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Overview

Address
502 EAST SECOND STREET, DULUTH, MN 55805
Phone
(218) 786-2652
Hospital Type
Acute Care
Ownership
Non-Profit
Emergency Services
No
Birthing Friendly
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.

Safety of Care 4 of 8 measures reported
4
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.
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 4 of 12 measures reported
4 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 does not have excess readmissions triggering HRRP penalties.
Acute Myocardial Infarction (Heart Attack)
— Not reported
Heart Failure
— Not reported
Pneumonia
— Not reported
COPD
— Not reported
Hip/Knee Replacement
— Not reported
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)
Not Penalized
Value-Based Purchasing
HAC Reduction
No Reduction
HAC Score: -0.3317

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 4.10 No Different Than the National Rate 86
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 Number of Cases Too Small
MORT_30_STK Number of Cases Too Small
PSI_03 0.46 No Different Than the National Rate 719
PSI_04
PSI_06 0.20 No Different Than the National Rate 910
PSI_08 0.35 No Different Than the National Rate 938
PSI_09 2.27 No Different Than the National Rate 84
PSI_10 1.64 No Different Than the National Rate 55
PSI_11 8.79 No Different Than the National Rate 51
PSI_12 3.40 No Different Than the National Rate 86
PSI_13 5.14 No Different Than the National Rate 47
PSI_14 Number of Cases Too Small
PSI_15 1.05 No Different Than the National Rate 72
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 83%
H_NURSE_RESPECT_SN_P: Nurses "sometimes" or "never" treated them with courtesy and respect 4%
H_NURSE_RESPECT_U_P: Nurses "usually" treated them with courtesy and respect 13%
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 76%
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 6%
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 18%
H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand 70%
H_NURSE_EXPLAIN_SN_P: Nurses "sometimes" or "never" explained things so they could understand 7%
H_NURSE_EXPLAIN_U_P: Nurses "usually" explained things so they could understand 23%
H_COMP_2_A_P: Doctors "always" communicated well 76%
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 5%
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 83%
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 14%
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 70%
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 24%
H_COMP_5_A_P: Staff "always" explained 59%
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 22%
H_COMP_5_U_P: Staff "usually" explained 19%
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 13%
H_MED_FOR_U_P: Staff "usually" explained new medications 13%
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 31%
H_SIDE_EFFECTS_U_P: Staff "usually" explained possible side effects 26%
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 11%
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge 89%
H_SYMPTOMS_N_P: No, staff "did not" give patients information about possible symptoms 16%
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms 84%
H_CLEAN_HSP_A_P: Room was "always" clean 66%
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 12%
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 60%
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 8%
H_QUIET_HSP_U_P: "Usually" quiet at night 32%
H_QUIET_LINEAR_SCORE: Quietness - linear mean score
H_QUIET_STAR_RATING: Quietness - star rating 3
H_HSP_RATING_0_6: Patients who gave a rating of "6" or lower (low) 14%
H_HSP_RATING_7_8: Patients who gave a rating of "7" or "8" (medium) 25%
H_HSP_RATING_9_10: Patients who gave a rating of "9" or "10" (high) 61%
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) 8%
H_RECMND_DY: "YES", patients would definitely recommend the hospital 63%
H_RECMND_PY: "YES", patients would probably recommend the hospital 29%
H_RECMND_LINEAR_SCORE: Recommend hospital - linear mean score
H_RECMND_STAR_RATING: Recommend hospital - star rating 3
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 518.000
HAI_1_ELIGCASES 0.439
HAI_1_NUMERATOR 0.000
HAI_1_SIR
HAI_2_CILOWER
HAI_2_CIUPPER
HAI_2_DOPC 535.000
HAI_2_ELIGCASES 0.509
HAI_2_NUMERATOR 0.000
HAI_2_SIR
HAI_3_CILOWER
HAI_3_CIUPPER
HAI_3_DOPC 27.000
HAI_3_ELIGCASES 0.687
HAI_3_NUMERATOR 0.000
HAI_3_SIR
HAI_4_CILOWER
HAI_4_CIUPPER
HAI_4_DOPC 41.000
HAI_4_ELIGCASES 0.365
HAI_4_NUMERATOR 0.000
HAI_4_SIR
HAI_5_CILOWER
HAI_5_CIUPPER
HAI_5_DOPC 29693.000
HAI_5_ELIGCASES 0.996
HAI_5_NUMERATOR 0.000
HAI_5_SIR
HAI_6_CILOWER N/A Better than the National Benchmark
HAI_6_CIUPPER 0.401 Better than the National Benchmark
HAI_6_DOPC 29693.000 Better than the National Benchmark
HAI_6_ELIGCASES 7.475 Better than the National Benchmark
HAI_6_NUMERATOR 0.000 Better than the National Benchmark
HAI_6_SIR 0.000 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 Electronic Clinical Quality Measure
HH_HYPO Electronic Clinical Quality Measure
HH_ORAE Electronic Clinical Quality Measure
IMM_3 59.0 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 14.0 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 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 Number of Cases Too Small
EDAC_30_PN Number of Cases Too Small
Hybrid_HWR 14.70 No Different Than the National Rate
OP_32
OP_35_ADM 12.60 No Different Than the National Rate
OP_35_ED 6.70 No Different Than the National Rate
OP_36 0.90 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 Number of Cases Too Small

Medicare Spending Per Beneficiary

MSPB ratio: values > 1.0 mean this hospital's episode spending is higher than the national median hospital.

Value
0.96

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 0.61 metrics.cost_to_charge_ratio
Cost Report Employees per Bed 13.62 metrics.employees_per_bed
Cost Report fiscal_year 2,024 fiscal_year
Cost Report Fund Balance ($) $185,386,502 metrics.fund_balance
Cost Report Net Income ($) $-2,175,654 metrics.net_income
Cost Report Net Patient Revenue ($) $546,030,110 metrics.net_patient_revenue
Cost Report Operating Margin (%) -12.0% metrics.operating_margin
Cost Report Total Assets ($) $883,196,335 metrics.total_assets
Cost Report Total Costs ($) $368,238,950 metrics.total_costs
Cost Report Total Liabilities ($) $697,809,833 metrics.total_liabilities
Cost Report Total Margin (%) -0.4% metrics.total_margin
Cost Report Uncompensated Care (%) 0.6% metrics.uncompensated_care_pct
General Information Address 502 EAST SECOND STREET Address
General Information City/Town DULUTH City/Town
General Information Count of Facility MORT Measures Not Available 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 5 Count of Facility READM Measures
General Information Count of Facility Safety Measures 4 Count of Facility Safety Measures
General Information Count of Facility TE Measures 4 Count of Facility TE Measures
General Information Count of MORT Measures Better Not Available Count of MORT Measures Better
General Information Count of MORT Measures No Different Not Available Count of MORT Measures No Different
General Information Count of MORT Measures Worse Not Available 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 4 Count of Safety Measures No Different
General Information Count of Safety Measures Worse 0 Count of Safety Measures Worse
General Information County/Parish ST. LOUIS County/Parish
General Information Emergency Services No Emergency Services
General Information Facility ID 240019 Facility ID
General Information Facility Name ESSENTIA HEALTH DULUTH 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 Y Meets criteria for birthing friendly designation
General Information MORT Group Footnote 5 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 MN State
General Information TE Group Footnote TE Group Footnote
General Information TE Group Measure Count 12 TE Group Measure Count
General Information Telephone Number (218) 786-2652 Telephone Number
General Information ZIP Code 55805 ZIP Code
HAC Reduction Program fiscal_year 2,026 fiscal_year
HAC Reduction Program measures — cauti — sir 0.69 measures.cauti.sir
HAC Reduction Program measures — cdi — sir 0.41 measures.cdi.sir
HAC Reduction Program measures — clabsi — sir 0.47 measures.clabsi.sir
HAC Reduction Program measures — mrsa — sir 0 measures.mrsa.sir
HAC Reduction Program payment_reduction No payment_reduction
HAC Reduction Program total_hac_score -0.33 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 0.96 Value
Methodology

Full methodology →