Hospital

ST JOHN'S EPISCOPAL HOSPITAL AT SOUTH SHORE

CCN: 330395 · FAR ROCKAWAY, NY 11691 · QUEENS County

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

Overview

Address
327 BEACH 19TH STREET, FAR ROCKAWAY, NY 11691
Phone
(718) 869-7000
Hospital Type
Acute Care
Ownership
Non-Profit
Emergency Services
Yes
Birthing Friendly
Yes
1 /5
★★★★★
CMS Overall Rating
p0
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 5 of 7 measures reported
4
1
Better No different Worse
30-day death rates for heart attack, heart failure, pneumonia, COPD, stroke, CABG, and kidney disease.
Safety of Care 5 of 8 measures reported
4
1
Better No different Worse
Healthcare-associated infections and patient safety indicators (PSI-90 composite).
Readmission 5 of 11 measures reported
2
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 9 of 12 measures reported
9 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)
— Not reported
Heart Failure 86 discharges
1.0835 p89
Pneumonia 263 discharges
1.3274 p99
COPD 77 discharges
1.0796 p94
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)
Penalized
Worst ERR: 1.3274
Value-Based Purchasing
—
HAC Reduction
Payment Reduced
HAC Score: 1.4565

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 5.90 Worse Than the National Rate 669
MORT_30_AMI 11.80 No Different Than the National Rate 42
MORT_30_CABG — — —
MORT_30_COPD 10.60 No Different Than the National Rate 69
MORT_30_HF 10.70 No Different Than the National Rate 81
MORT_30_PN 26.50 Worse Than the National Rate 306
MORT_30_STK 17.60 No Different Than the National Rate 76
PSI_03 1.53 Worse Than the National Rate 3,342
PSI_04 177.83 No Different Than the National Rate 27
PSI_06 0.18 No Different Than the National Rate 4,042
PSI_08 0.28 No Different Than the National Rate 4,031
PSI_09 2.18 No Different Than the National Rate 314
PSI_10 — Number of Cases Too Small —
PSI_11 — Number of Cases Too Small —
PSI_12 3.90 No Different Than the National Rate 281
PSI_13 — Number of Cases Too Small —
PSI_14 2.07 No Different Than the National Rate 63
PSI_15 0.97 No Different Than the National Rate 545
PSI_90 1.26 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 64% —
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 17% —
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 — 1
H_NURSE_RESPECT_A_P: Nurses "always" treated them with courtesy and respect 71% —
H_NURSE_RESPECT_SN_P: Nurses "sometimes" or "never" treated them with courtesy and respect 15% —
H_NURSE_RESPECT_U_P: Nurses "usually" treated them with courtesy and respect 14% —
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 60% —
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 18% —
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 22% —
H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand 60% —
H_NURSE_EXPLAIN_SN_P: Nurses "sometimes" or "never" explained things so they could understand 17% —
H_NURSE_EXPLAIN_U_P: Nurses "usually" explained things so they could understand 23% —
H_COMP_2_A_P: Doctors "always" communicated well 70% —
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 12% —
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 — 1
H_DOCTOR_RESPECT_A_P: Doctors "always" treated them with courtesy and respect 77% —
H_DOCTOR_RESPECT_SN_P: Doctors "sometimes" or "never" treated them with courtesy and respect 9% —
H_DOCTOR_RESPECT_U_P: Doctors "usually" treated them with courtesy and respect 14% —
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 68% —
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 13% —
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 19% —
H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand 64% —
H_DOCTOR_EXPLAIN_SN_P: Doctors "sometimes" or "never" explained things so they could understand 15% —
H_DOCTOR_EXPLAIN_U_P: Doctors "usually" explained things so they could understand 21% —
H_COMP_5_A_P: Staff "always" explained 47% —
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 33% —
H_COMP_5_U_P: Staff "usually" explained 20% —
H_COMP_5_LINEAR_SCORE: Communication about medicines - linear mean score — —
H_COMP_5_STAR_RATING: Communication about medicines - star rating — 1
H_MED_FOR_A_P: Staff "always" explained new medications 61% —
H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications 19% —
H_MED_FOR_U_P: Staff "usually" explained new medications 20% —
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 33% —
H_SIDE_EFFECTS_SN_P: Staff "sometimes" or "never" explained possible side effects 46% —
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 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 25% —
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge 75% —
H_SYMPTOMS_N_P: No, staff "did not" give patients information about possible symptoms 18% —
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms 82% —
H_CLEAN_HSP_A_P: Room was "always" clean 69% —
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 14% —
H_CLEAN_HSP_U_P: Room was "usually" clean 17% —
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 43% —
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 30% —
H_QUIET_HSP_U_P: "Usually" quiet at night 27% —
H_QUIET_LINEAR_SCORE: Quietness - linear mean score — —
H_QUIET_STAR_RATING: Quietness - star rating — 1
H_HSP_RATING_0_6: Patients who gave a rating of "6" or lower (low) 25% —
H_HSP_RATING_7_8: Patients who gave a rating of "7" or "8" (medium) 26% —
H_HSP_RATING_9_10: Patients who gave a rating of "9" or "10" (high) 49% —
H_HSP_RATING_LINEAR_SCORE: Overall hospital rating - linear mean score — —
H_HSP_RATING_STAR_RATING: Overall hospital rating - star rating — 1
H_RECMND_DN: "NO", patients would not recommend the hospital (they probably would not or definitely would not recommend it) 22% —
H_RECMND_DY: "YES", patients would definitely recommend the hospital 47% —
H_RECMND_PY: "YES", patients would probably recommend the hospital 31% —
H_RECMND_LINEAR_SCORE: Recommend hospital - linear mean score — —
H_RECMND_STAR_RATING: Recommend hospital - star rating — 1
H_STAR_RATING: Summary star rating — 1

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 1.539 Worse than the National Benchmark
HAI_1_CIUPPER 5.088 Worse than the National Benchmark
HAI_1_DOPC 4120.000 Worse than the National Benchmark
HAI_1_ELIGCASES 3.758 Worse than the National Benchmark
HAI_1_NUMERATOR 11.000 Worse than the National Benchmark
HAI_1_SIR 2.927 Worse than the National Benchmark
HAI_2_CILOWER 1.027 Worse than the National Benchmark
HAI_2_CIUPPER 3.393 Worse than the National Benchmark
HAI_2_DOPC 5652.000 Worse than the National Benchmark
HAI_2_ELIGCASES 5.635 Worse than the National Benchmark
HAI_2_NUMERATOR 11.000 Worse than the National Benchmark
HAI_2_SIR 1.952 Worse than the National Benchmark
HAI_3_CILOWER — —
HAI_3_CIUPPER — —
HAI_3_DOPC 30.000 —
HAI_3_ELIGCASES 0.805 —
HAI_3_NUMERATOR 0.000 —
HAI_3_SIR — —
HAI_4_CILOWER — —
HAI_4_CIUPPER — —
HAI_4_DOPC 14.000 —
HAI_4_ELIGCASES 0.132 —
HAI_4_NUMERATOR 0.000 —
HAI_4_SIR — —
HAI_5_CILOWER 0.016 No Different than National Benchmark
HAI_5_CIUPPER 1.618 No Different than National Benchmark
HAI_5_DOPC 48994.000 No Different than National Benchmark
HAI_5_ELIGCASES 3.049 No Different than National Benchmark
HAI_5_NUMERATOR 1.000 No Different than National Benchmark
HAI_5_SIR 0.328 No Different than National Benchmark
HAI_6_CILOWER 0.513 No Different than National Benchmark
HAI_6_CIUPPER 1.212 No Different than National Benchmark
HAI_6_DOPC 47468.000 No Different than National Benchmark
HAI_6_ELIGCASES 26.039 No Different than National Benchmark
HAI_6_NUMERATOR 21.000 No Different than National Benchmark
HAI_6_SIR 0.806 No Different than 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 0.0 Electronic Clinical Quality Measure
IMM_3 60.0 Healthcare Personnel Vaccination
OP_18a 264.0 Emergency Department
OP_18b 247.0 Emergency Department
OP_18c 438.0 Emergency Department
OP_18d 795.0 Emergency Department
OP_22 2.0 Emergency Department
OP_23 — Emergency Department
OP_29 100.0 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 55.0 Sepsis Care
SEP_SH_3HR 83.0 Sepsis Care
SEP_SH_6HR 77.0 Sepsis Care
SEV_SEP_3HR 75.0 Sepsis Care
SEV_SEP_6HR 83.0 Sepsis Care
STK_02 96.0 Electronic Clinical Quality Measure
STK_03 — Electronic Clinical Quality Measure
STK_05 — Electronic Clinical Quality Measure
VTE_1 — Electronic Clinical Quality Measure
VTE_2 96.0 Electronic Clinical Quality Measure

Unplanned Hospital Visits

Readmission and ED return rates within 30 days of discharge.

Measure Score vs. National
EDAC_30_AMI — Number of Cases Too Small
EDAC_30_HF 122.70 More Days Than Average per 100 Discharges
EDAC_30_PN 134.10 More Days Than Average per 100 Discharges
Hybrid_HWR 18.20 Worse Than the National Rate
OP_32 12.60 No Different Than the National Rate
OP_35_ADM — Number of Cases Too Small
OP_35_ED — Number of Cases Too Small
OP_36 — Number of cases too small
READM_30_AMI — Number of Cases Too Small
READM_30_CABG — —
READM_30_COPD 19.60 No Different Than the National Rate
READM_30_HF 21.30 No Different Than the National Rate
READM_30_HIP_KNEE — Number of Cases Too Small
READM_30_PN 21.20 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
1.16

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.

Download CSV

Show 78 rows
Source Metric Value National Median Pctl. Raw key
Cost Report Cost-to-Charge Ratio 0.38 — metrics.cost_to_charge_ratio
Cost Report Current Ratio 0.50 — metrics.current_ratio
Cost Report Employees per Bed 11.03 — metrics.employees_per_bed
Cost Report fiscal_year 2,023 — fiscal_year
Cost Report Fund Balance ($) $57,765,000 — metrics.fund_balance
Cost Report Net Income ($) $9,638,575 — metrics.net_income
Cost Report Net Patient Revenue ($) $238,874,000 — metrics.net_patient_revenue
Cost Report Operating Margin (%) -59.5% — metrics.operating_margin
Cost Report Total Assets ($) $339,705,000 — metrics.total_assets
Cost Report Total Costs ($) $307,340,448 — metrics.total_costs
Cost Report Total Liabilities ($) $279,755,000 — metrics.total_liabilities
Cost Report Total Margin (%) 2.5% — metrics.total_margin
Cost Report Uncompensated Care (%) 1.3% — metrics.uncompensated_care_pct
General Information Address 327 BEACH 19TH STREET — Address
General Information City/Town FAR ROCKAWAY — City/Town
General Information Count of Facility MORT Measures 5 — 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 5 — Count of Facility Safety Measures
General Information Count of Facility TE Measures 9 — 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 4 — Count of MORT Measures No Different
General Information Count of MORT Measures Worse 1 — 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 2 — 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 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 1 — Count of Safety Measures Worse
General Information County/Parish QUEENS — County/Parish
General Information Emergency Services Yes — Emergency Services
General Information Facility ID 330395 — Facility ID
General Information Facility Name ST JOHN'S EPISCOPAL HOSPITAL AT SOUTH SHORE — Facility Name
General Information Hospital overall rating 1 — 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 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 (718) 869-7000 — Telephone Number
General Information ZIP Code 11691 — ZIP Code
HAC Reduction Program fiscal_year 2,026 — fiscal_year
HAC Reduction Program measures — cauti — sir 1.51 — measures.cauti.sir
HAC Reduction Program measures — cdi — sir 0.76 — measures.cdi.sir
HAC Reduction Program measures — clabsi — sir 3.41 — measures.clabsi.sir
HAC Reduction Program measures — mrsa — sir 1.24 — measures.mrsa.sir
HAC Reduction Program measures — ssi — sir 0.57 — measures.ssi.sir
HAC Reduction Program payment_reduction Yes — payment_reduction
HAC Reduction Program total_hac_score 1.46 — 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 1.16 — Value
Readmissions (HRRP) COPD — Excess readmission ratio 1.08 0.9969 p94 READM-30-COPD-HRRP.excess_readmission_ratio
Readmissions (HRRP) COPD — Expected readmission rate 18.3% — READM-30-COPD-HRRP.expected_readmission_rate
Readmissions (HRRP) COPD — Number of discharges 77 — READM-30-COPD-HRRP.num_discharges
Readmissions (HRRP) COPD — Number of readmissions 21 — READM-30-COPD-HRRP.num_readmissions
Readmissions (HRRP) COPD — Predicted readmission rate 19.7% — READM-30-COPD-HRRP.predicted_readmission_rate
Readmissions (HRRP) Heart Failure — Excess readmission ratio 1.08 0.9983 p89 READM-30-HF-HRRP.excess_readmission_ratio
Readmissions (HRRP) Heart Failure — Expected readmission rate 19.4% — READM-30-HF-HRRP.expected_readmission_rate
Readmissions (HRRP) Heart Failure — Number of discharges 86 — READM-30-HF-HRRP.num_discharges
Readmissions (HRRP) Heart Failure — Number of readmissions 24 — READM-30-HF-HRRP.num_readmissions
Readmissions (HRRP) Heart Failure — Predicted readmission rate 21.0% — READM-30-HF-HRRP.predicted_readmission_rate
Readmissions (HRRP) Pneumonia — Excess readmission ratio 1.33 0.9955 p99 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 17.4% — READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Number of discharges 263 — READM-30-PN-HRRP.num_discharges
Readmissions (HRRP) Pneumonia — Number of readmissions 81 — READM-30-PN-HRRP.num_readmissions
Readmissions (HRRP) Pneumonia — Predicted readmission rate 23.1% — READM-30-PN-HRRP.predicted_readmission_rate
Methodology

Full methodology →