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

Overview

Address
7601 SOUTHCREST PARKWAY, SOUTHAVEN, MS 38671
Phone
(662) 772-4000
Hospital Type
Acute Care
Ownership
For-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 6 of 8 measures reported
2
4
Better No different Worse
Healthcare-associated infections and patient safety indicators (PSI-90 composite).
Readmission 10 of 11 measures reported
7
3
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 11 of 12 measures reported
11 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) 139 discharges
0.9375 p15
Heart Failure 638 discharges
1.0634 p83
Pneumonia 735 discharges
1.1060 p93
COPD 203 discharges
1.0119 p62
Hip/Knee Replacement 0 discharges
— Not reported
CABG Surgery
0.9767 p40
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 below the national median, suggesting a negative payment adjustment.

15.7 p5
Total Performance Score
National median: 29.5
Clinical Outcomes 25% weight
6.5 p60
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
4.2 p9
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
5.0 p19
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
0.0 p0
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: 1.1060
Value-Based Purchasing
15.7 TPS
Below national median
HAC Reduction
Payment Reduced
HAC Score: 0.5171

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
Hybrid_HWM 3.30 Better Than the National Rate 1,986
MORT_30_AMI 12.10 No Different Than the National Rate 136
MORT_30_CABG 2.00 No Different Than the National Rate 103
MORT_30_COPD 8.40 No Different Than the National Rate 190
MORT_30_HF 11.10 No Different Than the National Rate 552
MORT_30_PN 17.50 No Different Than the National Rate 701
MORT_30_STK 12.40 No Different Than the National Rate 270
PSI_03 1.04 No Different Than the National Rate 7,732
PSI_04 161.40 No Different Than the National Rate 114
PSI_06 0.19 No Different Than the National Rate 8,677
PSI_08 0.30 No Different Than the National Rate 8,832
PSI_09 2.89 No Different Than the National Rate 1,224
PSI_10 2.16 No Different Than the National Rate 278
PSI_11 13.35 No Different Than the National Rate 286
PSI_12 5.52 Worse Than the National Rate 1,401
PSI_13 9.17 Worse Than the National Rate 288
PSI_14 1.87 No Different Than the National Rate 235
PSI_15 0.82 No Different Than the National Rate 1,335
PSI_90 1.47 Worse 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 77%
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 6%
H_COMP_1_U_P: Nurses "usually" communicated well 17%
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 4%
H_NURSE_RESPECT_U_P: Nurses "usually" treated them with courtesy and respect 12%
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 75%
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 6%
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 7%
H_NURSE_EXPLAIN_U_P: Nurses "usually" explained things so they could understand 22%
H_COMP_2_A_P: Doctors "always" communicated well 75%
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 7%
H_COMP_2_U_P: Doctors "usually" communicated well 18%
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 81%
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 14%
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 75%
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 9%
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 16%
H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand 68%
H_DOCTOR_EXPLAIN_SN_P: Doctors "sometimes" or "never" explained things so they could understand 9%
H_DOCTOR_EXPLAIN_U_P: Doctors "usually" explained things so they could understand 23%
H_COMP_5_A_P: Staff "always" explained 57%
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 24%
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 71%
H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications 13%
H_MED_FOR_U_P: Staff "usually" explained new medications 16%
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 44%
H_SIDE_EFFECTS_SN_P: Staff "sometimes" or "never" explained possible side effects 35%
H_SIDE_EFFECTS_U_P: Staff "usually" explained possible side effects 21%
H_COMP_6_N_P: No, staff "did not" give patients this information 17%
H_COMP_6_Y_P: Yes, staff "did" give patients this information 83%
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 17%
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms 83%
H_CLEAN_HSP_A_P: Room was "always" clean 54%
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 22%
H_CLEAN_HSP_U_P: Room was "usually" clean 24%
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 60%
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 9%
H_QUIET_HSP_U_P: "Usually" quiet at night 31%
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) 10%
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) 65%
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) 6%
H_RECMND_DY: "YES", patients would definitely recommend the hospital 68%
H_RECMND_PY: "YES", patients would probably recommend the hospital 26%
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 0.189 Better than the National Benchmark
HAI_1_CIUPPER 0.972 Better than the National Benchmark
HAI_1_DOPC 12527.000 Better than the National Benchmark
HAI_1_ELIGCASES 12.835 Better than the National Benchmark
HAI_1_NUMERATOR 6.000 Better than the National Benchmark
HAI_1_SIR 0.467 Better than the National Benchmark
HAI_2_CILOWER 0.088 Better than the National Benchmark
HAI_2_CIUPPER 0.946 Better than the National Benchmark
HAI_2_DOPC 7104.000 Better than the National Benchmark
HAI_2_ELIGCASES 8.627 Better than the National Benchmark
HAI_2_NUMERATOR 3.000 Better than the National Benchmark
HAI_2_SIR 0.348 Better than the National Benchmark
HAI_3_CILOWER 0.382 No Different than National Benchmark
HAI_3_CIUPPER 2.900 No Different than National Benchmark
HAI_3_DOPC 124.000 No Different than National Benchmark
HAI_3_ELIGCASES 3.327 No Different than National Benchmark
HAI_3_NUMERATOR 4.000 No Different than National Benchmark
HAI_3_SIR 1.202 No Different than National Benchmark
HAI_4_CILOWER
HAI_4_CIUPPER
HAI_4_DOPC 41.000
HAI_4_ELIGCASES 0.359
HAI_4_NUMERATOR 0.000
HAI_4_SIR
HAI_5_CILOWER 0.355 No Different than National Benchmark
HAI_5_CIUPPER 1.822 No Different than National Benchmark
HAI_5_DOPC 88929.000 No Different than National Benchmark
HAI_5_ELIGCASES 6.849 No Different than National Benchmark
HAI_5_NUMERATOR 6.000 No Different than National Benchmark
HAI_5_SIR 0.876 No Different than National Benchmark
HAI_6_CILOWER 0.183 Better than the National Benchmark
HAI_6_CIUPPER 0.548 Better than the National Benchmark
HAI_6_DOPC 85762.000 Better than the National Benchmark
HAI_6_ELIGCASES 39.566 Better than the National Benchmark
HAI_6_NUMERATOR 13.000 Better than the National Benchmark
HAI_6_SIR 0.329 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 very high 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 10.0 Electronic Clinical Quality Measure
HH_HYPO 3.0 Electronic Clinical Quality Measure
HH_ORAE Electronic Clinical Quality Measure
IMM_3 92.0 Healthcare Personnel Vaccination
OP_18a 264.0 Emergency Department
OP_18b 254.0 Emergency Department
OP_18c 355.0 Emergency Department
OP_18d 381.0 Emergency Department
OP_22 2.0 Emergency Department
OP_23 93.0 Emergency Department
OP_29 98.0 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 57.0 Sepsis Care
SEP_SH_3HR 72.0 Sepsis Care
SEP_SH_6HR 86.0 Sepsis Care
SEV_SEP_3HR 74.0 Sepsis Care
SEV_SEP_6HR 91.0 Sepsis Care
STK_02 Electronic Clinical Quality Measure
STK_03 Electronic Clinical Quality Measure
STK_05 Electronic Clinical Quality Measure
VTE_1 97.0 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 2.50 Average Days per 100 Discharges
EDAC_30_HF 38.20 More Days Than Average per 100 Discharges
EDAC_30_PN 37.10 More Days Than Average per 100 Discharges
Hybrid_HWR 15.70 No Different Than the National Rate
OP_32 13.30 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 12.70 No Different Than the National Rate
READM_30_CABG 10.30 No Different Than the National Rate
READM_30_COPD 18.50 No Different Than the National Rate
READM_30_HF 21.00 No Different Than the National Rate
READM_30_HIP_KNEE
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
1.00

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 91 rows
Source Metric Value National Median Pctl. Raw key
Cost Report Cost-to-Charge Ratio 0.18 metrics.cost_to_charge_ratio
Cost Report Employees per Bed 4.89 metrics.employees_per_bed
Cost Report fiscal_year 2,023 fiscal_year
Cost Report Fund Balance ($) $224,342,942 metrics.fund_balance
Cost Report Net Income ($) $-3,038,592 metrics.net_income
Cost Report Net Patient Revenue ($) $316,449,190 metrics.net_patient_revenue
Cost Report Operating Margin (%) -1.9% metrics.operating_margin
Cost Report Total Assets ($) $197,347,713 metrics.total_assets
Cost Report Total Costs ($) $293,398,667 metrics.total_costs
Cost Report Total Liabilities ($) $-26,995,229 metrics.total_liabilities
Cost Report Total Margin (%) -0.9% metrics.total_margin
Cost Report Uncompensated Care (%) 9.9% metrics.uncompensated_care_pct
General Information Address 7601 SOUTHCREST PARKWAY Address
General Information City/Town SOUTHAVEN 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 10 Count of Facility READM Measures
General Information Count of Facility Safety Measures 6 Count of Facility Safety Measures
General Information Count of Facility TE Measures 11 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 3 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 4 Count of Safety Measures No Different
General Information Count of Safety Measures Worse 0 Count of Safety Measures Worse
General Information County/Parish DE SOTO County/Parish
General Information Emergency Services Yes Emergency Services
General Information Facility ID 250141 Facility ID
General Information Facility Name BAPTIST MEMORIAL HOSPITAL DESOTO 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 Proprietary 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 MS State
General Information TE Group Footnote TE Group Footnote
General Information TE Group Measure Count 12 TE Group Measure Count
General Information Telephone Number (662) 772-4000 Telephone Number
General Information ZIP Code 38671 ZIP Code
HAC Reduction Program fiscal_year 2,026 fiscal_year
HAC Reduction Program measures — cauti — sir 0.54 measures.cauti.sir
HAC Reduction Program measures — cdi — sir 0.34 measures.cdi.sir
HAC Reduction Program measures — clabsi — sir 0.71 measures.clabsi.sir
HAC Reduction Program measures — mrsa — sir 0.56 measures.mrsa.sir
HAC Reduction Program measures — ssi — sir 1.30 measures.ssi.sir
HAC Reduction Program payment_reduction Yes payment_reduction
HAC Reduction Program total_hac_score 0.52 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 1.00 Value
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Excess readmission ratio 0.94 0.9995 p15 READM-30-AMI-HRRP.excess_readmission_ratio
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Expected readmission rate 13.2% READM-30-AMI-HRRP.expected_readmission_rate
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of discharges 139 READM-30-AMI-HRRP.num_discharges
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of readmissions 14 READM-30-AMI-HRRP.num_readmissions
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Predicted readmission rate 12.4% READM-30-AMI-HRRP.predicted_readmission_rate
Readmissions (HRRP) CABG Surgery — Excess readmission ratio 0.98 1.0000 p40 READM-30-CABG-HRRP.excess_readmission_ratio
Readmissions (HRRP) CABG Surgery — Expected readmission rate 10.9% READM-30-CABG-HRRP.expected_readmission_rate
Readmissions (HRRP) CABG Surgery — Predicted readmission rate 10.6% READM-30-CABG-HRRP.predicted_readmission_rate
Readmissions (HRRP) COPD — Excess readmission ratio 1.01 0.9969 p62 READM-30-COPD-HRRP.excess_readmission_ratio
Readmissions (HRRP) COPD — Expected readmission rate 17.1% READM-30-COPD-HRRP.expected_readmission_rate
Readmissions (HRRP) COPD — Number of discharges 203 READM-30-COPD-HRRP.num_discharges
Readmissions (HRRP) COPD — Number of readmissions 36 READM-30-COPD-HRRP.num_readmissions
Readmissions (HRRP) COPD — Predicted readmission rate 17.3% 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 20.4% READM-30-HF-HRRP.expected_readmission_rate
Readmissions (HRRP) Heart Failure — Number of discharges 638 READM-30-HF-HRRP.num_discharges
Readmissions (HRRP) Heart Failure — Number of readmissions 143 READM-30-HF-HRRP.num_readmissions
Readmissions (HRRP) Heart Failure — Predicted readmission rate 21.7% READM-30-HF-HRRP.predicted_readmission_rate
Readmissions (HRRP) Hip/Knee Replacement — Number of discharges 0 READM-30-HIP-KNEE-HRRP.num_discharges
Readmissions (HRRP) Pneumonia — Excess readmission ratio 1.11 0.9955 p93 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 16.7% READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Number of discharges 735 READM-30-PN-HRRP.num_discharges
Readmissions (HRRP) Pneumonia — Number of readmissions 143 READM-30-PN-HRRP.num_readmissions
Readmissions (HRRP) Pneumonia — Predicted readmission rate 18.5% READM-30-PN-HRRP.predicted_readmission_rate
Value-Based Purchasing Clinical Outcomes 6.50 5.00 p60 clinical_outcomes_score
Value-Based Purchasing Efficiency & Cost Reduction 0.00 2.50 p0 efficiency_score
Value-Based Purchasing Person & Community Engagement 5.00 8.75 p19 person_community_score
Value-Based Purchasing Safety 4.17 10.00 p9 safety_score
Value-Based Purchasing Total Performance Score 15.67 29.50 p5 total_performance_score
Methodology

Full methodology →