name SUSAN B ALLEN MEMORIAL HOSPITAL — Facility Name
General Information Hospital overall rating 2 — 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 5 — 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 KS — State
General Information TE Group Footnote — — TE Group Footnote
General Information TE Group Measure Count 12 — TE Group Measure Count
General Information Telephone Number (316) 321-3300 — Telephone Number
General Information ZIP Code 67042 — ZIP Code
HAC Reduction Program fiscal_year 2,026 — fiscal_year
HAC Reduction Program measures — cdi — sir 2.24 — measures.cdi.sir
HAC Reduction Program payment_reduction Yes — payment_reduction
HAC Reduction Program total_hac_score 0.99 — 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 0.84 — Value
Readmissions (HRRP) Pneumonia — Excess readmission ratio 1.01 0.9955 p59 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 12.7% — READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Predicted readmission rate 12.8% — READM-30-PN-HRRP.predicted_readmission_rate
Value-Based Purchasing Efficiency & Cost Reduction 33.33 2.50 p99 efficiency_score
Value-Based Purchasing Person & Community Engagement 15.33 8.75 p86 person_community_score
Value-Based Purchasing Safety 8.33 10.00 p35 safety_score
Value-Based Purchasing Total Performance Score 57.00 29.50 p97 total_performance_score
Methodology

Full methodology →