Hospital

LEGACY MOUNT HOOD MEDICAL CENTER

CCN: 380025 · GRESHAM, OR 97030 · MULTNOMAH County

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

Overview

Address
24800 SE STARK STREET, GRESHAM, OR 97030
Phone
(503) 674-1122
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 5 of 7 measures reported
5
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
1
4
1
Better No different Worse
Healthcare-associated infections and patient safety indicators (PSI-90 composite).
Readmission 6 of 11 measures reported
1
5
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 does not have excess readmissions triggering HRRP penalties.
Acute Myocardial Infarction (Heart Attack)
— Not reported
Heart Failure 179 discharges
0.9858 p40
Pneumonia 104 discharges
0.9788 p38
COPD
0.9690 p23
Hip/Knee Replacement
— Not reported
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.

38.1 p75
Total Performance Score
National median: 29.5
Clinical Outcomes 25% weight
0.6 p12
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
11.5 p59
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
8.5 p47
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
17.5 p91
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: 0.9858
Value-Based Purchasing
38.1 TPS
Above national median
HAC Reduction
Payment Reduced
HAC Score: 0.7341

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 3.90 No Different Than the National Rate 360
MORT_30_AMI 12.50 No Different Than the National Rate 40
MORT_30_CABG — — —
MORT_30_COPD 8.90 No Different Than the National Rate 52
MORT_30_HF 12.90 No Different Than the National Rate 162
MORT_30_PN 16.60 No Different Than the National Rate 103
MORT_30_STK 10.90 No Different Than the National Rate 64
PSI_03 1.14 No Different Than the National Rate 1,325
PSI_04 — Number of Cases Too Small —
PSI_06 0.19 No Different Than the National Rate 1,662
PSI_08 0.30 No Different Than the National Rate 1,692
PSI_09 2.16 No Different Than the National Rate 274
PSI_10 1.61 No Different Than the National Rate 81
PSI_11 7.78 No Different Than the National Rate 91
PSI_12 5.24 No Different Than the National Rate 287
PSI_13 4.79 No Different Than the National Rate 74
PSI_14 2.06 No Different Than the National Rate 109
PSI_15 1.18 No Different Than the National Rate 359
PSI_90 1.16 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 79% —
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 5% —
H_COMP_1_U_P: Nurses "usually" communicated well 16% —
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 85% —
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 11% —
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 7% —
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 5% —
H_COMP_2_U_P: Doctors "usually" communicated well 15% —
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 5% —
H_DOCTOR_RESPECT_U_P: Doctors "usually" treated them with courtesy and respect 10% —
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 78% —
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 5% —
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 17% —
H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand 76% —
H_DOCTOR_EXPLAIN_SN_P: Doctors "sometimes" or "never" explained things so they could understand 6% —
H_DOCTOR_EXPLAIN_U_P: Doctors "usually" explained things so they could understand 18% —
H_COMP_5_A_P: Staff "always" explained 62% —
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 19% —
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 — 3
H_MED_FOR_A_P: Staff "always" explained new medications 73% —
H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications 11% —
H_MED_FOR_U_P: Staff "usually" explained new medications 16% —
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 50% —
H_SIDE_EFFECTS_SN_P: Staff "sometimes" or "never" explained possible side effects 28% —
H_SIDE_EFFECTS_U_P: Staff "usually" explained possible side effects 22% —
H_COMP_6_N_P: No, staff "did not" give patients this information 13% —
H_COMP_6_Y_P: Yes, staff "did" give patients this information 87% —
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 12% —
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge 88% —
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 69% —
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 11% —
H_CLEAN_HSP_U_P: Room was "usually" clean 20% —
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 50% —
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 10% —
H_QUIET_HSP_U_P: "Usually" quiet at night 40% —
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) 9% —
H_HSP_RATING_7_8: Patients who gave a rating of "7" or "8" (medium) 22% —
H_HSP_RATING_9_10: Patients who gave a rating of "9" or "10" (high) 69% —
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 69% —
H_RECMND_PY: "YES", patients would probably recommend the hospital 25% —
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 N/A No Different than National Benchmark
HAI_1_CIUPPER 1.416 No Different than National Benchmark
HAI_1_DOPC 3066.000 No Different than National Benchmark
HAI_1_ELIGCASES 2.115 No Different than National Benchmark
HAI_1_NUMERATOR 0.000 No Different than National Benchmark
HAI_1_SIR 0.000 No Different than National Benchmark
HAI_2_CILOWER 0.354 No Different than National Benchmark
HAI_2_CIUPPER 3.792 No Different than National Benchmark
HAI_2_DOPC 3028.000 No Different than National Benchmark
HAI_2_ELIGCASES 2.153 No Different than National Benchmark
HAI_2_NUMERATOR 3.000 No Different than National Benchmark
HAI_2_SIR 1.393 No Different than National Benchmark
HAI_3_CILOWER 0.019 No Different than National Benchmark
HAI_3_CIUPPER 1.851 No Different than National Benchmark
HAI_3_DOPC 103.000 No Different than National Benchmark
HAI_3_ELIGCASES 2.665 No Different than National Benchmark
HAI_3_NUMERATOR 1.000 No Different than National Benchmark
HAI_3_SIR 0.375 No Different than National Benchmark
HAI_4_CILOWER — —
HAI_4_CIUPPER — —
HAI_4_DOPC 8.000 —
HAI_4_ELIGCASES 0.077 —
HAI_4_NUMERATOR 0.000 —
HAI_4_SIR — —
HAI_5_CILOWER 0.049 No Different than National Benchmark
HAI_5_CIUPPER 4.840 No Different than National Benchmark
HAI_5_DOPC 26658.000 No Different than National Benchmark
HAI_5_ELIGCASES 1.019 No Different than National Benchmark
HAI_5_NUMERATOR 1.000 No Different than National Benchmark
HAI_5_SIR 0.981 No Different than National Benchmark
HAI_6_CILOWER 0.137 Better than the National Benchmark
HAI_6_CIUPPER 0.830 Better than the National Benchmark
HAI_6_DOPC 26658.000 Better than the National Benchmark
HAI_6_ELIGCASES 13.359 Better than the National Benchmark
HAI_6_NUMERATOR 5.000 Better than the National Benchmark
HAI_6_SIR 0.374 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 1.0 Electronic Clinical Quality Measure
HH_ORAE — Electronic Clinical Quality Measure
IMM_3 51.0 Healthcare Personnel Vaccination
OP_18a 173.0 Emergency Department
OP_18b 171.0 Emergency Department
OP_18c 218.0 Emergency Department
OP_18d — 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 11.0 Electronic Clinical Quality Measure
SAFE_USE_OF_OPIOIDS 12.0 Electronic Clinical Quality Measure
SEP_1 19.0 Sepsis Care
SEP_SH_3HR 38.0 Sepsis Care
SEP_SH_6HR — Sepsis Care
SEV_SEP_3HR 45.0 Sepsis Care
SEV_SEP_6HR 58.0 Sepsis Care
STK_02 99.0 Electronic Clinical Quality Measure
STK_03 — Electronic Clinical Quality Measure
STK_05 99.0 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 — Number of Cases Too Small
EDAC_30_HF 23.10 More Days Than Average per 100 Discharges
EDAC_30_PN 3.40 Average Days per 100 Discharges
Hybrid_HWR 14.40 No Different Than the National Rate
OP_32 12.10 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 — Number of Cases Too Small
READM_30_CABG — —
READM_30_COPD 17.60 No Different Than the National Rate
READM_30_HF 19.40 No Different Than the National Rate
READM_30_HIP_KNEE — Number of Cases Too Small
READM_30_PN 15.60 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
0.87

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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Source Metric Value National Median Pctl. Raw key
Cost Report Cost-to-Charge Ratio 0.33 — metrics.cost_to_charge_ratio
Cost Report Current Ratio 2.28 — metrics.current_ratio
Cost Report Employees per Bed 6.48 — metrics.employees_per_bed
Cost Report fiscal_year 2,024 — fiscal_year
Cost Report Fund Balance ($) $75,597,603 — metrics.fund_balance
Cost Report Net Income ($) $-10,331,129 — metrics.net_income
Cost Report Net Patient Revenue ($) $197,245,443 — metrics.net_patient_revenue
Cost Report Operating Margin (%) -9.2% — metrics.operating_margin
Cost Report Total Assets ($) $90,229,441 — metrics.total_assets
Cost Report Total Costs ($) $204,987,038 — metrics.total_costs
Cost Report Total Liabilities ($) $14,631,838 — metrics.total_liabilities
Cost Report Total Margin (%) -5.0% — metrics.total_margin
Cost Report Uncompensated Care (%) 4.9% — metrics.uncompensated_care_pct
General Information Address 24800 SE STARK STREET — Address
General Information City/Town GRESHAM — 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 6 — 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 5 — 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 1 — Count of READM Measures Better
General Information Count of READM Measures No Different 5 — 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 1 — 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 MULTNOMAH — County/Parish
General Information Emergency Services Yes — Emergency Services
General Information Facility ID 380025 — Facility ID
General Information Facility Name LEGACY MOUNT HOOD 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) 674-1122 — Telephone Number
General Information ZIP Code 97030 — ZIP Code
HAC Reduction Program fiscal_year 2,026 — fiscal_year
HAC Reduction Program measures — cauti — sir 2.23 — measures.cauti.sir
HAC Reduction Program measures — cdi — sir 0.34 — measures.cdi.sir
HAC Reduction Program measures — clabsi — sir 0.81 — measures.clabsi.sir
HAC Reduction Program measures — mrsa — sir 1.04 — measures.mrsa.sir
HAC Reduction Program measures — ssi — sir 0.69 — measures.ssi.sir
HAC Reduction Program payment_reduction Yes — payment_reduction
HAC Reduction Program total_hac_score 0.73 — 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 0.87 — Value
Readmissions (HRRP) COPD — Excess readmission ratio 0.97 0.9969 p23 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 — Predicted readmission rate 16.6% — READM-30-COPD-HRRP.predicted_readmission_rate
Readmissions (HRRP) Heart Failure — Excess readmission ratio 0.99 0.9983 p40 READM-30-HF-HRRP.excess_readmission_ratio
Readmissions (HRRP) Heart Failure — Expected readmission rate 18.7% — READM-30-HF-HRRP.expected_readmission_rate
Readmissions (HRRP) Heart Failure — Number of discharges 179 — READM-30-HF-HRRP.num_discharges
Readmissions (HRRP) Heart Failure — Number of readmissions 32 — READM-30-HF-HRRP.num_readmissions
Readmissions (HRRP) Heart Failure — Predicted readmission rate 18.5% — READM-30-HF-HRRP.predicted_readmission_rate
Readmissions (HRRP) Pneumonia — Excess readmission ratio 0.98 0.9955 p38 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 15.2% — READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Number of discharges 104 — READM-30-PN-HRRP.num_discharges
Readmissions (HRRP) Pneumonia — Number of readmissions 14 — READM-30-PN-HRRP.num_readmissions
Readmissions (HRRP) Pneumonia — Predicted readmission rate 14.8% — READM-30-PN-HRRP.predicted_readmission_rate
Value-Based Purchasing Clinical Outcomes 0.63 5.00 p12 clinical_outcomes_score
Value-Based Purchasing Efficiency & Cost Reduction 17.50 2.50 p91 efficiency_score
Value-Based Purchasing Person & Community Engagement 8.50 8.75 p47 person_community_score
Value-Based Purchasing Safety 11.50 10.00 p59 safety_score
Value-Based Purchasing Total Performance Score 38.13 29.50 p75 total_performance_score
Methodology

Full methodology →