Hospital

TIDELANDS GEORGETOWN MEMORIAL HOSPITAL

CCN: 420020 · GEORGETOWN, SC 29440 · GEORGETOWN County

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

Overview

Address
606 BLACK RIVER RD DRAWER 1718, GEORGETOWN, SC 29440
Phone
(843) 527-7000
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 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 2 of 8 measures reported
1
1
Better No different Worse
Healthcare-associated infections and patient safety indicators (PSI-90 composite).
Readmission 9 of 11 measures reported
9
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) 139 discharges
1.0921 p92
Heart Failure 158 discharges
0.9970 p48
Pneumonia 150 discharges
0.9958 p50
COPD
0.9928 p45
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.

15.7 p5
Total Performance Score
National median: 29.5
Clinical Outcomes 25% weight
1.9 p20
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
3.3 p5
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
7.5 p67
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: 1.0921
Value-Based Purchasing
15.7 TPS
Below national median
HAC Reduction
No Reduction
HAC Score: 0.3113

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 4.40 No Different Than the National Rate 471
MORT_30_AMI 13.10 No Different Than the National Rate 113
MORT_30_CABG — — —
MORT_30_COPD 9.40 No Different Than the National Rate 39
MORT_30_HF 15.90 Worse Than the National Rate 154
MORT_30_PN 14.30 No Different Than the National Rate 150
MORT_30_STK 11.70 No Different Than the National Rate 53
PSI_03 0.38 No Different Than the National Rate 1,332
PSI_04 — Number of Cases Too Small —
PSI_06 0.30 No Different Than the National Rate 1,803
PSI_08 0.26 No Different Than the National Rate 1,798
PSI_09 2.79 No Different Than the National Rate 323
PSI_10 1.61 No Different Than the National Rate 134
PSI_11 9.60 No Different Than the National Rate 139
PSI_12 3.16 No Different Than the National Rate 334
PSI_13 4.91 No Different Than the National Rate 131
PSI_14 1.73 No Different Than the National Rate 63
PSI_15 1.00 No Different Than the National Rate 270
PSI_90 0.92 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 75% —
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 8% —
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 — 2
H_NURSE_RESPECT_A_P: Nurses "always" treated them with courtesy and respect 81% —
H_NURSE_RESPECT_SN_P: Nurses "sometimes" or "never" treated them with courtesy and respect 5% —
H_NURSE_RESPECT_U_P: Nurses "usually" treated them with courtesy and respect 14% —
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 73% —
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 8% —
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 19% —
H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand 70% —
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 20% —
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 83% —
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 13% —
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 79% —
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 5% —
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 16% —
H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand 77% —
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 18% —
H_COMP_5_A_P: Staff "always" explained 56% —
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 25% —
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 — 2
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 39% —
H_SIDE_EFFECTS_SN_P: Staff "sometimes" or "never" explained possible side effects 38% —
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 16% —
H_COMP_6_Y_P: Yes, staff "did" give patients this information 84% —
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 19% —
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge 81% —
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 63% —
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 16% —
H_CLEAN_HSP_U_P: Room was "usually" clean 21% —
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 56% —
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 12% —
H_QUIET_HSP_U_P: "Usually" quiet at night 32% —
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) 14% —
H_HSP_RATING_7_8: Patients who gave a rating of "7" or "8" (medium) 24% —
H_HSP_RATING_9_10: Patients who gave a rating of "9" or "10" (high) 62% —
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) 10% —
H_RECMND_DY: "YES", patients would definitely recommend the hospital 57% —
H_RECMND_PY: "YES", patients would probably recommend the hospital 33% —
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 — —
HAI_1_CIUPPER — —
HAI_1_DOPC 1628.000 —
HAI_1_ELIGCASES 0.945 —
HAI_1_NUMERATOR 2.000 —
HAI_1_SIR — —
HAI_2_CILOWER — —
HAI_2_CIUPPER — —
HAI_2_DOPC 1621.000 —
HAI_2_ELIGCASES 0.797 —
HAI_2_NUMERATOR 1.000 —
HAI_2_SIR — —
HAI_3_CILOWER — —
HAI_3_CIUPPER — —
HAI_3_DOPC 24.000 —
HAI_3_ELIGCASES 0.621 —
HAI_3_NUMERATOR 0.000 —
HAI_3_SIR — —
HAI_4_CILOWER — —
HAI_4_CIUPPER — —
HAI_4_DOPC 47.000 —
HAI_4_ELIGCASES 0.387 —
HAI_4_NUMERATOR 1.000 —
HAI_4_SIR — —
HAI_5_CILOWER 0.269 No Different than National Benchmark
HAI_5_CIUPPER 5.299 No Different than National Benchmark
HAI_5_DOPC 20985.000 No Different than National Benchmark
HAI_5_ELIGCASES 1.247 No Different than National Benchmark
HAI_5_NUMERATOR 2.000 No Different than National Benchmark
HAI_5_SIR 1.604 No Different than National Benchmark
HAI_6_CILOWER 0.006 Better than the National Benchmark
HAI_6_CIUPPER 0.636 Better than the National Benchmark
HAI_6_DOPC 20985.000 Better than the National Benchmark
HAI_6_ELIGCASES 7.752 Better than the National Benchmark
HAI_6_NUMERATOR 1.000 Better than the National Benchmark
HAI_6_SIR 0.129 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 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 — Electronic Clinical Quality Measure
HH_ORAE — Electronic Clinical Quality Measure
IMM_3 87.0 Healthcare Personnel Vaccination
OP_18a 170.0 Emergency Department
OP_18b 168.0 Emergency Department
OP_18c — Emergency Department
OP_18d — Emergency Department
OP_22 3.0 Emergency Department
OP_23 — Emergency Department
OP_29 90.0 Colonoscopy care
OP_31 — Cataract surgery outcome
OP_40 — Electronic Clinical Quality Measure
SAFE_USE_OF_OPIOIDS 19.0 Electronic Clinical Quality Measure
SEP_1 31.0 Sepsis Care
SEP_SH_3HR 51.0 Sepsis Care
SEP_SH_6HR 21.0 Sepsis Care
SEV_SEP_3HR 68.0 Sepsis Care
SEV_SEP_6HR 79.0 Sepsis Care
STK_02 99.0 Electronic Clinical Quality Measure
STK_03 — Electronic Clinical Quality Measure
STK_05 91.0 Electronic Clinical Quality Measure
VTE_1 66.0 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 19.50 More Days Than Average per 100 Discharges
EDAC_30_HF 13.60 Average Days per 100 Discharges
EDAC_30_PN 1.70 Average Days per 100 Discharges
Hybrid_HWR 14.40 No Different Than the National Rate
OP_32 12.50 No Different Than the National Rate
OP_35_ADM 10.70 No Different Than the National Rate
OP_35_ED 6.90 No Different Than the National Rate
OP_36 1.00 No Different than expected
READM_30_AMI 14.70 No Different Than the National Rate
READM_30_CABG — —
READM_30_COPD 18.00 No Different Than the National Rate
READM_30_HF 19.60 No Different Than the National Rate
READM_30_HIP_KNEE — Number of Cases Too Small
READM_30_PN 15.90 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
0.94

Financial Health (Cost Report — FY 2023)

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 0.24 — metrics.cost_to_charge_ratio
Cost Report Current Ratio 1.77 — metrics.current_ratio
Cost Report Employees per Bed 11.81 — metrics.employees_per_bed
Cost Report fiscal_year 2,023 — fiscal_year
Cost Report Fund Balance ($) $94,665,777 — metrics.fund_balance
Cost Report Net Income ($) $21,646,281 — metrics.net_income
Cost Report Net Patient Revenue ($) $190,399,612 — metrics.net_patient_revenue
Cost Report Operating Margin (%) 0.4% — metrics.operating_margin
Cost Report Total Assets ($) $409,946,074 — metrics.total_assets
Cost Report Total Costs ($) $151,464,827 — metrics.total_costs
Cost Report Total Liabilities ($) $315,280,297 — metrics.total_liabilities
Cost Report Total Margin (%) 10.2% — metrics.total_margin
Cost Report Uncompensated Care (%) 5.9% — metrics.uncompensated_care_pct
General Information Address 606 BLACK RIVER RD DRAWER 1718 — Address
General Information City/Town GEORGETOWN — 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 9 — Count of Facility READM Measures
General Information Count of Facility Safety Measures 2 — 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 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 0 — Count of READM Measures Better
General Information Count of READM Measures No Different 9 — 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 1 — Count of Safety Measures No Different
General Information Count of Safety Measures Worse 0 — Count of Safety Measures Worse
General Information County/Parish GEORGETOWN — County/Parish
General Information Emergency Services Yes — Emergency Services
General Information Facility ID 420020 — Facility ID
General Information Facility Name TIDELANDS GEORGETOWN MEMORIAL HOSPITAL — 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 SC — State
General Information TE Group Footnote — — TE Group Footnote
General Information TE Group Measure Count 12 — TE Group Measure Count
General Information Telephone Number (843) 527-7000 — Telephone Number
General Information ZIP Code 29440 — ZIP Code
HAC Reduction Program fiscal_year 2,026 — fiscal_year
HAC Reduction Program measures — cdi — sir 0.18 — measures.cdi.sir
HAC Reduction Program measures — clabsi — sir 0.74 — measures.clabsi.sir
HAC Reduction Program measures — mrsa — sir 2.68 — measures.mrsa.sir
HAC Reduction Program measures — ssi — sir 0.99 — measures.ssi.sir
HAC Reduction Program payment_reduction No — payment_reduction
HAC Reduction Program total_hac_score 0.31 — 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 0.94 — Value
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Excess readmission ratio 1.09 0.9995 p92 READM-30-AMI-HRRP.excess_readmission_ratio
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Expected readmission rate 11.0% — READM-30-AMI-HRRP.expected_readmission_rate
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of discharges 139 — READM-30-AMI-HRRP.num_discharges
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of readmissions 21 — READM-30-AMI-HRRP.num_readmissions
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Predicted readmission rate 12.0% — READM-30-AMI-HRRP.predicted_readmission_rate
Readmissions (HRRP) COPD — Excess readmission ratio 0.99 0.9969 p45 READM-30-COPD-HRRP.excess_readmission_ratio
Readmissions (HRRP) COPD — Expected readmission rate 15.0% — READM-30-COPD-HRRP.expected_readmission_rate
Readmissions (HRRP) COPD — Predicted readmission rate 14.9% — READM-30-COPD-HRRP.predicted_readmission_rate
Readmissions (HRRP) Heart Failure — Excess readmission ratio 1.00 0.9983 p48 READM-30-HF-HRRP.excess_readmission_ratio
Readmissions (HRRP) Heart Failure — Expected readmission rate 18.5% — READM-30-HF-HRRP.expected_readmission_rate
Readmissions (HRRP) Heart Failure — Number of discharges 158 — READM-30-HF-HRRP.num_discharges
Readmissions (HRRP) Heart Failure — Number of readmissions 29 — 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 1.00 0.9955 p50 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 14.9% — READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Number of discharges 150 — READM-30-PN-HRRP.num_discharges
Readmissions (HRRP) Pneumonia — Number of readmissions 22 — READM-30-PN-HRRP.num_readmissions
Readmissions (HRRP) Pneumonia — Predicted readmission rate 14.9% — READM-30-PN-HRRP.predicted_readmission_rate
Value-Based Purchasing Clinical Outcomes 1.88 5.00 p20 clinical_outcomes_score
Value-Based Purchasing Efficiency & Cost Reduction 7.50 2.50 p67 efficiency_score
Value-Based Purchasing Person & Community Engagement 3.00 8.75 p5 person_community_score
Value-Based Purchasing Safety 3.33 10.00 p5 safety_score
Value-Based Purchasing Total Performance Score 15.71 29.50 p5 total_performance_score
Methodology

Full methodology →