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

Overview

Address
148 CHESTNUT STREET, NEEDHAM, MA 02494
Phone
(781) 453-3002
Hospital Type
Acute Care
Ownership
Non-Profit
Emergency Services
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 4 of 7 measures reported
2
2
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
5
Better No different Worse
Healthcare-associated infections and patient safety indicators (PSI-90 composite).
Readmission 7 of 11 measures reported
6
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)
— Not reported
Heart Failure 536 discharges
1.0635 p83
Pneumonia 706 discharges
1.1018 p92
COPD 107 discharges
0.9687 p23
Hip/Knee Replacement
0.9601 p40
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.

40.6 p81
Total Performance Score
National median: 29.5
Clinical Outcomes 25% weight
11.9 p88
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
5.0 p12
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
8.8 p49
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
15.0 p88
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: 1.1018
Value-Based Purchasing
40.6 TPS
Above national median
HAC Reduction
Payment Reduced
HAC Score: 0.4598

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 3.20 No Different Than the National Rate 58
Hybrid_HWM 3.00 Better Than the National Rate 1,297
MORT_30_AMI Number of Cases Too Small
MORT_30_CABG
MORT_30_COPD 8.10 No Different Than the National Rate 91
MORT_30_HF 8.80 Better Than the National Rate 489
MORT_30_PN 10.70 Better Than the National Rate 671
MORT_30_STK 11.50 No Different Than the National Rate 135
PSI_03 0.25 No Different Than the National Rate 3,674
PSI_04 Number of Cases Too Small
PSI_06 0.18 No Different Than the National Rate 4,910
PSI_08 0.31 No Different Than the National Rate 4,857
PSI_09 2.48 No Different Than the National Rate 369
PSI_10 Number of Cases Too Small
PSI_11 Number of Cases Too Small
PSI_12 3.36 No Different Than the National Rate 390
PSI_13 Number of Cases Too Small
PSI_14 1.71 No Different Than the National Rate 111
PSI_15 0.97 No Different Than the National Rate 408
PSI_90 0.88 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 80%
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 4%
H_COMP_1_U_P: Nurses "usually" communicated well 16%
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 86%
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 11%
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 77%
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 4%
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 19%
H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand 76%
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 20%
H_COMP_2_A_P: Doctors "always" communicated well 79%
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 4%
H_COMP_2_U_P: Doctors "usually" communicated well 17%
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 86%
H_DOCTOR_RESPECT_SN_P: Doctors "sometimes" or "never" treated them with courtesy and respect 2%
H_DOCTOR_RESPECT_U_P: Doctors "usually" treated them with courtesy and respect 12%
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 77%
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 5%
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 18%
H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand 73%
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 21%
H_COMP_5_A_P: Staff "always" explained 57%
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 23%
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 12%
H_MED_FOR_U_P: Staff "usually" explained new medications 16%
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 42%
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 24%
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 16%
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge 84%
H_SYMPTOMS_N_P: No, staff "did not" give patients information about possible symptoms 12%
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms 88%
H_CLEAN_HSP_A_P: Room was "always" clean 66%
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 11%
H_CLEAN_HSP_U_P: Room was "usually" clean 23%
H_CLEAN_LINEAR_SCORE: Cleanliness - linear mean score
H_CLEAN_STAR_RATING: Cleanliness - star rating 3
H_QUIET_HSP_A_P: "Always" quiet at night 43%
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 20%
H_QUIET_HSP_U_P: "Usually" quiet at night 37%
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) 8%
H_HSP_RATING_7_8: Patients who gave a rating of "7" or "8" (medium) 24%
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) 5%
H_RECMND_DY: "YES", patients would definitely recommend the hospital 72%
H_RECMND_PY: "YES", patients would probably recommend the hospital 23%
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 0.184 No Different than National Benchmark
HAI_1_CIUPPER 3.625 No Different than National Benchmark
HAI_1_DOPC 2961.000 No Different than National Benchmark
HAI_1_ELIGCASES 1.823 No Different than National Benchmark
HAI_1_NUMERATOR 2.000 No Different than National Benchmark
HAI_1_SIR 1.097 No Different than National Benchmark
HAI_2_CILOWER 0.184 No Different than National Benchmark
HAI_2_CIUPPER 3.617 No Different than National Benchmark
HAI_2_DOPC 3609.000 No Different than National Benchmark
HAI_2_ELIGCASES 1.827 No Different than National Benchmark
HAI_2_NUMERATOR 2.000 No Different than National Benchmark
HAI_2_SIR 1.095 No Different than National Benchmark
HAI_3_CILOWER 0.028 No Different than National Benchmark
HAI_3_CIUPPER 2.719 No Different than National Benchmark
HAI_3_DOPC 74.000 No Different than National Benchmark
HAI_3_ELIGCASES 1.814 No Different than National Benchmark
HAI_3_NUMERATOR 1.000 No Different than National Benchmark
HAI_3_SIR 0.551 No Different than National Benchmark
HAI_4_CILOWER
HAI_4_CIUPPER
HAI_4_DOPC
HAI_4_ELIGCASES
HAI_4_NUMERATOR
HAI_4_SIR
HAI_5_CILOWER N/A No Different than National Benchmark
HAI_5_CIUPPER 2.926 No Different than National Benchmark
HAI_5_DOPC 23132.000 No Different than National Benchmark
HAI_5_ELIGCASES 1.024 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 0.405 No Different than National Benchmark
HAI_6_CIUPPER 1.832 No Different than National Benchmark
HAI_6_DOPC 23132.000 No Different than National Benchmark
HAI_6_ELIGCASES 7.558 No Different than National Benchmark
HAI_6_NUMERATOR 7.000 No Different than National Benchmark
HAI_6_SIR 0.926 No Different than National Benchmark

Timely & Effective Care

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

Measure Score Condition
EDV medium 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 99.0 Healthcare Personnel Vaccination
OP_18a 215.0 Emergency Department
OP_18b 208.0 Emergency Department
OP_18c 243.0 Emergency Department
OP_18d 322.0 Emergency Department
OP_22 1.0 Emergency Department
OP_23 74.0 Emergency Department
OP_29 98.0 Colonoscopy care
OP_31 Cataract surgery outcome
OP_40 Electronic Clinical Quality Measure
SAFE_USE_OF_OPIOIDS 18.0 Electronic Clinical Quality Measure
SEP_1 28.0 Sepsis Care
SEP_SH_3HR 38.0 Sepsis Care
SEP_SH_6HR 73.0 Sepsis Care
SEV_SEP_3HR 56.0 Sepsis Care
SEV_SEP_6HR 73.0 Sepsis Care
STK_02 99.0 Electronic Clinical Quality Measure
STK_03 89.0 Electronic Clinical Quality Measure
STK_05 95.0 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 26.30 More Days Than Average per 100 Discharges
EDAC_30_PN 10.00 More Days Than Average per 100 Discharges
Hybrid_HWR 15.80 No Different Than the National Rate
OP_32 13.00 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 17.60 No Different Than the National Rate
READM_30_HF 20.90 No Different Than the National Rate
READM_30_HIP_KNEE 4.70 No Different Than the National Rate
READM_30_PN 17.60 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
0.89

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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Show 86 rows
Source Metric Value National Median Pctl. Raw key
Cost Report Cost-to-Charge Ratio 0.41 metrics.cost_to_charge_ratio
Cost Report Current Ratio 1.30 metrics.current_ratio
Cost Report Employees per Bed 9.40 metrics.employees_per_bed
Cost Report fiscal_year 2,023 fiscal_year
Cost Report Fund Balance ($) $20,137,483 metrics.fund_balance
Cost Report Net Income ($) $-131,852,053 metrics.net_income
Cost Report Net Patient Revenue ($) $143,539,976 metrics.net_patient_revenue
Cost Report Operating Margin (%) -95.1% metrics.operating_margin
Cost Report Total Assets ($) $334,541,893 metrics.total_assets
Cost Report Total Costs ($) $130,834,816 metrics.total_costs
Cost Report Total Liabilities ($) $281,543,940 metrics.total_liabilities
Cost Report Total Margin (%) -89.0% metrics.total_margin
Cost Report Uncompensated Care (%) 1.1% metrics.uncompensated_care_pct
General Information Address 148 CHESTNUT STREET Address
General Information City/Town NEEDHAM City/Town
General Information Count of Facility MORT Measures 4 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 7 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 10 Count of Facility TE Measures
General Information Count of MORT Measures Better 2 Count of MORT Measures Better
General Information Count of MORT Measures No Different 2 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 1 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 5 Count of Safety Measures No Different
General Information Count of Safety Measures Worse 0 Count of Safety Measures Worse
General Information County/Parish NORFOLK County/Parish
General Information Emergency Services Yes Emergency Services
General Information Facility ID 220083 Facility ID
General Information Facility Name BETH ISRAEL DEACONESS HOSPITAL - NEEDHAM 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 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 MA State
General Information TE Group Footnote TE Group Footnote
General Information TE Group Measure Count 12 TE Group Measure Count
General Information Telephone Number (781) 453-3002 Telephone Number
General Information ZIP Code 02494 ZIP Code
HAC Reduction Program fiscal_year 2,026 fiscal_year
HAC Reduction Program measures — cauti — sir 0.59 measures.cauti.sir
HAC Reduction Program measures — cdi — sir 0.50 measures.cdi.sir
HAC Reduction Program measures — clabsi — sir 1.62 measures.clabsi.sir
HAC Reduction Program measures — mrsa — sir 1.08 measures.mrsa.sir
HAC Reduction Program measures — ssi — sir 0.80 measures.ssi.sir
HAC Reduction Program payment_reduction Yes payment_reduction
HAC Reduction Program total_hac_score 0.46 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 0.89 Value
Readmissions (HRRP) COPD — Excess readmission ratio 0.97 0.9969 p23 READM-30-COPD-HRRP.excess_readmission_ratio
Readmissions (HRRP) COPD — Expected readmission rate 16.7% READM-30-COPD-HRRP.expected_readmission_rate
Readmissions (HRRP) COPD — Number of discharges 107 READM-30-COPD-HRRP.num_discharges
Readmissions (HRRP) COPD — Number of readmissions 15 READM-30-COPD-HRRP.num_readmissions
Readmissions (HRRP) COPD — Predicted readmission rate 16.2% READM-30-COPD-HRRP.predicted_readmission_rate
Readmissions (HRRP) Heart Failure — Excess readmission ratio 1.06 0.9983 p83 READM-30-HF-HRRP.excess_readmission_ratio
Readmissions (HRRP) Heart Failure — Expected readmission rate 18.2% READM-30-HF-HRRP.expected_readmission_rate
Readmissions (HRRP) Heart Failure — Number of discharges 536 READM-30-HF-HRRP.num_discharges
Readmissions (HRRP) Heart Failure — Number of readmissions 108 READM-30-HF-HRRP.num_readmissions
Readmissions (HRRP) Heart Failure — Predicted readmission rate 19.3% READM-30-HF-HRRP.predicted_readmission_rate
Readmissions (HRRP) Hip/Knee Replacement — Excess readmission ratio 0.96 0.9916 p40 READM-30-HIP-KNEE-HRRP.excess_readmission_ratio
Readmissions (HRRP) Hip/Knee Replacement — Expected readmission rate 4.7% READM-30-HIP-KNEE-HRRP.expected_readmission_rate
Readmissions (HRRP) Hip/Knee Replacement — Predicted readmission rate 4.5% READM-30-HIP-KNEE-HRRP.predicted_readmission_rate
Readmissions (HRRP) Pneumonia — Excess readmission ratio 1.10 0.9955 p92 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 14.5% READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Number of discharges 706 READM-30-PN-HRRP.num_discharges
Readmissions (HRRP) Pneumonia — Number of readmissions 119 READM-30-PN-HRRP.num_readmissions
Readmissions (HRRP) Pneumonia — Predicted readmission rate 15.9% READM-30-PN-HRRP.predicted_readmission_rate
Value-Based Purchasing Clinical Outcomes 11.88 5.00 p88 clinical_outcomes_score
Value-Based Purchasing Efficiency & Cost Reduction 15.00 2.50 p88 efficiency_score
Value-Based Purchasing Person & Community Engagement 8.75 8.75 p49 person_community_score
Value-Based Purchasing Safety 5.00 10.00 p12 safety_score
Value-Based Purchasing Total Performance Score 40.63 29.50 p81 total_performance_score
Methodology

Full methodology →