Hospital

MCLAREN BAY REGION

CCN: 230041 · BAY CITY, MI 48708 · BAY County

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

Overview

Address
1900 COLUMBUS AVE, BAY CITY, MI 48708
Phone
(989) 894-9510
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 7 of 7 measures reported
7
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 11 of 11 measures reported
7
4
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 12 of 12 measures reported
12 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) 350 discharges
1.1073 p94
Heart Failure 507 discharges
1.0889 p90
Pneumonia 301 discharges
1.0066 p57
COPD 212 discharges
1.0750 p93
Hip/Knee Replacement 148 discharges
1.1646 p85
CABG Surgery 103 discharges
1.3880 p99
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: 1.3880
Value-Based Purchasing
—
HAC Reduction
No Reduction
HAC Score: -0.4804

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 4.10 No Different Than the National Rate 162
Hybrid_HWM 4.10 No Different Than the National Rate 1,346
MORT_30_AMI 11.90 No Different Than the National Rate 342
MORT_30_CABG 2.60 No Different Than the National Rate 105
MORT_30_COPD 8.70 No Different Than the National Rate 186
MORT_30_HF 10.30 No Different Than the National Rate 437
MORT_30_PN 17.00 No Different Than the National Rate 294
MORT_30_STK 14.00 No Different Than the National Rate 133
PSI_03 0.34 No Different Than the National Rate 4,829
PSI_04 161.41 No Different Than the National Rate 58
PSI_06 0.23 No Different Than the National Rate 5,636
PSI_08 0.26 No Different Than the National Rate 5,789
PSI_09 2.27 No Different Than the National Rate 1,559
PSI_10 1.78 No Different Than the National Rate 585
PSI_11 10.08 No Different Than the National Rate 596
PSI_12 3.18 No Different Than the National Rate 1,586
PSI_13 5.39 No Different Than the National Rate 587
PSI_14 1.66 No Different Than the National Rate 196
PSI_15 1.38 No Different Than the National Rate 859
PSI_90 0.94 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 76% —
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 5% —
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 — 3
H_NURSE_RESPECT_A_P: Nurses "always" treated them with courtesy and respect 84% —
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 13% —
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 73% —
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 5% —
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 22% —
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 6% —
H_NURSE_EXPLAIN_U_P: Nurses "usually" explained things so they could understand 23% —
H_COMP_2_A_P: Doctors "always" communicated well 74% —
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 7% —
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 — 2
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 5% —
H_DOCTOR_RESPECT_U_P: Doctors "usually" treated them with courtesy and respect 13% —
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 73% —
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 7% —
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 20% —
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 8% —
H_DOCTOR_EXPLAIN_U_P: Doctors "usually" explained things so they could understand 26% —
H_COMP_5_A_P: Staff "always" explained 55% —
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 23% —
H_COMP_5_U_P: Staff "usually" explained 22% —
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 70% —
H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications 8% —
H_MED_FOR_U_P: Staff "usually" explained new medications 22% —
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 41% —
H_SIDE_EFFECTS_SN_P: Staff "sometimes" or "never" explained possible side effects 37% —
H_SIDE_EFFECTS_U_P: Staff "usually" explained possible side effects 22% —
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 53% —
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 19% —
H_CLEAN_HSP_U_P: Room was "usually" clean 28% —
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 47% —
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 16% —
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) 15% —
H_HSP_RATING_7_8: Patients who gave a rating of "7" or "8" (medium) 31% —
H_HSP_RATING_9_10: Patients who gave a rating of "9" or "10" (high) 54% —
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) 9% —
H_RECMND_DY: "YES", patients would definitely recommend the hospital 49% —
H_RECMND_PY: "YES", patients would probably recommend the hospital 42% —
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 N/A No Different than National Benchmark
HAI_1_CIUPPER 1.221 No Different than National Benchmark
HAI_1_DOPC 2544.000 No Different than National Benchmark
HAI_1_ELIGCASES 2.454 No Different than National Benchmark
HAI_1_NUMERATOR 0.000 No Different than National Benchmark
HAI_1_SIR 0.000 No Different than National Benchmark
HAI_2_CILOWER N/A Better than the National Benchmark
HAI_2_CIUPPER 0.666 Better than the National Benchmark
HAI_2_DOPC 4558.000 Better than the National Benchmark
HAI_2_ELIGCASES 4.497 Better than the National Benchmark
HAI_2_NUMERATOR 0.000 Better than the National Benchmark
HAI_2_SIR 0.000 Better than the National Benchmark
HAI_3_CILOWER N/A No Different than National Benchmark
HAI_3_CIUPPER 1.734 No Different than National Benchmark
HAI_3_DOPC 67.000 No Different than National Benchmark
HAI_3_ELIGCASES 1.728 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 17.000 —
HAI_4_ELIGCASES 0.141 —
HAI_4_NUMERATOR 0.000 —
HAI_4_SIR — —
HAI_5_CILOWER 0.028 No Different than National Benchmark
HAI_5_CIUPPER 2.785 No Different than National Benchmark
HAI_5_DOPC 46451.000 No Different than National Benchmark
HAI_5_ELIGCASES 1.771 No Different than National Benchmark
HAI_5_NUMERATOR 1.000 No Different than National Benchmark
HAI_5_SIR 0.565 No Different than National Benchmark
HAI_6_CILOWER 0.194 Better than the National Benchmark
HAI_6_CIUPPER 0.791 Better than the National Benchmark
HAI_6_DOPC 45808.000 Better than the National Benchmark
HAI_6_ELIGCASES 19.195 Better than the National Benchmark
HAI_6_NUMERATOR 8.000 Better than the National Benchmark
HAI_6_SIR 0.417 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 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 57.0 Healthcare Personnel Vaccination
OP_18a 184.0 Emergency Department
OP_18b 175.0 Emergency Department
OP_18c 339.0 Emergency Department
OP_18d 233.0 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 13.0 Electronic Clinical Quality Measure
SEP_1 54.0 Sepsis Care
SEP_SH_3HR 66.0 Sepsis Care
SEP_SH_6HR 100.0 Sepsis Care
SEV_SEP_3HR 71.0 Sepsis Care
SEV_SEP_6HR 91.0 Sepsis Care
STK_02 91.0 Electronic Clinical Quality Measure
STK_03 60.0 Electronic Clinical Quality Measure
STK_05 90.0 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 35.30 More Days Than Average per 100 Discharges
EDAC_30_HF 19.50 More Days Than Average per 100 Discharges
EDAC_30_PN 26.50 More Days Than Average per 100 Discharges
Hybrid_HWR 16.30 Worse Than the National Rate
OP_32 14.00 No Different Than the National Rate
OP_35_ADM 12.40 No Different Than the National Rate
OP_35_ED 4.50 No Different Than the National Rate
OP_36 1.00 No Different than expected
READM_30_AMI 14.80 No Different Than the National Rate
READM_30_CABG 14.60 Worse Than the National Rate
READM_30_COPD 19.80 No Different Than the National Rate
READM_30_HF 21.40 No Different Than the National Rate
READM_30_HIP_KNEE 5.60 No Different Than the National Rate
READM_30_PN 16.30 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 0.28 — metrics.cost_to_charge_ratio
Cost Report Employees per Bed 5.81 — metrics.employees_per_bed
Cost Report fiscal_year 2,023 — fiscal_year
Cost Report Fund Balance ($) $308,775,145 — metrics.fund_balance
Cost Report Net Income ($) $-55,957,993 — metrics.net_income
Cost Report Net Patient Revenue ($) $295,578,874 — metrics.net_patient_revenue
Cost Report Operating Margin (%) -10.4% — metrics.operating_margin
Cost Report Total Assets ($) $406,345,219 — metrics.total_assets
Cost Report Total Costs ($) $289,749,839 — metrics.total_costs
Cost Report Total Liabilities ($) $97,570,074 — metrics.total_liabilities
Cost Report Total Margin (%) -20.7% — metrics.total_margin
Cost Report Uncompensated Care (%) 1.9% — metrics.uncompensated_care_pct
General Information Address 1900 COLUMBUS AVE — Address
General Information City/Town BAY CITY — City/Town
General Information Count of Facility MORT Measures 7 — 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 11 — 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 12 — 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 7 — 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 7 — Count of READM Measures No Different
General Information Count of READM Measures Worse 4 — 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 BAY — County/Parish
General Information Emergency Services Yes — Emergency Services
General Information Facility ID 230041 — Facility ID
General Information Facility Name MCLAREN BAY REGION — 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 — — 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 MI — State
General Information TE Group Footnote — — TE Group Footnote
General Information TE Group Measure Count 12 — TE Group Measure Count
General Information Telephone Number (989) 894-9510 — Telephone Number
General Information ZIP Code 48708 — ZIP Code
HAC Reduction Program fiscal_year 2,026 — fiscal_year
HAC Reduction Program measures — cauti — sir 0.94 — measures.cauti.sir
HAC Reduction Program measures — cdi — sir 0.34 — measures.cdi.sir
HAC Reduction Program measures — clabsi — sir 0.22 — measures.clabsi.sir
HAC Reduction Program measures — mrsa — sir 0.23 — measures.mrsa.sir
HAC Reduction Program measures — ssi — sir 0 — measures.ssi.sir
HAC Reduction Program payment_reduction No — payment_reduction
HAC Reduction Program total_hac_score -0.48 — 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 1.11 0.9995 p94 READM-30-AMI-HRRP.excess_readmission_ratio
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Expected readmission rate 14.4% — READM-30-AMI-HRRP.expected_readmission_rate
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of discharges 350 — READM-30-AMI-HRRP.num_discharges
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of readmissions 61 — READM-30-AMI-HRRP.num_readmissions
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Predicted readmission rate 15.9% — READM-30-AMI-HRRP.predicted_readmission_rate
Readmissions (HRRP) CABG Surgery — Excess readmission ratio 1.39 1.0000 p99 READM-30-CABG-HRRP.excess_readmission_ratio
Readmissions (HRRP) CABG Surgery — Expected readmission rate 11.2% — READM-30-CABG-HRRP.expected_readmission_rate
Readmissions (HRRP) CABG Surgery — Number of discharges 103 — READM-30-CABG-HRRP.num_discharges
Readmissions (HRRP) CABG Surgery — Number of readmissions 25 — READM-30-CABG-HRRP.num_readmissions
Readmissions (HRRP) CABG Surgery — Predicted readmission rate 15.6% — READM-30-CABG-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 19.9% — READM-30-COPD-HRRP.expected_readmission_rate
Readmissions (HRRP) COPD — Number of discharges 212 — READM-30-COPD-HRRP.num_discharges
Readmissions (HRRP) COPD — Number of readmissions 51 — READM-30-COPD-HRRP.num_readmissions
Readmissions (HRRP) COPD — Predicted readmission rate 21.4% — 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 20.1% — READM-30-HF-HRRP.expected_readmission_rate
Readmissions (HRRP) Heart Failure — Number of discharges 507 — READM-30-HF-HRRP.num_discharges
Readmissions (HRRP) Heart Failure — Number of readmissions 117 — READM-30-HF-HRRP.num_readmissions
Readmissions (HRRP) Heart Failure — Predicted readmission rate 21.8% — READM-30-HF-HRRP.predicted_readmission_rate
Readmissions (HRRP) Hip/Knee Replacement — Excess readmission ratio 1.16 0.9916 p85 READM-30-HIP-KNEE-HRRP.excess_readmission_ratio
Readmissions (HRRP) Hip/Knee Replacement — Expected readmission rate 5.9% — READM-30-HIP-KNEE-HRRP.expected_readmission_rate
Readmissions (HRRP) Hip/Knee Replacement — Number of discharges 148 — READM-30-HIP-KNEE-HRRP.num_discharges
Readmissions (HRRP) Hip/Knee Replacement — Number of readmissions 12 — READM-30-HIP-KNEE-HRRP.num_readmissions
Readmissions (HRRP) Hip/Knee Replacement — Predicted readmission rate 6.9% — READM-30-HIP-KNEE-HRRP.predicted_readmission_rate
Readmissions (HRRP) Pneumonia — Excess readmission ratio 1.01 0.9955 p57 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 17.0% — READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Number of discharges 301 — READM-30-PN-HRRP.num_discharges
Readmissions (HRRP) Pneumonia — Number of readmissions 52 — READM-30-PN-HRRP.num_readmissions
Readmissions (HRRP) Pneumonia — Predicted readmission rate 17.1% — READM-30-PN-HRRP.predicted_readmission_rate
Methodology

Full methodology →