Hospital

ASCENSION SAINT THOMAS HOSPITAL

CCN: 440082 · NASHVILLE, TN 37205 · DAVIDSON County

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

Overview

Address
4220 HARDING RD, PO BOX 380, NASHVILLE, TN 37205
Phone
(615) 222-2111
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
3
4
Better No different Worse
30-day death rates for heart attack, heart failure, pneumonia, COPD, stroke, CABG, and kidney disease.
Safety of Care 8 of 8 measures reported
4
4
Better No different Worse
Healthcare-associated infections and patient safety indicators (PSI-90 composite).
Readmission 11 of 11 measures reported
2
8
1
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 10 of 12 measures reported
10 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) 717 discharges
0.9478 p19
Heart Failure 1,211 discharges
0.9846 p39
Pneumonia 719 discharges
0.8828 p2
COPD 188 discharges
0.9578 p15
Hip/Knee Replacement 261 discharges
1.0746 p72
CABG Surgery 629 discharges
1.0226 p58
Expected (1.0) National median

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: 1.0746
Value-Based Purchasing
—
HAC Reduction
No Reduction
HAC Score: -0.2453

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 288
Hybrid_HWM 4.00 No Different Than the National Rate 2,286
MORT_30_AMI 13.00 No Different Than the National Rate 587
MORT_30_CABG 1.80 No Different Than the National Rate 639
MORT_30_COPD 9.20 No Different Than the National Rate 171
MORT_30_HF 10.00 No Different Than the National Rate 1,035
MORT_30_PN 14.50 No Different Than the National Rate 694
MORT_30_STK 13.40 No Different Than the National Rate 523
PSI_03 0.07 Better Than the National Rate 10,077
PSI_04 223.48 Worse Than the National Rate 193
PSI_06 0.19 No Different Than the National Rate 12,028
PSI_08 0.29 No Different Than the National Rate 12,978
PSI_09 1.53 No Different Than the National Rate 4,403
PSI_10 1.58 No Different Than the National Rate 2,171
PSI_11 8.15 No Different Than the National Rate 2,189
PSI_12 3.21 No Different Than the National Rate 4,635
PSI_13 5.38 No Different Than the National Rate 2,129
PSI_14 1.37 No Different Than the National Rate 947
PSI_15 0.64 No Different Than the National Rate 2,396
PSI_90 0.76 Better 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 86% —
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 10% —
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 74% —
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 6% —
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 20% —
H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand 76% —
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 18% —
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 — 3
H_DOCTOR_RESPECT_A_P: Doctors "always" treated them with courtesy and respect 87% —
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 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 75% —
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 20% —
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 69% —
H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications 12% —
H_MED_FOR_U_P: Staff "usually" explained new medications 19% —
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 43% —
H_SIDE_EFFECTS_SN_P: Staff "sometimes" or "never" explained possible side effects 39% —
H_SIDE_EFFECTS_U_P: Staff "usually" explained possible side effects 18% —
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 16% —
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge 84% —
H_SYMPTOMS_N_P: No, staff "did not" give patients information about possible symptoms 9% —
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms 91% —
H_CLEAN_HSP_A_P: Room was "always" clean 62% —
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 12% —
H_CLEAN_HSP_U_P: Room was "usually" clean 26% —
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 58% —
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 11% —
H_QUIET_HSP_U_P: "Usually" quiet at night 31% —
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) 8% —
H_HSP_RATING_7_8: Patients who gave a rating of "7" or "8" (medium) 19% —
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) 4% —
H_RECMND_DY: "YES", patients would definitely recommend the hospital 76% —
H_RECMND_PY: "YES", patients would probably recommend the hospital 20% —
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 0.255 Better than the National Benchmark
HAI_1_CIUPPER 0.800 Better than the National Benchmark
HAI_1_DOPC 24034.000 Better than the National Benchmark
HAI_1_ELIGCASES 25.497 Better than the National Benchmark
HAI_1_NUMERATOR 12.000 Better than the National Benchmark
HAI_1_SIR 0.471 Better than the National Benchmark
HAI_2_CILOWER 0.202 Better than the National Benchmark
HAI_2_CIUPPER 0.668 Better than the National Benchmark
HAI_2_DOPC 20416.000 Better than the National Benchmark
HAI_2_ELIGCASES 28.624 Better than the National Benchmark
HAI_2_NUMERATOR 11.000 Better than the National Benchmark
HAI_2_SIR 0.384 Better than the National Benchmark
HAI_3_CILOWER 0.579 No Different than National Benchmark
HAI_3_CIUPPER 2.032 No Different than National Benchmark
HAI_3_DOPC 303.000 No Different than National Benchmark
HAI_3_ELIGCASES 8.770 No Different than National Benchmark
HAI_3_NUMERATOR 10.000 No Different than National Benchmark
HAI_3_SIR 1.140 No Different than National Benchmark
HAI_4_CILOWER 0.461 No Different than National Benchmark
HAI_4_CIUPPER 3.503 No Different than National Benchmark
HAI_4_DOPC 314.000 No Different than National Benchmark
HAI_4_ELIGCASES 2.754 No Different than National Benchmark
HAI_4_NUMERATOR 4.000 No Different than National Benchmark
HAI_4_SIR 1.452 No Different than National Benchmark
HAI_5_CILOWER 0.197 No Different than National Benchmark
HAI_5_CIUPPER 1.194 No Different than National Benchmark
HAI_5_DOPC 111280.000 No Different than National Benchmark
HAI_5_ELIGCASES 9.279 No Different than National Benchmark
HAI_5_NUMERATOR 5.000 No Different than National Benchmark
HAI_5_SIR 0.539 No Different than National Benchmark
HAI_6_CILOWER 0.287 Better than the National Benchmark
HAI_6_CIUPPER 0.666 Better than the National Benchmark
HAI_6_DOPC 99784.000 Better than the National Benchmark
HAI_6_ELIGCASES 49.211 Better than the National Benchmark
HAI_6_NUMERATOR 22.000 Better than the National Benchmark
HAI_6_SIR 0.447 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 — 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 6.0 Electronic Clinical Quality Measure
HH_HYPO 2.0 Electronic Clinical Quality Measure
HH_ORAE — Electronic Clinical Quality Measure
IMM_3 70.0 Healthcare Personnel Vaccination
OP_18a 206.0 Emergency Department
OP_18b 205.0 Emergency Department
OP_18c 272.0 Emergency Department
OP_18d — Emergency Department
OP_22 — Emergency Department
OP_23 — Emergency Department
OP_29 — Colonoscopy care
OP_31 — Cataract surgery outcome
OP_40 71.0 Electronic Clinical Quality Measure
SAFE_USE_OF_OPIOIDS 13.0 Electronic Clinical Quality Measure
SEP_1 49.0 Sepsis Care
SEP_SH_3HR 68.0 Sepsis Care
SEP_SH_6HR 100.0 Sepsis Care
SEV_SEP_3HR 65.0 Sepsis Care
SEV_SEP_6HR 80.0 Sepsis Care
STK_02 — Electronic Clinical Quality Measure
STK_03 — Electronic Clinical Quality Measure
STK_05 — Electronic Clinical Quality Measure
VTE_1 78.0 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 1.40 Average Days per 100 Discharges
EDAC_30_HF -11.20 Fewer Days Than Average per 100 Discharges
EDAC_30_PN -15.40 Fewer Days Than Average per 100 Discharges
Hybrid_HWR 13.90 Better Than the National Rate
OP_32 12.70 No Different Than the National Rate
OP_35_ADM — Number of Cases Too Small
OP_35_ED — Number of Cases Too Small
OP_36 1.20 No Different than expected
READM_30_AMI 13.20 No Different Than the National Rate
READM_30_CABG 10.80 No Different Than the National Rate
READM_30_COPD 17.40 No Different Than the National Rate
READM_30_HF 19.50 No Different Than the National Rate
READM_30_HIP_KNEE 5.40 No Different Than the National Rate
READM_30_PN 14.50 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
1.02
Footnote
29.00

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 94 rows
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 1.24 — metrics.current_ratio
Cost Report Employees per Bed 4.80 — metrics.employees_per_bed
Cost Report fiscal_year 2,024 — fiscal_year
Cost Report Fund Balance ($) $227,342,195 — metrics.fund_balance
Cost Report Net Income ($) $85,230,332 — metrics.net_income
Cost Report Net Patient Revenue ($) $1,132,311,546 — metrics.net_patient_revenue
Cost Report Operating Margin (%) -2.2% — metrics.operating_margin
Cost Report Total Assets ($) $815,650,130 — metrics.total_assets
Cost Report Total Costs ($) $1,024,071,664 — metrics.total_costs
Cost Report Total Liabilities ($) $588,307,935 — metrics.total_liabilities
Cost Report Total Margin (%) 6.8% — metrics.total_margin
Cost Report Uncompensated Care (%) 4.5% — metrics.uncompensated_care_pct
General Information Address 4220 HARDING RD, PO BOX 380 — Address
General Information City/Town NASHVILLE — 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 8 — Count of Facility Safety Measures
General Information Count of Facility TE Measures 10 — Count of Facility TE Measures
General Information Count of MORT Measures Better 3 — Count of MORT Measures Better
General Information Count of MORT Measures No Different 4 — 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 2 — Count of READM Measures Better
General Information Count of READM Measures No Different 8 — Count of READM Measures No Different
General Information Count of READM Measures Worse 1 — Count of READM Measures Worse
General Information Count of Safety Measures Better 4 — 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 0 — Count of Safety Measures Worse
General Information County/Parish DAVIDSON — County/Parish
General Information Emergency Services Yes — Emergency Services
General Information Facility ID 440082 — Facility ID
General Information Facility Name ASCENSION SAINT THOMAS 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 TN — State
General Information TE Group Footnote — — TE Group Footnote
General Information TE Group Measure Count 12 — TE Group Measure Count
General Information Telephone Number (615) 222-2111 — Telephone Number
General Information ZIP Code 37205 — ZIP Code
HAC Reduction Program fiscal_year 2,026 — fiscal_year
HAC Reduction Program measures — cauti — sir 0.47 — measures.cauti.sir
HAC Reduction Program measures — cdi — sir 0.36 — measures.cdi.sir
HAC Reduction Program measures — clabsi — sir 0.67 — measures.clabsi.sir
HAC Reduction Program measures — mrsa — sir 0.59 — measures.mrsa.sir
HAC Reduction Program measures — ssi — sir 1.05 — measures.ssi.sir
HAC Reduction Program payment_reduction No — payment_reduction
HAC Reduction Program total_hac_score -0.25 — total_hac_score
Medicare Spending per Beneficiary End Date 12/31/2024 — End Date
Medicare Spending per Beneficiary Footnote 29 — Footnote
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 1.02 — Value
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Excess readmission ratio 0.95 0.9995 p19 READM-30-AMI-HRRP.excess_readmission_ratio
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Expected readmission rate 13.5% — READM-30-AMI-HRRP.expected_readmission_rate
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of discharges 717 — READM-30-AMI-HRRP.num_discharges
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of readmissions 89 — READM-30-AMI-HRRP.num_readmissions
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Predicted readmission rate 12.8% — READM-30-AMI-HRRP.predicted_readmission_rate
Readmissions (HRRP) CABG Surgery — Excess readmission ratio 1.02 1.0000 p58 READM-30-CABG-HRRP.excess_readmission_ratio
Readmissions (HRRP) CABG Surgery — Expected readmission rate 10.5% — READM-30-CABG-HRRP.expected_readmission_rate
Readmissions (HRRP) CABG Surgery — Number of discharges 629 — READM-30-CABG-HRRP.num_discharges
Readmissions (HRRP) CABG Surgery — Number of readmissions 68 — READM-30-CABG-HRRP.num_readmissions
Readmissions (HRRP) CABG Surgery — Predicted readmission rate 10.7% — READM-30-CABG-HRRP.predicted_readmission_rate
Readmissions (HRRP) COPD — Excess readmission ratio 0.96 0.9969 p15 READM-30-COPD-HRRP.excess_readmission_ratio
Readmissions (HRRP) COPD — Expected readmission rate 17.3% — READM-30-COPD-HRRP.expected_readmission_rate
Readmissions (HRRP) COPD — Number of discharges 188 — READM-30-COPD-HRRP.num_discharges
Readmissions (HRRP) COPD — Number of readmissions 28 — READM-30-COPD-HRRP.num_readmissions
Readmissions (HRRP) COPD — Predicted readmission rate 16.6% — READM-30-COPD-HRRP.predicted_readmission_rate
Readmissions (HRRP) Heart Failure — Excess readmission ratio 0.98 0.9983 p39 READM-30-HF-HRRP.excess_readmission_ratio
Readmissions (HRRP) Heart Failure — Expected readmission rate 19.6% — READM-30-HF-HRRP.expected_readmission_rate
Readmissions (HRRP) Heart Failure — Number of discharges 1,211 — READM-30-HF-HRRP.num_discharges
Readmissions (HRRP) Heart Failure — Number of readmissions 233 — READM-30-HF-HRRP.num_readmissions
Readmissions (HRRP) Heart Failure — Predicted readmission rate 19.3% — READM-30-HF-HRRP.predicted_readmission_rate
Readmissions (HRRP) Hip/Knee Replacement — Excess readmission ratio 1.07 0.9916 p72 READM-30-HIP-KNEE-HRRP.excess_readmission_ratio
Readmissions (HRRP) Hip/Knee Replacement — Expected readmission rate 5.4% — READM-30-HIP-KNEE-HRRP.expected_readmission_rate
Readmissions (HRRP) Hip/Knee Replacement — Number of discharges 261 — READM-30-HIP-KNEE-HRRP.num_discharges
Readmissions (HRRP) Hip/Knee Replacement — Number of readmissions 16 — READM-30-HIP-KNEE-HRRP.num_readmissions
Readmissions (HRRP) Hip/Knee Replacement — Predicted readmission rate 5.8% — READM-30-HIP-KNEE-HRRP.predicted_readmission_rate
Readmissions (HRRP) Pneumonia — Excess readmission ratio 0.88 0.9955 p2 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 15.6% — READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Number of discharges 719 — READM-30-PN-HRRP.num_discharges
Readmissions (HRRP) Pneumonia — Number of readmissions 91 — READM-30-PN-HRRP.num_readmissions
Readmissions (HRRP) Pneumonia — Predicted readmission rate 13.8% — READM-30-PN-HRRP.predicted_readmission_rate
Methodology

Full methodology →