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

Overview

Address
160 NORTH MIDLAND AVENUE, NYACK, NY 10960
Phone
(845) 348-2000
Hospital Type
Acute Care
Ownership
Non-Profit (Other)
Emergency Services
No
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 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
1
6
Better No different Worse
Healthcare-associated infections and patient safety indicators (PSI-90 composite).
Readmission 10 of 11 measures reported
8
2
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) 100 discharges
1.0347 p71
Heart Failure 334 discharges
0.9452 p17
Pneumonia 752 discharges
1.1390 p96
COPD 130 discharges
1.0591 p89
Hip/Knee Replacement 140 discharges
1.2247 p91
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 below the national median, suggesting a negative payment adjustment.

23.8 p29
Total Performance Score
National median: 29.5
Clinical Outcomes 25% weight
9.5 p79
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
8.8 p38
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
5.5 p23
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: 1.2247
Value-Based Purchasing
23.8 TPS
Below national median
HAC Reduction
No Reduction
HAC Score: 0.0169

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 3.00 No Different Than the National Rate 145
Hybrid_HWM 4.00 No Different Than the National Rate 1,450
MORT_30_AMI 10.80 No Different Than the National Rate 119
MORT_30_CABG
MORT_30_COPD 8.70 No Different Than the National Rate 111
MORT_30_HF 9.70 No Different Than the National Rate 310
MORT_30_PN 15.00 No Different Than the National Rate 757
MORT_30_STK 12.90 No Different Than the National Rate 151
PSI_03 0.34 No Different Than the National Rate 5,496
PSI_04 187.07 No Different Than the National Rate 42
PSI_06 0.16 No Different Than the National Rate 6,177
PSI_08 0.29 No Different Than the National Rate 6,172
PSI_09 2.35 No Different Than the National Rate 775
PSI_10 1.62 No Different Than the National Rate 216
PSI_11 7.38 No Different Than the National Rate 222
PSI_12 3.18 No Different Than the National Rate 807
PSI_13 4.67 No Different Than the National Rate 209
PSI_14 1.64 No Different Than the National Rate 194
PSI_15 0.88 No Different Than the National Rate 974
PSI_90 0.81 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 74%
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 6%
H_COMP_1_U_P: Nurses "usually" communicated well 20%
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 81%
H_NURSE_RESPECT_SN_P: Nurses "sometimes" or "never" treated them with courtesy and respect 5%
H_NURSE_RESPECT_U_P: Nurses "usually" treated them with courtesy and respect 14%
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 71%
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 6%
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 23%
H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand 69%
H_NURSE_EXPLAIN_SN_P: Nurses "sometimes" or "never" explained things so they could understand 8%
H_NURSE_EXPLAIN_U_P: Nurses "usually" explained things so they could understand 23%
H_COMP_2_A_P: Doctors "always" communicated well 71%
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 8%
H_COMP_2_U_P: Doctors "usually" communicated well 21%
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 78%
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 17%
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 70%
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 9%
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 21%
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 10%
H_DOCTOR_EXPLAIN_U_P: Doctors "usually" explained things so they could understand 24%
H_COMP_5_A_P: Staff "always" explained 53%
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 28%
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 14%
H_MED_FOR_U_P: Staff "usually" explained new medications 15%
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 35%
H_SIDE_EFFECTS_SN_P: Staff "sometimes" or "never" explained possible side effects 41%
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 22%
H_COMP_6_Y_P: Yes, staff "did" give patients this information 78%
H_COMP_6_LINEAR_SCORE: Discharge information - linear mean score
H_COMP_6_STAR_RATING: Discharge information - star rating 1
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 21%
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms 79%
H_CLEAN_HSP_A_P: Room was "always" clean 65%
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 11%
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 3
H_QUIET_HSP_A_P: "Always" quiet at night 47%
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 19%
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) 13%
H_HSP_RATING_7_8: Patients who gave a rating of "7" or "8" (medium) 30%
H_HSP_RATING_9_10: Patients who gave a rating of "9" or "10" (high) 57%
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 57%
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 0.079 No Different than National Benchmark
HAI_1_CIUPPER 1.561 No Different than National Benchmark
HAI_1_DOPC 5363.000 No Different than National Benchmark
HAI_1_ELIGCASES 4.232 No Different than National Benchmark
HAI_1_NUMERATOR 2.000 No Different than National Benchmark
HAI_1_SIR 0.473 No Different than National Benchmark
HAI_2_CILOWER 0.158 No Different than National Benchmark
HAI_2_CIUPPER 1.691 No Different than National Benchmark
HAI_2_DOPC 5390.000 No Different than National Benchmark
HAI_2_ELIGCASES 4.829 No Different than National Benchmark
HAI_2_NUMERATOR 3.000 No Different than National Benchmark
HAI_2_SIR 0.621 No Different than National Benchmark
HAI_3_CILOWER N/A No Different than National Benchmark
HAI_3_CIUPPER 1.681 No Different than National Benchmark
HAI_3_DOPC 78.000 No Different than National Benchmark
HAI_3_ELIGCASES 1.782 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 29.000
HAI_4_ELIGCASES 0.213
HAI_4_NUMERATOR 0.000
HAI_4_SIR
HAI_5_CILOWER 0.072 No Different than National Benchmark
HAI_5_CIUPPER 1.428 No Different than National Benchmark
HAI_5_DOPC 67405.000 No Different than National Benchmark
HAI_5_ELIGCASES 4.626 No Different than National Benchmark
HAI_5_NUMERATOR 2.000 No Different than National Benchmark
HAI_5_SIR 0.432 No Different than National Benchmark
HAI_6_CILOWER 0.060 Better than the National Benchmark
HAI_6_CIUPPER 0.308 Better than the National Benchmark
HAI_6_DOPC 63996.000 Better than the National Benchmark
HAI_6_ELIGCASES 40.561 Better than the National Benchmark
HAI_6_NUMERATOR 6.000 Better than the National Benchmark
HAI_6_SIR 0.148 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 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 Electronic Clinical Quality Measure
HH_HYPO Electronic Clinical Quality Measure
HH_ORAE Electronic Clinical Quality Measure
IMM_3 69.0 Healthcare Personnel Vaccination
OP_18a 234.0 Emergency Department
OP_18b 231.0 Emergency Department
OP_18c 249.0 Emergency Department
OP_18d 438.0 Emergency Department
OP_22 3.0 Emergency Department
OP_23 58.0 Emergency Department
OP_29 99.0 Colonoscopy care
OP_31 Cataract surgery outcome
OP_40 Electronic Clinical Quality Measure
SAFE_USE_OF_OPIOIDS 16.0 Electronic Clinical Quality Measure
SEP_1 67.0 Sepsis Care
SEP_SH_3HR 83.0 Sepsis Care
SEP_SH_6HR 89.0 Sepsis Care
SEV_SEP_3HR 85.0 Sepsis Care
SEV_SEP_6HR 85.0 Sepsis Care
STK_02 98.0 Electronic Clinical Quality Measure
STK_03 Electronic Clinical Quality Measure
STK_05 Electronic Clinical Quality Measure
VTE_1 99.0 Electronic Clinical Quality Measure
VTE_2 100.0 Electronic Clinical Quality Measure

Unplanned Hospital Visits

Readmission and ED return rates within 30 days of discharge.

Measure Score vs. National
EDAC_30_AMI 26.90 More Days Than Average per 100 Discharges
EDAC_30_HF 4.10 Average Days per 100 Discharges
EDAC_30_PN 64.40 More Days Than Average per 100 Discharges
Hybrid_HWR 16.00 No Different Than the National Rate
OP_32 12.90 No Different Than the National Rate
OP_35_ADM 12.00 No Different Than the National Rate
OP_35_ED 5.40 No Different Than the National Rate
OP_36 0.90 No Different than expected
READM_30_AMI 14.00 No Different Than the National Rate
READM_30_CABG
READM_30_COPD 19.50 No Different Than the National Rate
READM_30_HF 18.60 No Different Than the National Rate
READM_30_HIP_KNEE 5.90 No Different Than the National Rate
READM_30_PN 18.20 Worse 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
1.08

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 93 rows
Source Metric Value National Median Pctl. Raw key
Cost Report Cost-to-Charge Ratio 0.19 metrics.cost_to_charge_ratio
Cost Report Current Ratio 1.19 metrics.current_ratio
Cost Report Employees per Bed 5.51 metrics.employees_per_bed
Cost Report fiscal_year 2,023 fiscal_year
Cost Report Fund Balance ($) $95,354,523 metrics.fund_balance
Cost Report Net Income ($) $-3,717,321 metrics.net_income
Cost Report Net Patient Revenue ($) $342,019,564 metrics.net_patient_revenue
Cost Report Operating Margin (%) -3.1% metrics.operating_margin
Cost Report Total Assets ($) $308,647,077 metrics.total_assets
Cost Report Total Costs ($) $335,939,853 metrics.total_costs
Cost Report Total Liabilities ($) $213,292,554 metrics.total_liabilities
Cost Report Total Margin (%) -1.1% metrics.total_margin
Cost Report Uncompensated Care (%) 3.0% metrics.uncompensated_care_pct
General Information Address 160 NORTH MIDLAND AVENUE Address
General Information City/Town NYACK 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 10 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 8 Count of READM Measures No Different
General Information Count of READM Measures Worse 2 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 ROCKLAND County/Parish
General Information Emergency Services No Emergency Services
General Information Facility ID 330104 Facility ID
General Information Facility Name NYACK HOSPITAL 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 - Other 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 NY State
General Information TE Group Footnote TE Group Footnote
General Information TE Group Measure Count 12 TE Group Measure Count
General Information Telephone Number (845) 348-2000 Telephone Number
General Information ZIP Code 10960 ZIP Code
HAC Reduction Program fiscal_year 2,026 fiscal_year
HAC Reduction Program measures — cauti — sir 1.35 measures.cauti.sir
HAC Reduction Program measures — cdi — sir 0.26 measures.cdi.sir
HAC Reduction Program measures — clabsi — sir 0.66 measures.clabsi.sir
HAC Reduction Program measures — mrsa — sir 0.48 measures.mrsa.sir
HAC Reduction Program measures — ssi — sir 0.93 measures.ssi.sir
HAC Reduction Program payment_reduction No payment_reduction
HAC Reduction Program total_hac_score 0.02 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 1.08 Value
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Excess readmission ratio 1.03 0.9995 p71 READM-30-AMI-HRRP.excess_readmission_ratio
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Expected readmission rate 13.8% READM-30-AMI-HRRP.expected_readmission_rate
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of discharges 100 READM-30-AMI-HRRP.num_discharges
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of readmissions 16 READM-30-AMI-HRRP.num_readmissions
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Predicted readmission rate 14.3% READM-30-AMI-HRRP.predicted_readmission_rate
Readmissions (HRRP) COPD — Excess readmission ratio 1.06 0.9969 p89 READM-30-COPD-HRRP.excess_readmission_ratio
Readmissions (HRRP) COPD — Expected readmission rate 16.6% READM-30-COPD-HRRP.expected_readmission_rate
Readmissions (HRRP) COPD — Number of discharges 130 READM-30-COPD-HRRP.num_discharges
Readmissions (HRRP) COPD — Number of readmissions 27 READM-30-COPD-HRRP.num_readmissions
Readmissions (HRRP) COPD — Predicted readmission rate 17.6% READM-30-COPD-HRRP.predicted_readmission_rate
Readmissions (HRRP) Heart Failure — Excess readmission ratio 0.95 0.9983 p17 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 334 READM-30-HF-HRRP.num_discharges
Readmissions (HRRP) Heart Failure — Number of readmissions 56 READM-30-HF-HRRP.num_readmissions
Readmissions (HRRP) Heart Failure — Predicted readmission rate 18.0% READM-30-HF-HRRP.predicted_readmission_rate
Readmissions (HRRP) Hip/Knee Replacement — Excess readmission ratio 1.22 0.9916 p91 READM-30-HIP-KNEE-HRRP.excess_readmission_ratio
Readmissions (HRRP) Hip/Knee Replacement — Expected readmission rate 5.1% READM-30-HIP-KNEE-HRRP.expected_readmission_rate
Readmissions (HRRP) Hip/Knee Replacement — Number of discharges 140 READM-30-HIP-KNEE-HRRP.num_discharges
Readmissions (HRRP) Hip/Knee Replacement — Number of readmissions 11 READM-30-HIP-KNEE-HRRP.num_readmissions
Readmissions (HRRP) Hip/Knee Replacement — Predicted readmission rate 6.2% READM-30-HIP-KNEE-HRRP.predicted_readmission_rate
Readmissions (HRRP) Pneumonia — Excess readmission ratio 1.14 0.9955 p96 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 16.6% READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Number of discharges 752 READM-30-PN-HRRP.num_discharges
Readmissions (HRRP) Pneumonia — Number of readmissions 151 READM-30-PN-HRRP.num_readmissions
Readmissions (HRRP) Pneumonia — Predicted readmission rate 18.9% READM-30-PN-HRRP.predicted_readmission_rate
Value-Based Purchasing Clinical Outcomes 9.50 5.00 p79 clinical_outcomes_score
Value-Based Purchasing Efficiency & Cost Reduction 0.00 2.50 p0 efficiency_score
Value-Based Purchasing Person & Community Engagement 5.50 8.75 p23 person_community_score
Value-Based Purchasing Safety 8.75 10.00 p38 safety_score
Value-Based Purchasing Total Performance Score 23.75 29.50 p29 total_performance_score
Methodology

Full methodology →