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

Overview

Address
2801 N GANTENBEIN AVENUE, PORTLAND, OR 97227
Phone
(503) 413-2200
Hospital Type
Acute Care
Ownership
Non-Profit
Emergency Services
Yes
Birthing Friendly
Yes
3 /5
CMS Overall Rating
p30
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
6
1
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 8 of 11 measures reported
7
1
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) 104 discharges
0.9681 p28
Heart Failure 141 discharges
1.0264 p67
Pneumonia
0.9705 p32
COPD
0.9734 p27
Hip/Knee Replacement
— Not reported
CABG Surgery
0.8667 p6
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.

19.3 p14
Total Performance Score
National median: 29.5
Clinical Outcomes 25% weight
5.5 p52
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
2.5 p3
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
8.8 p49
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
2.5 p43
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: 1.0264
Value-Based Purchasing
19.3 TPS
Below national median
HAC Reduction
Payment Reduced
HAC Score: 0.4646

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 4.20 No Different Than the National Rate 742
MORT_30_AMI 12.70 No Different Than the National Rate 66
MORT_30_CABG 1.80 No Different Than the National Rate 68
MORT_30_COPD 9.90 No Different Than the National Rate 38
MORT_30_HF 10.70 No Different Than the National Rate 107
MORT_30_PN 16.90 No Different Than the National Rate 72
MORT_30_STK 15.10 No Different Than the National Rate 123
PSI_03 0.94 No Different Than the National Rate 2,977
PSI_04 220.63 Worse Than the National Rate 79
PSI_06 0.40 No Different Than the National Rate 3,393
PSI_08 0.27 No Different Than the National Rate 3,343
PSI_09 2.27 No Different Than the National Rate 1,240
PSI_10 2.09 No Different Than the National Rate 443
PSI_11 9.05 No Different Than the National Rate 449
PSI_12 2.64 No Different Than the National Rate 1,262
PSI_13 5.48 No Different Than the National Rate 438
PSI_14 1.67 No Different Than the National Rate 105
PSI_15 0.93 No Different Than the National Rate 426
PSI_90 1.09 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 78%
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 5%
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 76%
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 5%
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 19%
H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand 75%
H_NURSE_EXPLAIN_SN_P: Nurses "sometimes" or "never" explained things so they could understand 6%
H_NURSE_EXPLAIN_U_P: Nurses "usually" explained things so they could understand 19%
H_COMP_2_A_P: Doctors "always" communicated well 78%
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 6%
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 3
H_DOCTOR_RESPECT_A_P: Doctors "always" treated them with courtesy and respect 85%
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 11%
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 76%
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 7%
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 17%
H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand 72%
H_DOCTOR_EXPLAIN_SN_P: Doctors "sometimes" or "never" explained things so they could understand 7%
H_DOCTOR_EXPLAIN_U_P: Doctors "usually" explained things so they could understand 21%
H_COMP_5_A_P: Staff "always" explained 59%
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 21%
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 2
H_MED_FOR_A_P: Staff "always" explained new medications 72%
H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications 10%
H_MED_FOR_U_P: Staff "usually" explained new medications 18%
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 46%
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 23%
H_COMP_6_N_P: No, staff "did not" give patients this information 15%
H_COMP_6_Y_P: Yes, staff "did" give patients this information 85%
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 15%
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge 85%
H_SYMPTOMS_N_P: No, staff "did not" give patients information about possible symptoms 15%
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms 85%
H_CLEAN_HSP_A_P: Room was "always" clean 72%
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 9%
H_CLEAN_HSP_U_P: Room was "usually" clean 19%
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 56%
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 10%
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 3
H_HSP_RATING_0_6: Patients who gave a rating of "6" or lower (low) 9%
H_HSP_RATING_7_8: Patients who gave a rating of "7" or "8" (medium) 19%
H_HSP_RATING_9_10: Patients who gave a rating of "9" or "10" (high) 72%
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 72%
H_RECMND_PY: "YES", patients would probably recommend the hospital 22%
H_RECMND_LINEAR_SCORE: Recommend hospital - linear mean score
H_RECMND_STAR_RATING: Recommend hospital - star rating 4
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 0.233 Better than the National Benchmark
HAI_1_CIUPPER 0.816 Better than the National Benchmark
HAI_1_DOPC 19945.000 Better than the National Benchmark
HAI_1_ELIGCASES 21.842 Better than the National Benchmark
HAI_1_NUMERATOR 10.000 Better than the National Benchmark
HAI_1_SIR 0.458 Better than the National Benchmark
HAI_2_CILOWER 0.507 No Different than National Benchmark
HAI_2_CIUPPER 1.406 No Different than National Benchmark
HAI_2_DOPC 13323.000 No Different than National Benchmark
HAI_2_ELIGCASES 17.206 No Different than National Benchmark
HAI_2_NUMERATOR 15.000 No Different than National Benchmark
HAI_2_SIR 0.872 No Different than National Benchmark
HAI_3_CILOWER 0.314 No Different than National Benchmark
HAI_3_CIUPPER 3.364 No Different than National Benchmark
HAI_3_DOPC 75.000 No Different than National Benchmark
HAI_3_ELIGCASES 2.427 No Different than National Benchmark
HAI_3_NUMERATOR 3.000 No Different than National Benchmark
HAI_3_SIR 1.236 No Different than National Benchmark
HAI_4_CILOWER
HAI_4_CIUPPER
HAI_4_DOPC 14.000
HAI_4_ELIGCASES 0.163
HAI_4_NUMERATOR 0.000
HAI_4_SIR
HAI_5_CILOWER 0.190 No Different than National Benchmark
HAI_5_CIUPPER 1.147 No Different than National Benchmark
HAI_5_DOPC 120544.000 No Different than National Benchmark
HAI_5_ELIGCASES 9.666 No Different than National Benchmark
HAI_5_NUMERATOR 5.000 No Different than National Benchmark
HAI_5_SIR 0.517 No Different than National Benchmark
HAI_6_CILOWER 0.310 Better than the National Benchmark
HAI_6_CIUPPER 0.628 Better than the National Benchmark
HAI_6_DOPC 108639.000 Better than the National Benchmark
HAI_6_ELIGCASES 69.158 Better than the National Benchmark
HAI_6_NUMERATOR 31.000 Better than the National Benchmark
HAI_6_SIR 0.448 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 Electronic Clinical Quality Measure
HH_HYPO 1.0 Electronic Clinical Quality Measure
HH_ORAE Electronic Clinical Quality Measure
IMM_3 57.0 Healthcare Personnel Vaccination
OP_18a 175.0 Emergency Department
OP_18b 169.0 Emergency Department
OP_18c 304.0 Emergency Department
OP_18d Emergency Department
OP_22 3.0 Emergency Department
OP_23 Emergency Department
OP_29 100.0 Colonoscopy care
OP_31 Cataract surgery outcome
OP_40 73.0 Electronic Clinical Quality Measure
SAFE_USE_OF_OPIOIDS 11.0 Electronic Clinical Quality Measure
SEP_1 27.0 Sepsis Care
SEP_SH_3HR 52.0 Sepsis Care
SEP_SH_6HR 100.0 Sepsis Care
SEV_SEP_3HR 44.0 Sepsis Care
SEV_SEP_6HR 81.0 Sepsis Care
STK_02 99.0 Electronic Clinical Quality Measure
STK_03 83.0 Electronic Clinical Quality Measure
STK_05 88.0 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 -3.40 Average Days per 100 Discharges
EDAC_30_HF 36.20 More Days Than Average per 100 Discharges
EDAC_30_PN 49.90 More Days Than Average per 100 Discharges
Hybrid_HWR 14.70 No Different Than the National Rate
OP_32 12.90 No Different Than the National Rate
OP_35_ADM Number of Cases Too Small
OP_35_ED Number of Cases Too Small
OP_36 1.20 No Different than expected
READM_30_AMI 13.10 No Different Than the National Rate
READM_30_CABG 9.20 No Different Than the National Rate
READM_30_COPD 17.90 No Different Than the National Rate
READM_30_HF 20.30 No Different Than the National Rate
READM_30_HIP_KNEE Number of Cases Too Small
READM_30_PN 15.70 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
0.97

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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Show 87 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 4.44 metrics.current_ratio
Cost Report Employees per Bed 10.26 metrics.employees_per_bed
Cost Report fiscal_year 2,024 fiscal_year
Cost Report Fund Balance ($) $-302,596,039 metrics.fund_balance
Cost Report Net Income ($) $-15,919,637 metrics.net_income
Cost Report Net Patient Revenue ($) $1,077,348,373 metrics.net_patient_revenue
Cost Report Operating Margin (%) -16.4% metrics.operating_margin
Cost Report Total Assets ($) $-248,951,523 metrics.total_assets
Cost Report Total Costs ($) $851,428,248 metrics.total_costs
Cost Report Total Liabilities ($) $53,644,516 metrics.total_liabilities
Cost Report Total Margin (%) -1.3% metrics.total_margin
Cost Report Uncompensated Care (%) 3.6% metrics.uncompensated_care_pct
General Information Address 2801 N GANTENBEIN AVENUE Address
General Information City/Town PORTLAND 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 8 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 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 6 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 7 Count of READM Measures No Different
General Information Count of READM Measures Worse 1 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 MULTNOMAH County/Parish
General Information Emergency Services Yes Emergency Services
General Information Facility ID 380007 Facility ID
General Information Facility Name LEGACY EMANUEL MEDICAL CENTER Facility Name
General Information Hospital overall rating 3 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 OR State
General Information TE Group Footnote TE Group Footnote
General Information TE Group Measure Count 12 TE Group Measure Count
General Information Telephone Number (503) 413-2200 Telephone Number
General Information ZIP Code 97227 ZIP Code
HAC Reduction Program fiscal_year 2,026 fiscal_year
HAC Reduction Program measures — cauti — sir 1 measures.cauti.sir
HAC Reduction Program measures — cdi — sir 0.33 measures.cdi.sir
HAC Reduction Program measures — clabsi — sir 0.61 measures.clabsi.sir
HAC Reduction Program measures — mrsa — sir 1.08 measures.mrsa.sir
HAC Reduction Program measures — ssi — sir 1.04 measures.ssi.sir
HAC Reduction Program payment_reduction Yes payment_reduction
HAC Reduction Program total_hac_score 0.46 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 0.97 Value
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Excess readmission ratio 0.97 0.9995 p28 READM-30-AMI-HRRP.excess_readmission_ratio
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Expected readmission rate 13.5% READM-30-AMI-HRRP.expected_readmission_rate
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of discharges 104 READM-30-AMI-HRRP.num_discharges
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of readmissions 12 READM-30-AMI-HRRP.num_readmissions
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Predicted readmission rate 13.1% READM-30-AMI-HRRP.predicted_readmission_rate
Readmissions (HRRP) CABG Surgery — Excess readmission ratio 0.87 1.0000 p6 READM-30-CABG-HRRP.excess_readmission_ratio
Readmissions (HRRP) CABG Surgery — Expected readmission rate 9.5% READM-30-CABG-HRRP.expected_readmission_rate
Readmissions (HRRP) CABG Surgery — Predicted readmission rate 8.2% READM-30-CABG-HRRP.predicted_readmission_rate
Readmissions (HRRP) COPD — Excess readmission ratio 0.97 0.9969 p27 READM-30-COPD-HRRP.excess_readmission_ratio
Readmissions (HRRP) COPD — Expected readmission rate 17.9% READM-30-COPD-HRRP.expected_readmission_rate
Readmissions (HRRP) COPD — Predicted readmission rate 17.4% READM-30-COPD-HRRP.predicted_readmission_rate
Readmissions (HRRP) Heart Failure — Excess readmission ratio 1.03 0.9983 p67 READM-30-HF-HRRP.excess_readmission_ratio
Readmissions (HRRP) Heart Failure — Expected readmission rate 20.1% READM-30-HF-HRRP.expected_readmission_rate
Readmissions (HRRP) Heart Failure — Number of discharges 141 READM-30-HF-HRRP.num_discharges
Readmissions (HRRP) Heart Failure — Number of readmissions 31 READM-30-HF-HRRP.num_readmissions
Readmissions (HRRP) Heart Failure — Predicted readmission rate 20.6% READM-30-HF-HRRP.predicted_readmission_rate
Readmissions (HRRP) Pneumonia — Excess readmission ratio 0.97 0.9955 p32 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 15.5% READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Predicted readmission rate 15.0% READM-30-PN-HRRP.predicted_readmission_rate
Value-Based Purchasing Clinical Outcomes 5.50 5.00 p52 clinical_outcomes_score
Value-Based Purchasing Efficiency & Cost Reduction 2.50 2.50 p43 efficiency_score
Value-Based Purchasing Person & Community Engagement 8.75 8.75 p49 person_community_score
Value-Based Purchasing Safety 2.50 10.00 p3 safety_score
Value-Based Purchasing Total Performance Score 19.25 29.50 p14 total_performance_score
Methodology

Full methodology →