Hospital

SAINT AGNES HOSPITAL

CCN: 210011 · BALTIMORE, MD 21229 · BALTIMORE CITY County

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

Overview

Address
900 CATON AVENUE, BALTIMORE, MD 21229
Phone
(410) 368-6000
Hospital Type
Acute Care
Ownership
Non-Profit (Church)
Emergency Services
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 7 of 8 measures reported
2
5
Better No different Worse
Healthcare-associated infections and patient safety indicators (PSI-90 composite).
Readmission 10 of 11 measures reported
9
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 6 of 12 measures reported
6 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) 91 discharges
0.9821 p37
Heart Failure 364 discharges
0.9647 p27
Pneumonia 305 discharges
1.0132 p61
COPD 255 discharges
1.0270 p74
Hip/Knee Replacement
1.2082 p90
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: 1.2082
Value-Based Purchasing
—
HAC Reduction
No Reduction
HAC Score: -0.0138

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 3.90 No Different Than the National Rate 74
Hybrid_HWM 4.10 No Different Than the National Rate 807
MORT_30_AMI 11.60 No Different Than the National Rate 95
MORT_30_CABG — — —
MORT_30_COPD 9.80 No Different Than the National Rate 220
MORT_30_HF 8.50 Better Than the National Rate 332
MORT_30_PN 17.90 No Different Than the National Rate 295
MORT_30_STK 13.20 No Different Than the National Rate 201
PSI_03 0.76 No Different Than the National Rate 4,412
PSI_04 158.08 No Different Than the National Rate 58
PSI_06 0.22 No Different Than the National Rate 4,917
PSI_08 0.22 No Different Than the National Rate 5,151
PSI_09 2.57 No Different Than the National Rate 1,010
PSI_10 1.96 No Different Than the National Rate 402
PSI_11 7.15 No Different Than the National Rate 382
PSI_12 3.04 No Different Than the National Rate 1,035
PSI_13 4.86 No Different Than the National Rate 386
PSI_14 1.63 No Different Than the National Rate 252
PSI_15 1.32 No Different Than the National Rate 986
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 69% —
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 8% —
H_COMP_1_U_P: Nurses "usually" communicated well 23% —
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 8% —
H_NURSE_RESPECT_U_P: Nurses "usually" treated them with courtesy and respect 12% —
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 63% —
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 9% —
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 28% —
H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand 64% —
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 30% —
H_COMP_2_A_P: Doctors "always" communicated well 75% —
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 6% —
H_COMP_2_U_P: Doctors "usually" communicated well 19% —
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 87% —
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 10% —
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 73% —
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 8% —
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 19% —
H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand 66% —
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 27% —
H_COMP_5_A_P: Staff "always" explained 47% —
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 35% —
H_COMP_5_U_P: Staff "usually" explained 18% —
H_COMP_5_LINEAR_SCORE: Communication about medicines - linear mean score — —
H_COMP_5_STAR_RATING: Communication about medicines - star rating — 1
H_MED_FOR_A_P: Staff "always" explained new medications 64% —
H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications 19% —
H_MED_FOR_U_P: Staff "usually" explained new medications 17% —
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 30% —
H_SIDE_EFFECTS_SN_P: Staff "sometimes" or "never" explained possible side effects 52% —
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 23% —
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge 77% —
H_SYMPTOMS_N_P: No, staff "did not" give patients information about possible symptoms 14% —
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms 86% —
H_CLEAN_HSP_A_P: Room was "always" clean 51% —
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 20% —
H_CLEAN_HSP_U_P: Room was "usually" clean 29% —
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 50% —
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 16% —
H_QUIET_HSP_U_P: "Usually" quiet at night 34% —
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) 15% —
H_HSP_RATING_7_8: Patients who gave a rating of "7" or "8" (medium) 32% —
H_HSP_RATING_9_10: Patients who gave a rating of "9" or "10" (high) 53% —
H_HSP_RATING_LINEAR_SCORE: Overall hospital rating - linear mean score — —
H_HSP_RATING_STAR_RATING: Overall hospital rating - star rating — 2
H_RECMND_DN: "NO", patients would not recommend the hospital (they probably would not or definitely would not recommend it) 12% —
H_RECMND_DY: "YES", patients would definitely recommend the hospital 54% —
H_RECMND_PY: "YES", patients would probably recommend the hospital 34% —
H_RECMND_LINEAR_SCORE: Recommend hospital - linear mean score — —
H_RECMND_STAR_RATING: Recommend hospital - star rating — 2
H_STAR_RATING: Summary star rating — 2

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 0.412 No Different than National Benchmark
HAI_1_CIUPPER 3.125 No Different than National Benchmark
HAI_1_DOPC 2944.000 No Different than National Benchmark
HAI_1_ELIGCASES 3.088 No Different than National Benchmark
HAI_1_NUMERATOR 4.000 No Different than National Benchmark
HAI_1_SIR 1.295 No Different than National Benchmark
HAI_2_CILOWER 0.015 No Different than National Benchmark
HAI_2_CIUPPER 1.475 No Different than National Benchmark
HAI_2_DOPC 2688.000 No Different than National Benchmark
HAI_2_ELIGCASES 3.343 No Different than National Benchmark
HAI_2_NUMERATOR 1.000 No Different than National Benchmark
HAI_2_SIR 0.299 No Different than National Benchmark
HAI_3_CILOWER N/A No Different than National Benchmark
HAI_3_CIUPPER 1.774 No Different than National Benchmark
HAI_3_DOPC 57.000 No Different than National Benchmark
HAI_3_ELIGCASES 1.689 No Different than National Benchmark
HAI_3_NUMERATOR 0.000 No Different than National Benchmark
HAI_3_SIR 0.000 No Different than National Benchmark
HAI_4_CILOWER — —
HAI_4_CIUPPER — —
HAI_4_DOPC 2.000 —
HAI_4_ELIGCASES 0.011 —
HAI_4_NUMERATOR 0.000 —
HAI_4_SIR — —
HAI_5_CILOWER 0.508 No Different than National Benchmark
HAI_5_CIUPPER 3.853 No Different than National Benchmark
HAI_5_DOPC 39537.000 No Different than National Benchmark
HAI_5_ELIGCASES 2.504 No Different than National Benchmark
HAI_5_NUMERATOR 4.000 No Different than National Benchmark
HAI_5_SIR 1.597 No Different than National Benchmark
HAI_6_CILOWER 0.108 Better than the National Benchmark
HAI_6_CIUPPER 0.655 Better than the National Benchmark
HAI_6_DOPC 38158.000 Better than the National Benchmark
HAI_6_ELIGCASES 16.927 Better than the National Benchmark
HAI_6_NUMERATOR 5.000 Better than the National Benchmark
HAI_6_SIR 0.295 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 8.0 Electronic Clinical Quality Measure
HH_HYPO — Electronic Clinical Quality Measure
HH_ORAE — Electronic Clinical Quality Measure
IMM_3 96.0 Healthcare Personnel Vaccination
OP_18a — Emergency Department
OP_18b — 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 13.0 Electronic Clinical Quality Measure
SEP_1 — Sepsis Care
SEP_SH_3HR — Sepsis Care
SEP_SH_6HR — Sepsis Care
SEV_SEP_3HR — Sepsis Care
SEV_SEP_6HR — Sepsis Care
STK_02 — Electronic Clinical Quality Measure
STK_03 — Electronic Clinical Quality Measure
STK_05 94.0 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 18.20 Average Days per 100 Discharges
EDAC_30_HF -5.10 Average Days per 100 Discharges
EDAC_30_PN 30.90 More Days Than Average per 100 Discharges
Hybrid_HWR 14.10 Better Than the National Rate
OP_32 12.50 No Different Than the National Rate
OP_35_ADM 9.40 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 13.30 No Different Than the National Rate
READM_30_CABG — —
READM_30_COPD 18.70 No Different Than the National Rate
READM_30_HF 18.90 No Different Than the National Rate
READM_30_HIP_KNEE 5.80 No Different Than the National Rate
READM_30_PN 16.20 No Different Than the National Rate

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 0.62 — metrics.cost_to_charge_ratio
Cost Report Current Ratio 1.03 — metrics.current_ratio
Cost Report Employees per Bed 11.07 — metrics.employees_per_bed
Cost Report fiscal_year 2,024 — fiscal_year
Cost Report Fund Balance ($) $224,602,508 — metrics.fund_balance
Cost Report Net Income ($) $-27,040,267 — metrics.net_income
Cost Report Net Patient Revenue ($) $476,980,450 — metrics.net_patient_revenue
Cost Report Operating Margin (%) -14.8% — metrics.operating_margin
Cost Report Total Assets ($) $472,289,356 — metrics.total_assets
Cost Report Total Costs ($) $305,415,530 — metrics.total_costs
Cost Report Total Liabilities ($) $247,686,848 — metrics.total_liabilities
Cost Report Total Margin (%) -5.2% — metrics.total_margin
Cost Report Uncompensated Care (%) 4.5% — metrics.uncompensated_care_pct
General Information Address 900 CATON AVENUE — Address
General Information City/Town BALTIMORE — 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 7 — Count of Facility Safety Measures
General Information Count of Facility TE Measures 6 — 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 9 — 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 2 — Count of Safety Measures Better
General Information Count of Safety Measures No Different 5 — Count of Safety Measures No Different
General Information Count of Safety Measures Worse 0 — Count of Safety Measures Worse
General Information County/Parish BALTIMORE CITY — County/Parish
General Information Emergency Services Yes — Emergency Services
General Information Facility ID 210011 — Facility ID
General Information Facility Name SAINT AGNES HOSPITAL — 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 — — 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 MD — State
General Information TE Group Footnote — — TE Group Footnote
General Information TE Group Measure Count 12 — TE Group Measure Count
General Information Telephone Number (410) 368-6000 — Telephone Number
General Information ZIP Code 21229 — ZIP Code
HAC Reduction Program fiscal_year 2,026 — fiscal_year
HAC Reduction Program measures — cauti — sir 0.14 — measures.cauti.sir
HAC Reduction Program measures — cdi — sir 0.38 — measures.cdi.sir
HAC Reduction Program measures — clabsi — sir 1.06 — measures.clabsi.sir
HAC Reduction Program measures — mrsa — sir 1.19 — measures.mrsa.sir
HAC Reduction Program measures — ssi — sir 0.21 — measures.ssi.sir
HAC Reduction Program payment_reduction No — payment_reduction
HAC Reduction Program total_hac_score -0.01 — total_hac_score
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Excess readmission ratio 0.98 0.9995 p37 READM-30-AMI-HRRP.excess_readmission_ratio
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Expected readmission rate 14.5% — READM-30-AMI-HRRP.expected_readmission_rate
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of discharges 91 — 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 14.2% — READM-30-AMI-HRRP.predicted_readmission_rate
Readmissions (HRRP) COPD — Excess readmission ratio 1.03 0.9969 p74 READM-30-COPD-HRRP.excess_readmission_ratio
Readmissions (HRRP) COPD — Expected readmission rate 19.1% — READM-30-COPD-HRRP.expected_readmission_rate
Readmissions (HRRP) COPD — Number of discharges 255 — READM-30-COPD-HRRP.num_discharges
Readmissions (HRRP) COPD — Number of readmissions 52 — READM-30-COPD-HRRP.num_readmissions
Readmissions (HRRP) COPD — Predicted readmission rate 19.6% — READM-30-COPD-HRRP.predicted_readmission_rate
Readmissions (HRRP) Heart Failure — Excess readmission ratio 0.96 0.9983 p27 READM-30-HF-HRRP.excess_readmission_ratio
Readmissions (HRRP) Heart Failure — Expected readmission rate 19.0% — READM-30-HF-HRRP.expected_readmission_rate
Readmissions (HRRP) Heart Failure — Number of discharges 364 — READM-30-HF-HRRP.num_discharges
Readmissions (HRRP) Heart Failure — Number of readmissions 64 — READM-30-HF-HRRP.num_readmissions
Readmissions (HRRP) Heart Failure — Predicted readmission rate 18.3% — READM-30-HF-HRRP.predicted_readmission_rate
Readmissions (HRRP) Hip/Knee Replacement — Excess readmission ratio 1.21 0.9916 p90 READM-30-HIP-KNEE-HRRP.excess_readmission_ratio
Readmissions (HRRP) Hip/Knee Replacement — Expected readmission rate 5.4% — READM-30-HIP-KNEE-HRRP.expected_readmission_rate
Readmissions (HRRP) Hip/Knee Replacement — Predicted readmission rate 6.5% — READM-30-HIP-KNEE-HRRP.predicted_readmission_rate
Readmissions (HRRP) Pneumonia — Excess readmission ratio 1.01 0.9955 p61 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 15.2% — READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Number of discharges 305 — READM-30-PN-HRRP.num_discharges
Readmissions (HRRP) Pneumonia — Number of readmissions 48 — READM-30-PN-HRRP.num_readmissions
Readmissions (HRRP) Pneumonia — Predicted readmission rate 15.5% — READM-30-PN-HRRP.predicted_readmission_rate
Methodology

Full methodology →