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

Overview

Address
75 NORTH COUNTRY ROAD, PORT JEFFERSON, NY 11777
Phone
(631) 473-1320
Hospital Type
Acute Care
Ownership
Non-Profit
Emergency Services
Yes
5 /5
CMS Overall Rating
p89
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
2
4
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
3
4
Better No different Worse
Healthcare-associated infections and patient safety indicators (PSI-90 composite).
Readmission 8 of 11 measures reported
8
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 8 of 12 measures reported
8 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) 149 discharges
0.9847 p39
Heart Failure 497 discharges
0.9700 p30
Pneumonia 839 discharges
0.9029 p5
COPD 172 discharges
0.9007 p0
Hip/Knee Replacement
0.9994 p51
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.

43.8 p86
Total Performance Score
National median: 29.5
Clinical Outcomes 25% weight
15.0 p94
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
14.6 p78
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
14.3 p81
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)
Not Penalized
Worst ERR: 0.9994
Value-Based Purchasing
43.8 TPS
Above national median
HAC Reduction
No Reduction
HAC Score: -0.5047

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 2.60 No Different Than the National Rate 81
Hybrid_HWM 2.80 Better Than the National Rate 1,964
MORT_30_AMI 11.20 No Different Than the National Rate 182
MORT_30_CABG
MORT_30_COPD 8.20 No Different Than the National Rate 159
MORT_30_HF 9.00 Better Than the National Rate 455
MORT_30_PN 9.80 Better Than the National Rate 797
MORT_30_STK 11.90 No Different Than the National Rate 178
PSI_03 0.56 No Different Than the National Rate 7,124
PSI_04 172.68 No Different Than the National Rate 67
PSI_06 0.14 No Different Than the National Rate 8,028
PSI_08 0.27 No Different Than the National Rate 8,188
PSI_09 2.33 No Different Than the National Rate 1,559
PSI_10 1.91 No Different Than the National Rate 483
PSI_11 8.76 No Different Than the National Rate 486
PSI_12 3.09 No Different Than the National Rate 1,615
PSI_13 4.96 No Different Than the National Rate 441
PSI_14 1.57 No Different Than the National Rate 563
PSI_15 1.11 No Different Than the National Rate 1,699
PSI_90 0.93 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 81%
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 4%
H_COMP_1_U_P: Nurses "usually" communicated well 15%
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 87%
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 10%
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 79%
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 5%
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 16%
H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand 77%
H_NURSE_EXPLAIN_SN_P: Nurses "sometimes" or "never" explained things so they could understand 5%
H_NURSE_EXPLAIN_U_P: Nurses "usually" explained things so they could understand 18%
H_COMP_2_A_P: Doctors "always" communicated well 80%
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 4%
H_COMP_2_U_P: Doctors "usually" communicated well 16%
H_COMP_2_LINEAR_SCORE: Doctor communication - linear mean score
H_COMP_2_STAR_RATING: Doctor communication - star rating 4
H_DOCTOR_RESPECT_A_P: Doctors "always" treated them with courtesy and respect 87%
H_DOCTOR_RESPECT_SN_P: Doctors "sometimes" or "never" treated them with courtesy and respect 4%
H_DOCTOR_RESPECT_U_P: Doctors "usually" treated them with courtesy and respect 9%
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 77%
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 4%
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 19%
H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand 75%
H_DOCTOR_EXPLAIN_SN_P: Doctors "sometimes" or "never" explained things so they could understand 5%
H_DOCTOR_EXPLAIN_U_P: Doctors "usually" explained things so they could understand 20%
H_COMP_5_A_P: Staff "always" explained 62%
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 20%
H_COMP_5_U_P: Staff "usually" explained 18%
H_COMP_5_LINEAR_SCORE: Communication about medicines - linear mean score
H_COMP_5_STAR_RATING: Communication about medicines - star rating 3
H_MED_FOR_A_P: Staff "always" explained new medications 75%
H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications 9%
H_MED_FOR_U_P: Staff "usually" explained new medications 16%
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 49%
H_SIDE_EFFECTS_SN_P: Staff "sometimes" or "never" explained possible side effects 32%
H_SIDE_EFFECTS_U_P: Staff "usually" explained possible side effects 19%
H_COMP_6_N_P: No, staff "did not" give patients this information 11%
H_COMP_6_Y_P: Yes, staff "did" give patients this information 89%
H_COMP_6_LINEAR_SCORE: Discharge information - linear mean score
H_COMP_6_STAR_RATING: Discharge information - star rating 4
H_DISCH_HELP_N_P: No, staff "did not" give patients information about help after discharge 14%
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge 86%
H_SYMPTOMS_N_P: No, staff "did not" give patients information about possible symptoms 9%
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms 91%
H_CLEAN_HSP_A_P: Room was "always" clean 81%
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 6%
H_CLEAN_HSP_U_P: Room was "usually" clean 13%
H_CLEAN_LINEAR_SCORE: Cleanliness - linear mean score
H_CLEAN_STAR_RATING: Cleanliness - star rating 4
H_QUIET_HSP_A_P: "Always" quiet at night 60%
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 10%
H_QUIET_HSP_U_P: "Usually" quiet at night 30%
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) 6%
H_HSP_RATING_7_8: Patients who gave a rating of "7" or "8" (medium) 20%
H_HSP_RATING_9_10: Patients who gave a rating of "9" or "10" (high) 74%
H_HSP_RATING_LINEAR_SCORE: Overall hospital rating - linear mean score
H_HSP_RATING_STAR_RATING: Overall hospital rating - star rating 4
H_RECMND_DN: "NO", patients would not recommend the hospital (they probably would not or definitely would not recommend it) 4%
H_RECMND_DY: "YES", patients would definitely recommend the hospital 77%
H_RECMND_PY: "YES", patients would probably recommend the hospital 19%
H_RECMND_LINEAR_SCORE: Recommend hospital - linear mean score
H_RECMND_STAR_RATING: Recommend hospital - star rating 4
H_STAR_RATING: Summary star rating 4

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 Better than the National Benchmark
HAI_1_CIUPPER 0.750 Better than the National Benchmark
HAI_1_DOPC 3849.000 Better than the National Benchmark
HAI_1_ELIGCASES 3.995 Better than the National Benchmark
HAI_1_NUMERATOR 0.000 Better than the National Benchmark
HAI_1_SIR 0.000 Better than the National Benchmark
HAI_2_CILOWER 0.053 No Different than National Benchmark
HAI_2_CIUPPER 1.037 No Different than National Benchmark
HAI_2_DOPC 5228.000 No Different than National Benchmark
HAI_2_ELIGCASES 6.375 No Different than National Benchmark
HAI_2_NUMERATOR 2.000 No Different than National Benchmark
HAI_2_SIR 0.314 No Different than National Benchmark
HAI_3_CILOWER 0.015 No Different than National Benchmark
HAI_3_CIUPPER 1.494 No Different than National Benchmark
HAI_3_DOPC 126.000 No Different than National Benchmark
HAI_3_ELIGCASES 3.302 No Different than National Benchmark
HAI_3_NUMERATOR 1.000 No Different than National Benchmark
HAI_3_SIR 0.303 No Different than National Benchmark
HAI_4_CILOWER
HAI_4_CIUPPER
HAI_4_DOPC 58.000
HAI_4_ELIGCASES 0.441
HAI_4_NUMERATOR 0.000
HAI_4_SIR
HAI_5_CILOWER 0.388 No Different than National Benchmark
HAI_5_CIUPPER 2.949 No Different than National Benchmark
HAI_5_DOPC 47361.000 No Different than National Benchmark
HAI_5_ELIGCASES 3.272 No Different than National Benchmark
HAI_5_NUMERATOR 4.000 No Different than National Benchmark
HAI_5_SIR 1.222 No Different than National Benchmark
HAI_6_CILOWER N/A Better than the National Benchmark
HAI_6_CIUPPER 0.133 Better than the National Benchmark
HAI_6_DOPC 47361.000 Better than the National Benchmark
HAI_6_ELIGCASES 22.518 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 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 73.0 Healthcare Personnel Vaccination
OP_18a 256.0 Emergency Department
OP_18b 250.0 Emergency Department
OP_18c 270.0 Emergency Department
OP_18d 312.0 Emergency Department
OP_22 1.0 Emergency Department
OP_23 Emergency Department
OP_29 96.0 Colonoscopy care
OP_31 Cataract surgery outcome
OP_40 Electronic Clinical Quality Measure
SAFE_USE_OF_OPIOIDS 24.0 Electronic Clinical Quality Measure
SEP_1 76.0 Sepsis Care
SEP_SH_3HR 78.0 Sepsis Care
SEP_SH_6HR 93.0 Sepsis Care
SEV_SEP_3HR 86.0 Sepsis Care
SEV_SEP_6HR 97.0 Sepsis Care
STK_02 100.0 Electronic Clinical Quality Measure
STK_03 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 12.30 Average Days per 100 Discharges
EDAC_30_HF 1.60 Average Days per 100 Discharges
EDAC_30_PN -4.30 Average Days per 100 Discharges
Hybrid_HWR 12.20 Better Than the National Rate
OP_32 12.70 No Different Than the National Rate
OP_35_ADM Number of Cases Too Small
OP_35_ED Number of Cases Too Small
OP_36 0.90 No Different than expected
READM_30_AMI 13.30 No Different Than the National Rate
READM_30_CABG
READM_30_COPD 16.30 No Different Than the National Rate
READM_30_HF 19.00 No Different Than the National Rate
READM_30_HIP_KNEE 4.80 No Different Than the National Rate
READM_30_PN 14.40 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
1.02

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 0.24 metrics.cost_to_charge_ratio
Cost Report Current Ratio 2.44 metrics.current_ratio
Cost Report Employees per Bed 10.21 metrics.employees_per_bed
Cost Report fiscal_year 2,023 fiscal_year
Cost Report Fund Balance ($) $242,092,631 metrics.fund_balance
Cost Report Net Income ($) $1,063,420 metrics.net_income
Cost Report Net Patient Revenue ($) $394,023,793 metrics.net_patient_revenue
Cost Report Operating Margin (%) -7.9% metrics.operating_margin
Cost Report Total Assets ($) $384,593,652 metrics.total_assets
Cost Report Total Costs ($) $392,368,171 metrics.total_costs
Cost Report Total Liabilities ($) $132,821,906 metrics.total_liabilities
Cost Report Total Margin (%) 0.3% metrics.total_margin
Cost Report Uncompensated Care (%) 0.9% metrics.uncompensated_care_pct
General Information Address 75 NORTH COUNTRY ROAD Address
General Information City/Town PORT JEFFERSON 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 8 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 8 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 4 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 0 Count of READM Measures Worse
General Information Count of Safety Measures Better 3 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 SUFFOLK County/Parish
General Information Emergency Services Yes Emergency Services
General Information Facility ID 330185 Facility ID
General Information Facility Name JOHN T MATHER MEMORIAL HOSPITAL OF PORT JEFFERSON Facility Name
General Information Hospital overall rating 5 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 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 (631) 473-1320 Telephone Number
General Information ZIP Code 11777 ZIP Code
HAC Reduction Program fiscal_year 2,026 fiscal_year
HAC Reduction Program measures — cauti — sir 0.23 measures.cauti.sir
HAC Reduction Program measures — cdi — sir 0.10 measures.cdi.sir
HAC Reduction Program measures — clabsi — sir 0.25 measures.clabsi.sir
HAC Reduction Program measures — mrsa — sir 1.19 measures.mrsa.sir
HAC Reduction Program measures — ssi — sir 0.26 measures.ssi.sir
HAC Reduction Program payment_reduction No payment_reduction
HAC Reduction Program total_hac_score -0.50 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 1.02 Value
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Excess readmission ratio 0.98 0.9995 p39 READM-30-AMI-HRRP.excess_readmission_ratio
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Expected readmission rate 14.2% READM-30-AMI-HRRP.expected_readmission_rate
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of discharges 149 READM-30-AMI-HRRP.num_discharges
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of readmissions 20 READM-30-AMI-HRRP.num_readmissions
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Predicted readmission rate 14.0% READM-30-AMI-HRRP.predicted_readmission_rate
Readmissions (HRRP) COPD — Excess readmission ratio 0.90 0.9969 p0 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 172 READM-30-COPD-HRRP.num_discharges
Readmissions (HRRP) COPD — Number of readmissions 23 READM-30-COPD-HRRP.num_readmissions
Readmissions (HRRP) COPD — Predicted readmission rate 17.9% READM-30-COPD-HRRP.predicted_readmission_rate
Readmissions (HRRP) Heart Failure — Excess readmission ratio 0.97 0.9983 p30 READM-30-HF-HRRP.excess_readmission_ratio
Readmissions (HRRP) Heart Failure — Expected readmission rate 21.4% READM-30-HF-HRRP.expected_readmission_rate
Readmissions (HRRP) Heart Failure — Number of discharges 497 READM-30-HF-HRRP.num_discharges
Readmissions (HRRP) Heart Failure — Number of readmissions 101 READM-30-HF-HRRP.num_readmissions
Readmissions (HRRP) Heart Failure — Predicted readmission rate 20.8% READM-30-HF-HRRP.predicted_readmission_rate
Readmissions (HRRP) Hip/Knee Replacement — Excess readmission ratio 1.00 0.9916 p51 READM-30-HIP-KNEE-HRRP.excess_readmission_ratio
Readmissions (HRRP) Hip/Knee Replacement — Expected readmission rate 6.0% READM-30-HIP-KNEE-HRRP.expected_readmission_rate
Readmissions (HRRP) Hip/Knee Replacement — Predicted readmission rate 6.0% READM-30-HIP-KNEE-HRRP.predicted_readmission_rate
Readmissions (HRRP) Pneumonia — Excess readmission ratio 0.90 0.9955 p5 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 17.2% READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Number of discharges 839 READM-30-PN-HRRP.num_discharges
Readmissions (HRRP) Pneumonia — Number of readmissions 123 READM-30-PN-HRRP.num_readmissions
Readmissions (HRRP) Pneumonia — Predicted readmission rate 15.5% READM-30-PN-HRRP.predicted_readmission_rate
Value-Based Purchasing Clinical Outcomes 15.00 5.00 p94 clinical_outcomes_score
Value-Based Purchasing Efficiency & Cost Reduction 0.00 2.50 p0 efficiency_score
Value-Based Purchasing Person & Community Engagement 14.25 8.75 p81 person_community_score
Value-Based Purchasing Safety 14.58 10.00 p78 safety_score
Value-Based Purchasing Total Performance Score 43.83 29.50 p86 total_performance_score
Methodology

Full methodology →