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

Overview

Address
565 COAL VALLEY ROAD, JEFFERSON HILLS, PA 15025
Phone
(412) 469-5000
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
7
Better No different Worse
30-day death rates for heart attack, heart failure, pneumonia, COPD, stroke, CABG, and kidney disease.
Safety of Care 7 of 8 measures reported
2
5
Better No different Worse
Healthcare-associated infections and patient safety indicators (PSI-90 composite).
Readmission 11 of 11 measures reported
11
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) 115 discharges
1.1602 p98
Heart Failure 362 discharges
0.9572 p23
Pneumonia 272 discharges
0.9897 p45
COPD 76 discharges
1.0474 p84
Hip/Knee Replacement
1.2713 p94
CABG Surgery
1.1038 p87
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.

39.0 p77
Total Performance Score
National median: 29.5
Clinical Outcomes 25% weight
4.2 p41
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
15.8 p83
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
14.0 p80
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
5.0 p56
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: 1.2713
Value-Based Purchasing
39.0 TPS
Above national median
HAC Reduction
No Reduction
HAC Score: -0.2671

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 3.40 No Different Than the National Rate 40
Hybrid_HWM 3.60 No Different Than the National Rate 832
MORT_30_AMI 12.90 No Different Than the National Rate 126
MORT_30_CABG 2.50 No Different Than the National Rate 55
MORT_30_COPD 9.10 No Different Than the National Rate 67
MORT_30_HF 10.10 No Different Than the National Rate 314
MORT_30_PN 19.60 No Different Than the National Rate 271
MORT_30_STK 14.50 No Different Than the National Rate 83
PSI_03 1.70 Worse Than the National Rate 2,957
PSI_04 174.99 No Different Than the National Rate 38
PSI_06 0.29 No Different Than the National Rate 3,417
PSI_08 0.24 No Different Than the National Rate 3,527
PSI_09 2.07 No Different Than the National Rate 899
PSI_10 1.36 No Different Than the National Rate 378
PSI_11 5.61 No Different Than the National Rate 379
PSI_12 3.29 No Different Than the National Rate 927
PSI_13 4.78 No Different Than the National Rate 369
PSI_14 1.69 No Different Than the National Rate 180
PSI_15 0.92 No Different Than the National Rate 619
PSI_90 1.17 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 82%
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 4%
H_COMP_1_U_P: Nurses "usually" communicated well 14%
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 89%
H_NURSE_RESPECT_SN_P: Nurses "sometimes" or "never" treated them with courtesy and respect 2%
H_NURSE_RESPECT_U_P: Nurses "usually" treated them with courtesy and respect 9%
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 82%
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 4%
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 14%
H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand 77%
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 17%
H_COMP_2_A_P: Doctors "always" communicated well 80%
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 4%
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 4
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 3%
H_DOCTOR_RESPECT_U_P: Doctors "usually" treated them with courtesy and respect 11%
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 80%
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 4%
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 16%
H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand 75%
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 19%
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 75%
H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications 7%
H_MED_FOR_U_P: Staff "usually" explained new medications 18%
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 49%
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 21%
H_COMP_6_N_P: No, staff "did not" give patients this information 14%
H_COMP_6_Y_P: Yes, staff "did" give patients this information 86%
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 12%
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms 88%
H_CLEAN_HSP_A_P: Room was "always" clean 79%
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 5%
H_CLEAN_HSP_U_P: Room was "usually" clean 16%
H_CLEAN_LINEAR_SCORE: Cleanliness - linear mean score
H_CLEAN_STAR_RATING: Cleanliness - star rating 4
H_QUIET_HSP_A_P: "Always" quiet at night 52%
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 15%
H_QUIET_HSP_U_P: "Usually" quiet at night 33%
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) 5%
H_HSP_RATING_7_8: Patients who gave a rating of "7" or "8" (medium) 18%
H_HSP_RATING_9_10: Patients who gave a rating of "9" or "10" (high) 77%
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 74%
H_RECMND_PY: "YES", patients would probably recommend the hospital 23%
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 0.035 Better than the National Benchmark
HAI_1_CIUPPER 0.692 Better than the National Benchmark
HAI_1_DOPC 9346.000 Better than the National Benchmark
HAI_1_ELIGCASES 9.554 Better than the National Benchmark
HAI_1_NUMERATOR 2.000 Better than the National Benchmark
HAI_1_SIR 0.209 Better than the National Benchmark
HAI_2_CILOWER 0.105 Better than the National Benchmark
HAI_2_CIUPPER 0.794 Better than the National Benchmark
HAI_2_DOPC 10038.000 Better than the National Benchmark
HAI_2_ELIGCASES 12.155 Better than the National Benchmark
HAI_2_NUMERATOR 4.000 Better than the National Benchmark
HAI_2_SIR 0.329 Better than the National Benchmark
HAI_3_CILOWER 0.224 No Different than National Benchmark
HAI_3_CIUPPER 2.401 No Different than National Benchmark
HAI_3_DOPC 140.000 No Different than National Benchmark
HAI_3_ELIGCASES 3.400 No Different than National Benchmark
HAI_3_NUMERATOR 3.000 No Different than National Benchmark
HAI_3_SIR 0.882 No Different than National Benchmark
HAI_4_CILOWER
HAI_4_CIUPPER
HAI_4_DOPC 18.000
HAI_4_ELIGCASES 0.165
HAI_4_NUMERATOR 0.000
HAI_4_SIR
HAI_5_CILOWER 0.011 No Different than National Benchmark
HAI_5_CIUPPER 1.115 No Different than National Benchmark
HAI_5_DOPC 74091.000 No Different than National Benchmark
HAI_5_ELIGCASES 4.424 No Different than National Benchmark
HAI_5_NUMERATOR 1.000 No Different than National Benchmark
HAI_5_SIR 0.226 No Different than National Benchmark
HAI_6_CILOWER 0.181 Better than the National Benchmark
HAI_6_CIUPPER 0.600 Better than the National Benchmark
HAI_6_DOPC 71475.000 Better than the National Benchmark
HAI_6_ELIGCASES 31.876 Better than the National Benchmark
HAI_6_NUMERATOR 11.000 Better than the National Benchmark
HAI_6_SIR 0.345 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 39.0 Healthcare Personnel Vaccination
OP_18a 174.0 Emergency Department
OP_18b 170.0 Emergency Department
OP_18c 297.0 Emergency Department
OP_18d 264.0 Emergency Department
OP_22 0.0 Emergency Department
OP_23 79.0 Emergency Department
OP_29 98.0 Colonoscopy care
OP_31 Cataract surgery outcome
OP_40 Electronic Clinical Quality Measure
SAFE_USE_OF_OPIOIDS 14.0 Electronic Clinical Quality Measure
SEP_1 72.0 Sepsis Care
SEP_SH_3HR 84.0 Sepsis Care
SEP_SH_6HR 85.0 Sepsis Care
SEV_SEP_3HR 87.0 Sepsis Care
SEV_SEP_6HR 97.0 Sepsis Care
STK_02 98.0 Electronic Clinical Quality Measure
STK_03 Electronic Clinical Quality Measure
STK_05 95.0 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 23.50 More Days Than Average per 100 Discharges
EDAC_30_HF -4.20 Average Days per 100 Discharges
EDAC_30_PN 17.50 More Days Than Average per 100 Discharges
Hybrid_HWR 15.40 No Different Than the National Rate
OP_32 12.60 No Different Than the National Rate
OP_35_ADM 10.90 No Different Than the National Rate
OP_35_ED 5.50 No Different Than the National Rate
OP_36 1.00 No Different than expected
READM_30_AMI 15.50 No Different Than the National Rate
READM_30_CABG 11.70 No Different Than the National Rate
READM_30_COPD 19.10 No Different Than the National Rate
READM_30_HF 18.80 No Different Than the National Rate
READM_30_HIP_KNEE 6.10 No Different Than the National Rate
READM_30_PN 15.80 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 93 rows
Source Metric Value National Median Pctl. Raw key
Cost Report Cost-to-Charge Ratio 0.19 metrics.cost_to_charge_ratio
Cost Report Employees per Bed 5.01 metrics.employees_per_bed
Cost Report fiscal_year 2,024 fiscal_year
Cost Report Fund Balance ($) $441,036,657 metrics.fund_balance
Cost Report Net Income ($) $16,029,241 metrics.net_income
Cost Report Net Patient Revenue ($) $338,591,362 metrics.net_patient_revenue
Cost Report Operating Margin (%) -1.7% metrics.operating_margin
Cost Report Total Assets ($) $451,650,963 metrics.total_assets
Cost Report Total Costs ($) $340,390,057 metrics.total_costs
Cost Report Total Liabilities ($) $9,475,094 metrics.total_liabilities
Cost Report Total Margin (%) 4.5% metrics.total_margin
Cost Report Uncompensated Care (%) 0.8% metrics.uncompensated_care_pct
General Information Address 565 COAL VALLEY ROAD Address
General Information City/Town JEFFERSON HILLS 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 11 Count of Facility READM Measures
General Information Count of Facility Safety Measures 7 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 7 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 11 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 2 Count of Safety Measures Better
General Information Count of Safety Measures No Different 5 Count of Safety Measures No Different
General Information Count of Safety Measures Worse 0 Count of Safety Measures Worse
General Information County/Parish ALLEGHENY County/Parish
General Information Emergency Services Yes Emergency Services
General Information Facility ID 390265 Facility ID
General Information Facility Name JEFFERSON HOSPITAL 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 (412) 469-5000 Telephone Number
General Information ZIP Code 15025 ZIP Code
HAC Reduction Program fiscal_year 2,026 fiscal_year
HAC Reduction Program measures — cauti — sir 0.25 measures.cauti.sir
HAC Reduction Program measures — cdi — sir 0.27 measures.cdi.sir
HAC Reduction Program measures — clabsi — sir 0.37 measures.clabsi.sir
HAC Reduction Program measures — mrsa — sir 0.48 measures.mrsa.sir
HAC Reduction Program measures — ssi — sir 0.43 measures.ssi.sir
HAC Reduction Program payment_reduction No payment_reduction
HAC Reduction Program total_hac_score -0.27 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 1.16 0.9995 p98 READM-30-AMI-HRRP.excess_readmission_ratio
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Expected readmission rate 11.6% READM-30-AMI-HRRP.expected_readmission_rate
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of discharges 115 READM-30-AMI-HRRP.num_discharges
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of readmissions 23 READM-30-AMI-HRRP.num_readmissions
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Predicted readmission rate 13.5% READM-30-AMI-HRRP.predicted_readmission_rate
Readmissions (HRRP) CABG Surgery — Excess readmission ratio 1.10 1.0000 p87 READM-30-CABG-HRRP.excess_readmission_ratio
Readmissions (HRRP) CABG Surgery — Expected readmission rate 9.4% READM-30-CABG-HRRP.expected_readmission_rate
Readmissions (HRRP) CABG Surgery — Predicted readmission rate 10.4% READM-30-CABG-HRRP.predicted_readmission_rate
Readmissions (HRRP) COPD — Excess readmission ratio 1.05 0.9969 p84 READM-30-COPD-HRRP.excess_readmission_ratio
Readmissions (HRRP) COPD — Expected readmission rate 16.0% READM-30-COPD-HRRP.expected_readmission_rate
Readmissions (HRRP) COPD — Number of discharges 76 READM-30-COPD-HRRP.num_discharges
Readmissions (HRRP) COPD — Number of readmissions 16 READM-30-COPD-HRRP.num_readmissions
Readmissions (HRRP) COPD — Predicted readmission rate 16.7% READM-30-COPD-HRRP.predicted_readmission_rate
Readmissions (HRRP) Heart Failure — Excess readmission ratio 0.96 0.9983 p23 READM-30-HF-HRRP.excess_readmission_ratio
Readmissions (HRRP) Heart Failure — Expected readmission rate 19.1% READM-30-HF-HRRP.expected_readmission_rate
Readmissions (HRRP) Heart Failure — Number of discharges 362 READM-30-HF-HRRP.num_discharges
Readmissions (HRRP) Heart Failure — Number of readmissions 63 READM-30-HF-HRRP.num_readmissions
Readmissions (HRRP) Heart Failure — Predicted readmission rate 18.3% READM-30-HF-HRRP.predicted_readmission_rate
Readmissions (HRRP) Hip/Knee Replacement — Excess readmission ratio 1.27 0.9916 p94 READM-30-HIP-KNEE-HRRP.excess_readmission_ratio
Readmissions (HRRP) Hip/Knee Replacement — Expected readmission rate 4.7% READM-30-HIP-KNEE-HRRP.expected_readmission_rate
Readmissions (HRRP) Hip/Knee Replacement — Predicted readmission rate 6.0% READM-30-HIP-KNEE-HRRP.predicted_readmission_rate
Readmissions (HRRP) Pneumonia — Excess readmission ratio 0.99 0.9955 p45 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 16.2% READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Number of discharges 272 READM-30-PN-HRRP.num_discharges
Readmissions (HRRP) Pneumonia — Number of readmissions 43 READM-30-PN-HRRP.num_readmissions
Readmissions (HRRP) Pneumonia — Predicted readmission rate 16.1% READM-30-PN-HRRP.predicted_readmission_rate
Value-Based Purchasing Clinical Outcomes 4.17 5.00 p41 clinical_outcomes_score
Value-Based Purchasing Efficiency & Cost Reduction 5.00 2.50 p56 efficiency_score
Value-Based Purchasing Person & Community Engagement 14.00 8.75 p80 person_community_score
Value-Based Purchasing Safety 15.83 10.00 p83 safety_score
Value-Based Purchasing Total Performance Score 39.00 29.50 p77 total_performance_score
Methodology

Full methodology →