Hospital

MERCY CATHOLIC MEDICAL CENTER- MERCY FITZGERALD

CCN: 390156 · DARBY, PA 19023 · DELAWARE County

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

Overview

Address
1500 LANSDOWNE AVE, DARBY, PA 19023
Phone
(215) 237-4000
Hospital Type
Acute Care
Ownership
Non-Profit
Emergency Services
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 6 of 8 measures reported
1
4
1
Better No different Worse
Healthcare-associated infections and patient safety indicators (PSI-90 composite).
Readmission 8 of 11 measures reported
6
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 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)
0.9842 p38
Heart Failure 200 discharges
1.0995 p93
Pneumonia 84 discharges
1.0691 p85
COPD 107 discharges
1.0415 p81
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 below the national median, suggesting a negative payment adjustment.

13.0 p2
Total Performance Score
National median: 29.5
Clinical Outcomes 25% weight
7.5 p67
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
3.0 p5
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: 1.0995
Value-Based Purchasing
13.0 TPS
Below national median
HAC Reduction
Payment Reduced
HAC Score: 1.2253

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 3.80 No Different Than the National Rate 487
MORT_30_AMI 12.90 No Different Than the National Rate 49
MORT_30_CABG — Number of Cases Too Small —
MORT_30_COPD 7.00 No Different Than the National Rate 89
MORT_30_HF 9.10 No Different Than the National Rate 161
MORT_30_PN 17.60 No Different Than the National Rate 87
MORT_30_STK 12.60 No Different Than the National Rate 61
PSI_03 1.19 No Different Than the National Rate 2,049
PSI_04 166.08 No Different Than the National Rate 29
PSI_06 0.25 No Different Than the National Rate 2,673
PSI_08 0.33 No Different Than the National Rate 2,774
PSI_09 2.13 No Different Than the National Rate 317
PSI_10 1.64 No Different Than the National Rate 59
PSI_11 13.38 No Different Than the National Rate 54
PSI_12 4.32 No Different Than the National Rate 318
PSI_13 6.63 No Different Than the National Rate 59
PSI_14 1.68 No Different Than the National Rate 119
PSI_15 1.21 No Different Than the National Rate 384
PSI_90 1.36 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 73% —
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 8% —
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 — 2
H_NURSE_RESPECT_A_P: Nurses "always" treated them with courtesy and respect 79% —
H_NURSE_RESPECT_SN_P: Nurses "sometimes" or "never" treated them with courtesy and respect 7% —
H_NURSE_RESPECT_U_P: Nurses "usually" treated them with courtesy and respect 14% —
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 69% —
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 8% —
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 23% —
H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand 71% —
H_NURSE_EXPLAIN_SN_P: Nurses "sometimes" or "never" explained things so they could understand 10% —
H_NURSE_EXPLAIN_U_P: Nurses "usually" explained things so they could understand 19% —
H_COMP_2_A_P: Doctors "always" communicated well 76% —
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 8% —
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 — 2
H_DOCTOR_RESPECT_A_P: Doctors "always" treated them with courtesy and respect 82% —
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 13% —
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 75% —
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 8% —
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 17% —
H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand 71% —
H_DOCTOR_EXPLAIN_SN_P: Doctors "sometimes" or "never" explained things so they could understand 11% —
H_DOCTOR_EXPLAIN_U_P: Doctors "usually" explained things so they could understand 18% —
H_COMP_5_A_P: Staff "always" explained 59% —
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 24% —
H_COMP_5_U_P: Staff "usually" explained 17% —
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 74% —
H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications 12% —
H_MED_FOR_U_P: Staff "usually" explained new medications 14% —
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 44% —
H_SIDE_EFFECTS_SN_P: Staff "sometimes" or "never" explained possible side effects 36% —
H_SIDE_EFFECTS_U_P: Staff "usually" explained possible side effects 20% —
H_COMP_6_N_P: No, staff "did not" give patients this information 18% —
H_COMP_6_Y_P: Yes, staff "did" give patients this information 82% —
H_COMP_6_LINEAR_SCORE: Discharge information - linear mean score — —
H_COMP_6_STAR_RATING: Discharge information - star rating — 2
H_DISCH_HELP_N_P: No, staff "did not" give patients information about help after discharge 17% —
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge 83% —
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 63% —
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 15% —
H_CLEAN_HSP_U_P: Room was "usually" clean 22% —
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 54% —
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 16% —
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 — 2
H_HSP_RATING_0_6: Patients who gave a rating of "6" or lower (low) 15% —
H_HSP_RATING_7_8: Patients who gave a rating of "7" or "8" (medium) 25% —
H_HSP_RATING_9_10: Patients who gave a rating of "9" or "10" (high) 60% —
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) 12% —
H_RECMND_DY: "YES", patients would definitely recommend the hospital 56% —
H_RECMND_PY: "YES", patients would probably recommend the hospital 32% —
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 0.151 No Different than National Benchmark
HAI_1_CIUPPER 1.613 No Different than National Benchmark
HAI_1_DOPC 5721.000 No Different than National Benchmark
HAI_1_ELIGCASES 5.062 No Different than National Benchmark
HAI_1_NUMERATOR 3.000 No Different than National Benchmark
HAI_1_SIR 0.593 No Different than National Benchmark
HAI_2_CILOWER 0.737 No Different than National Benchmark
HAI_2_CIUPPER 3.015 No Different than National Benchmark
HAI_2_DOPC 4828.000 No Different than National Benchmark
HAI_2_ELIGCASES 5.039 No Different than National Benchmark
HAI_2_NUMERATOR 8.000 No Different than National Benchmark
HAI_2_SIR 1.588 No Different than National Benchmark
HAI_3_CILOWER 0.208 No Different than National Benchmark
HAI_3_CIUPPER 4.099 No Different than National Benchmark
HAI_3_DOPC 62.000 No Different than National Benchmark
HAI_3_ELIGCASES 1.612 No Different than National Benchmark
HAI_3_NUMERATOR 2.000 No Different than National Benchmark
HAI_3_SIR 1.241 No Different than National Benchmark
HAI_4_CILOWER — —
HAI_4_CIUPPER — —
HAI_4_DOPC 20.000 —
HAI_4_ELIGCASES 0.185 —
HAI_4_NUMERATOR 1.000 —
HAI_4_SIR — —
HAI_5_CILOWER 0.032 No Different than National Benchmark
HAI_5_CIUPPER 3.110 No Different than National Benchmark
HAI_5_DOPC 31891.000 No Different than National Benchmark
HAI_5_ELIGCASES 1.586 No Different than National Benchmark
HAI_5_NUMERATOR 1.000 No Different than National Benchmark
HAI_5_SIR 0.631 No Different than National Benchmark
HAI_6_CILOWER 0.174 Better than the National Benchmark
HAI_6_CIUPPER 0.892 Better than the National Benchmark
HAI_6_DOPC 31891.000 Better than the National Benchmark
HAI_6_ELIGCASES 13.997 Better than the National Benchmark
HAI_6_NUMERATOR 6.000 Better than the National Benchmark
HAI_6_SIR 0.429 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 38.0 Healthcare Personnel Vaccination
OP_18a 204.0 Emergency Department
OP_18b 201.0 Emergency Department
OP_18c — Emergency Department
OP_18d — Emergency Department
OP_22 1.0 Emergency Department
OP_23 65.0 Emergency Department
OP_29 97.0 Colonoscopy care
OP_31 — Cataract surgery outcome
OP_40 — Electronic Clinical Quality Measure
SAFE_USE_OF_OPIOIDS 13.0 Electronic Clinical Quality Measure
SEP_1 72.0 Sepsis Care
SEP_SH_3HR 85.0 Sepsis Care
SEP_SH_6HR 91.0 Sepsis Care
SEV_SEP_3HR 87.0 Sepsis Care
SEV_SEP_6HR 91.0 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 24.30 More Days Than Average per 100 Discharges
EDAC_30_PN 114.50 More Days Than Average per 100 Discharges
Hybrid_HWR 15.00 No Different Than the National Rate
OP_32 13.50 No Different Than the National Rate
OP_35_ADM 13.20 No Different Than the National Rate
OP_35_ED 5.00 No Different Than the National Rate
OP_36 1.10 No Different than expected
READM_30_AMI 13.40 No Different Than the National Rate
READM_30_CABG — Number of Cases Too Small
READM_30_COPD 19.10 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 17.10 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
1.04

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 0.18 — metrics.cost_to_charge_ratio
Cost Report Current Ratio 0.44 — metrics.current_ratio
Cost Report Employees per Bed 5.23 — metrics.employees_per_bed
Cost Report fiscal_year 2,024 — fiscal_year
Cost Report Fund Balance ($) $-15,493,968 — metrics.fund_balance
Cost Report Net Income ($) $10,500,649 — metrics.net_income
Cost Report Net Patient Revenue ($) $198,896,114 — metrics.net_patient_revenue
Cost Report Operating Margin (%) -7.9% — metrics.operating_margin
Cost Report Total Assets ($) $85,511,872 — metrics.total_assets
Cost Report Total Costs ($) $161,166,648 — metrics.total_costs
Cost Report Total Liabilities ($) $101,005,840 — metrics.total_liabilities
Cost Report Total Margin (%) 4.7% — metrics.total_margin
Cost Report Uncompensated Care (%) 3.1% — metrics.uncompensated_care_pct
General Information Address 1500 LANSDOWNE AVE — Address
General Information City/Town DARBY — 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 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 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 6 — 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 4 — Count of Safety Measures No Different
General Information Count of Safety Measures Worse 1 — Count of Safety Measures Worse
General Information County/Parish DELAWARE — County/Parish
General Information Emergency Services Yes — Emergency Services
General Information Facility ID 390156 — Facility ID
General Information Facility Name MERCY CATHOLIC MEDICAL CENTER- MERCY FITZGERALD — 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 - 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 PA — State
General Information TE Group Footnote — — TE Group Footnote
General Information TE Group Measure Count 12 — TE Group Measure Count
General Information Telephone Number (215) 237-4000 — Telephone Number
General Information ZIP Code 19023 — 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 0.26 — measures.cdi.sir
HAC Reduction Program measures — clabsi — sir 1.70 — measures.clabsi.sir
HAC Reduction Program measures — mrsa — sir 1.45 — measures.mrsa.sir
HAC Reduction Program measures — ssi — sir 1.08 — measures.ssi.sir
HAC Reduction Program payment_reduction Yes — payment_reduction
HAC Reduction Program total_hac_score 1.23 — 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 1.04 — Value
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Excess readmission ratio 0.98 0.9995 p38 READM-30-AMI-HRRP.excess_readmission_ratio
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Expected readmission rate 17.4% — READM-30-AMI-HRRP.expected_readmission_rate
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Predicted readmission rate 17.2% — READM-30-AMI-HRRP.predicted_readmission_rate
Readmissions (HRRP) COPD — Excess readmission ratio 1.04 0.9969 p81 READM-30-COPD-HRRP.excess_readmission_ratio
Readmissions (HRRP) COPD — Expected readmission rate 20.5% — READM-30-COPD-HRRP.expected_readmission_rate
Readmissions (HRRP) COPD — Number of discharges 107 — READM-30-COPD-HRRP.num_discharges
Readmissions (HRRP) COPD — Number of readmissions 26 — READM-30-COPD-HRRP.num_readmissions
Readmissions (HRRP) COPD — Predicted readmission rate 21.3% — READM-30-COPD-HRRP.predicted_readmission_rate
Readmissions (HRRP) Heart Failure — Excess readmission ratio 1.10 0.9983 p93 READM-30-HF-HRRP.excess_readmission_ratio
Readmissions (HRRP) Heart Failure — Expected readmission rate 20.0% — READM-30-HF-HRRP.expected_readmission_rate
Readmissions (HRRP) Heart Failure — Number of discharges 200 — READM-30-HF-HRRP.num_discharges
Readmissions (HRRP) Heart Failure — Number of readmissions 51 — READM-30-HF-HRRP.num_readmissions
Readmissions (HRRP) Heart Failure — Predicted readmission rate 22.0% — READM-30-HF-HRRP.predicted_readmission_rate
Readmissions (HRRP) Pneumonia — Excess readmission ratio 1.07 0.9955 p85 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 18.2% — READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Number of discharges 84 — READM-30-PN-HRRP.num_discharges
Readmissions (HRRP) Pneumonia — Number of readmissions 21 — READM-30-PN-HRRP.num_readmissions
Readmissions (HRRP) Pneumonia — Predicted readmission rate 19.4% — READM-30-PN-HRRP.predicted_readmission_rate
Value-Based Purchasing Clinical Outcomes 7.50 5.00 p67 clinical_outcomes_score
Value-Based Purchasing Efficiency & Cost Reduction 0.00 2.50 p0 efficiency_score
Value-Based Purchasing Person & Community Engagement 3.00 8.75 p5 person_community_score
Value-Based Purchasing Safety 2.50 10.00 p3 safety_score
Value-Based Purchasing Total Performance Score 13.00 29.50 p2 total_performance_score
Methodology

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