Hospital

UPMC HANOVER

CCN: 390233 · HANOVER, PA 17331 · YORK County

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

Overview

Address
300 HIGHLAND AVE, HANOVER, PA 17331
Phone
(717) 637-3711
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 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
6
Better No different Worse
Healthcare-associated infections and patient safety indicators (PSI-90 composite).
Readmission 10 of 11 measures reported
10
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 has excess readmissions in at least one condition and is subject to HRRP payment reduction.
Acute Myocardial Infarction (Heart Attack) 93 discharges
1.1205 p95
Heart Failure 366 discharges
0.9640 p26
Pneumonia 403 discharges
0.9511 p20
COPD 148 discharges
0.9988 p51
Hip/Knee Replacement
0.9463 p36
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.

28.2 p45
Total Performance Score
National median: 29.5
Clinical Outcomes 25% weight
5.0 p47
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
11.7 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
11.5 p68
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: 1.1205
Value-Based Purchasing
28.2 TPS
Below national median
HAC Reduction
Payment Reduced
HAC Score: 0.5290

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 3.10 No Different Than the National Rate 65
Hybrid_HWM 4.00 No Different Than the National Rate 1,008
MORT_30_AMI 12.60 No Different Than the National Rate 126
MORT_30_CABG — — —
MORT_30_COPD 9.90 No Different Than the National Rate 141
MORT_30_HF 12.40 No Different Than the National Rate 338
MORT_30_PN 15.30 No Different Than the National Rate 390
MORT_30_STK 11.30 No Different Than the National Rate 140
PSI_03 0.60 No Different Than the National Rate 3,114
PSI_04 — Number of Cases Too Small —
PSI_06 0.28 No Different Than the National Rate 3,847
PSI_08 0.24 No Different Than the National Rate 3,844
PSI_09 2.62 No Different Than the National Rate 613
PSI_10 1.62 No Different Than the National Rate 135
PSI_11 14.38 No Different Than the National Rate 141
PSI_12 3.15 No Different Than the National Rate 629
PSI_13 5.71 No Different Than the National Rate 127
PSI_14 2.67 No Different Than the National Rate 167
PSI_15 1.19 No Different Than the National Rate 615
PSI_90 1.14 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 80% —
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 2% —
H_COMP_1_U_P: Nurses "usually" communicated well 18% —
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 88% —
H_NURSE_RESPECT_SN_P: Nurses "sometimes" or "never" treated them with courtesy and respect 1% —
H_NURSE_RESPECT_U_P: Nurses "usually" treated them with courtesy and respect 11% —
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 78% —
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 2% —
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 20% —
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 3% —
H_NURSE_EXPLAIN_U_P: Nurses "usually" explained things so they could understand 22% —
H_COMP_2_A_P: Doctors "always" communicated well 78% —
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 3% —
H_COMP_2_U_P: Doctors "usually" communicated well 19% —
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 86% —
H_DOCTOR_RESPECT_SN_P: Doctors "sometimes" or "never" treated them with courtesy and respect 2% —
H_DOCTOR_RESPECT_U_P: Doctors "usually" treated them with courtesy and respect 12% —
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 76% —
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 3% —
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 21% —
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 5% —
H_DOCTOR_EXPLAIN_U_P: Doctors "usually" explained things so they could understand 23% —
H_COMP_5_A_P: Staff "always" explained 59% —
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 18% —
H_COMP_5_U_P: Staff "usually" explained 23% —
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 7% —
H_MED_FOR_U_P: Staff "usually" explained new medications 20% —
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 45% —
H_SIDE_EFFECTS_SN_P: Staff "sometimes" or "never" explained possible side effects 30% —
H_SIDE_EFFECTS_U_P: Staff "usually" explained possible side effects 25% —
H_COMP_6_N_P: No, staff "did not" give patients this information 12% —
H_COMP_6_Y_P: Yes, staff "did" give patients this information 88% —
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 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 13% —
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms 87% —
H_CLEAN_HSP_A_P: Room was "always" clean 80% —
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 5% —
H_CLEAN_HSP_U_P: Room was "usually" clean 15% —
H_CLEAN_LINEAR_SCORE: Cleanliness - linear mean score — —
H_CLEAN_STAR_RATING: Cleanliness - star rating — 5
H_QUIET_HSP_A_P: "Always" quiet at night 57% —
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 7% —
H_QUIET_HSP_U_P: "Usually" quiet at night 36% —
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) 5% —
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) 73% —
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) 3% —
H_RECMND_DY: "YES", patients would definitely recommend the hospital 66% —
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 — 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 0.023 No Different than National Benchmark
HAI_1_CIUPPER 2.220 No Different than National Benchmark
HAI_1_DOPC 3276.000 No Different than National Benchmark
HAI_1_ELIGCASES 2.222 No Different than National Benchmark
HAI_1_NUMERATOR 1.000 No Different than National Benchmark
HAI_1_SIR 0.450 No Different than National Benchmark
HAI_2_CILOWER 0.122 No Different than National Benchmark
HAI_2_CIUPPER 2.398 No Different than National Benchmark
HAI_2_DOPC 4058.000 No Different than National Benchmark
HAI_2_ELIGCASES 2.756 No Different than National Benchmark
HAI_2_NUMERATOR 2.000 No Different than National Benchmark
HAI_2_SIR 0.726 No Different than National Benchmark
HAI_3_CILOWER 1.005 Worse than the National Benchmark
HAI_3_CIUPPER 7.627 Worse than the National Benchmark
HAI_3_DOPC 52.000 Worse than the National Benchmark
HAI_3_ELIGCASES 1.265 Worse than the National Benchmark
HAI_3_NUMERATOR 4.000 Worse than the National Benchmark
HAI_3_SIR 3.162 Worse than the National Benchmark
HAI_4_CILOWER — —
HAI_4_CIUPPER — —
HAI_4_DOPC 47.000 —
HAI_4_ELIGCASES 0.387 —
HAI_4_NUMERATOR 0.000 —
HAI_4_SIR — —
HAI_5_CILOWER 0.325 No Different than National Benchmark
HAI_5_CIUPPER 6.409 No Different than National Benchmark
HAI_5_DOPC 25370.000 No Different than National Benchmark
HAI_5_ELIGCASES 1.031 No Different than National Benchmark
HAI_5_NUMERATOR 2.000 No Different than National Benchmark
HAI_5_SIR 1.940 No Different than National Benchmark
HAI_6_CILOWER 0.503 No Different than National Benchmark
HAI_6_CIUPPER 1.579 No Different than National Benchmark
HAI_6_DOPC 24555.000 No Different than National Benchmark
HAI_6_ELIGCASES 12.919 No Different than National Benchmark
HAI_6_NUMERATOR 12.000 No Different than National Benchmark
HAI_6_SIR 0.929 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 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 2.0 Electronic Clinical Quality Measure
HH_ORAE — Electronic Clinical Quality Measure
IMM_3 94.0 Healthcare Personnel Vaccination
OP_18a 212.0 Emergency Department
OP_18b 209.0 Emergency Department
OP_18c 494.0 Emergency Department
OP_18d 289.0 Emergency Department
OP_22 1.0 Emergency Department
OP_23 93.0 Emergency Department
OP_29 98.0 Colonoscopy care
OP_31 — Cataract surgery outcome
OP_40 — Electronic Clinical Quality Measure
SAFE_USE_OF_OPIOIDS 18.0 Electronic Clinical Quality Measure
SEP_1 81.0 Sepsis Care
SEP_SH_3HR 86.0 Sepsis Care
SEP_SH_6HR 88.0 Sepsis Care
SEV_SEP_3HR 88.0 Sepsis Care
SEV_SEP_6HR 100.0 Sepsis Care
STK_02 99.0 Electronic Clinical Quality Measure
STK_03 — Electronic Clinical Quality Measure
STK_05 97.0 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 7.70 Average Days per 100 Discharges
EDAC_30_HF -5.20 Average Days per 100 Discharges
EDAC_30_PN -19.30 Fewer Days Than Average per 100 Discharges
Hybrid_HWR 15.90 No Different Than the National Rate
OP_32 13.10 No Different Than the National Rate
OP_35_ADM 11.30 No Different Than the National Rate
OP_35_ED 4.40 No Different Than the National Rate
OP_36 1.10 No Different than expected
READM_30_AMI 15.00 No Different Than the National Rate
READM_30_CABG — —
READM_30_COPD 18.10 No Different Than the National Rate
READM_30_HF 18.90 No Different Than the National Rate
READM_30_HIP_KNEE 4.60 No Different Than the National Rate
READM_30_PN 15.20 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
1.01

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 0.21 — metrics.cost_to_charge_ratio
Cost Report Employees per Bed 9.97 — metrics.employees_per_bed
Cost Report fiscal_year 2,024 — fiscal_year
Cost Report Fund Balance ($) $-30,601,627 — metrics.fund_balance
Cost Report Net Income ($) $22,202,431 — metrics.net_income
Cost Report Net Patient Revenue ($) $223,993,389 — metrics.net_patient_revenue
Cost Report Operating Margin (%) 22.3% — metrics.operating_margin
Cost Report Total Assets ($) $4,109,251 — metrics.total_assets
Cost Report Total Costs ($) $157,664,756 — metrics.total_costs
Cost Report Total Liabilities ($) $34,710,878 — metrics.total_liabilities
Cost Report Total Margin (%) 11.3% — metrics.total_margin
Cost Report Uncompensated Care (%) 2.5% — metrics.uncompensated_care_pct
General Information Address 300 HIGHLAND AVE — Address
General Information City/Town HANOVER — 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 10 — 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 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 10 — 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 0 — Count of Safety Measures Better
General Information Count of Safety Measures No Different 6 — Count of Safety Measures No Different
General Information Count of Safety Measures Worse 0 — Count of Safety Measures Worse
General Information County/Parish YORK — County/Parish
General Information Emergency Services Yes — Emergency Services
General Information Facility ID 390233 — Facility ID
General Information Facility Name UPMC HANOVER — 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 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 (717) 637-3711 — Telephone Number
General Information ZIP Code 17331 — ZIP Code
HAC Reduction Program fiscal_year 2,026 — fiscal_year
HAC Reduction Program measures — cauti — sir 1.10 — measures.cauti.sir
HAC Reduction Program measures — cdi — sir 0.86 — measures.cdi.sir
HAC Reduction Program measures — clabsi — sir 0 — measures.clabsi.sir
HAC Reduction Program measures — mrsa — sir 0 — measures.mrsa.sir
HAC Reduction Program measures — ssi — sir 1.88 — measures.ssi.sir
HAC Reduction Program payment_reduction Yes — payment_reduction
HAC Reduction Program total_hac_score 0.53 — 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 1.01 — Value
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Excess readmission ratio 1.12 0.9995 p95 READM-30-AMI-HRRP.excess_readmission_ratio
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Expected readmission rate 11.7% — READM-30-AMI-HRRP.expected_readmission_rate
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of discharges 93 — READM-30-AMI-HRRP.num_discharges
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of readmissions 18 — READM-30-AMI-HRRP.num_readmissions
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Predicted readmission rate 13.2% — READM-30-AMI-HRRP.predicted_readmission_rate
Readmissions (HRRP) COPD — Excess readmission ratio 1.00 0.9969 p51 READM-30-COPD-HRRP.excess_readmission_ratio
Readmissions (HRRP) COPD — Expected readmission rate 17.0% — READM-30-COPD-HRRP.expected_readmission_rate
Readmissions (HRRP) COPD — Number of discharges 148 — READM-30-COPD-HRRP.num_discharges
Readmissions (HRRP) COPD — Number of readmissions 25 — READM-30-COPD-HRRP.num_readmissions
Readmissions (HRRP) COPD — Predicted readmission rate 17.0% — READM-30-COPD-HRRP.predicted_readmission_rate
Readmissions (HRRP) Heart Failure — Excess readmission ratio 0.96 0.9983 p26 READM-30-HF-HRRP.excess_readmission_ratio
Readmissions (HRRP) Heart Failure — Expected readmission rate 18.9% — READM-30-HF-HRRP.expected_readmission_rate
Readmissions (HRRP) Heart Failure — Number of discharges 366 — READM-30-HF-HRRP.num_discharges
Readmissions (HRRP) Heart Failure — Number of readmissions 64 — READM-30-HF-HRRP.num_readmissions
Readmissions (HRRP) Heart Failure — Predicted readmission rate 18.2% — READM-30-HF-HRRP.predicted_readmission_rate
Readmissions (HRRP) Hip/Knee Replacement — Excess readmission ratio 0.95 0.9916 p36 READM-30-HIP-KNEE-HRRP.excess_readmission_ratio
Readmissions (HRRP) Hip/Knee Replacement — Expected readmission rate 5.9% — READM-30-HIP-KNEE-HRRP.expected_readmission_rate
Readmissions (HRRP) Hip/Knee Replacement — Predicted readmission rate 5.6% — READM-30-HIP-KNEE-HRRP.predicted_readmission_rate
Readmissions (HRRP) Pneumonia — Excess readmission ratio 0.95 0.9955 p20 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 15.0% — READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Number of discharges 403 — READM-30-PN-HRRP.num_discharges
Readmissions (HRRP) Pneumonia — Number of readmissions 54 — READM-30-PN-HRRP.num_readmissions
Readmissions (HRRP) Pneumonia — Predicted readmission rate 14.2% — READM-30-PN-HRRP.predicted_readmission_rate
Value-Based Purchasing Clinical Outcomes 5.00 5.00 p47 clinical_outcomes_score
Value-Based Purchasing Efficiency & Cost Reduction 0.00 2.50 p0 efficiency_score
Value-Based Purchasing Person & Community Engagement 11.50 8.75 p68 person_community_score
Value-Based Purchasing Safety 11.67 10.00 p59 safety_score
Value-Based Purchasing Total Performance Score 28.17 29.50 p45 total_performance_score
Methodology

Full methodology →