Hospital

REGIONAL ONE HEALTH

CCN: 440152 · MEMPHIS, TN 38103 · SHELBY County

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

Overview

Address
877 JEFFERSON AVENUE, MEMPHIS, TN 38103
Phone
(901) 545-7928
Hospital Type
Acute Care
Ownership
Government (District)
Emergency Services
Yes
Birthing Friendly
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 1 of 7 measures reported
1
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
4
1
1
Better No different Worse
Healthcare-associated infections and patient safety indicators (PSI-90 composite).
Readmission 5 of 11 measures reported
5
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 does not have excess readmissions triggering HRRP penalties.
Acute Myocardial Infarction (Heart Attack)
— Not reported
Heart Failure
— Not reported
Pneumonia
— Not reported
COPD
— Not reported
Hip/Knee Replacement 0 discharges
— 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.

17.4 p9
Total Performance Score
National median: 29.5
Safety 25% weight
11.1 p56
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
6.3 p31
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)
Not Penalized
Value-Based Purchasing
17.4 TPS
Below national median
HAC Reduction
No Reduction
HAC Score: 0.1505

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 — — —
Hybrid_HWM 5.10 No Different Than the National Rate 272
MORT_30_AMI — Number of Cases Too Small —
MORT_30_CABG — — —
MORT_30_COPD — Number of Cases Too Small —
MORT_30_HF — Number of Cases Too Small —
MORT_30_PN — Number of Cases Too Small —
MORT_30_STK — Number of Cases Too Small —
PSI_03 0.61 No Different Than the National Rate 1,368
PSI_04 208.35 No Different Than the National Rate 58
PSI_06 0.20 No Different Than the National Rate 1,479
PSI_08 0.25 No Different Than the National Rate 1,168
PSI_09 2.21 No Different Than the National Rate 692
PSI_10 2.48 No Different Than the National Rate 147
PSI_11 13.75 No Different Than the National Rate 155
PSI_12 5.00 No Different Than the National Rate 682
PSI_13 5.30 No Different Than the National Rate 122
PSI_14 1.66 No Different Than the National Rate 130
PSI_15 0.94 No Different Than the National Rate 326
PSI_90 1.20 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 69% —
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 9% —
H_COMP_1_U_P: Nurses "usually" communicated well 22% —
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 76% —
H_NURSE_RESPECT_SN_P: Nurses "sometimes" or "never" treated them with courtesy and respect 6% —
H_NURSE_RESPECT_U_P: Nurses "usually" treated them with courtesy and respect 18% —
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 66% —
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 12% —
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 22% —
H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand 67% —
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 23% —
H_COMP_2_A_P: Doctors "always" communicated well 73% —
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 8% —
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 — 2
H_DOCTOR_RESPECT_A_P: Doctors "always" treated them with courtesy and respect 78% —
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 17% —
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 71% —
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 9% —
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 20% —
H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand 69% —
H_DOCTOR_EXPLAIN_SN_P: Doctors "sometimes" or "never" explained things so they could understand 9% —
H_DOCTOR_EXPLAIN_U_P: Doctors "usually" explained things so they could understand 22% —
H_COMP_5_A_P: Staff "always" explained 55% —
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 23% —
H_COMP_5_U_P: Staff "usually" explained 22% —
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 41% —
H_SIDE_EFFECTS_SN_P: Staff "sometimes" or "never" explained possible side effects 33% —
H_SIDE_EFFECTS_U_P: Staff "usually" explained possible side effects 26% —
H_COMP_6_N_P: No, staff "did not" give patients this information 19% —
H_COMP_6_Y_P: Yes, staff "did" give patients this information 81% —
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 21% —
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge 79% —
H_SYMPTOMS_N_P: No, staff "did not" give patients information about possible symptoms 17% —
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms 83% —
H_CLEAN_HSP_A_P: Room was "always" clean 60% —
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 18% —
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 56% —
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 13% —
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) 12% —
H_HSP_RATING_7_8: Patients who gave a rating of "7" or "8" (medium) 26% —
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 — 3
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 65% —
H_RECMND_PY: "YES", patients would probably recommend the hospital 25% —
H_RECMND_LINEAR_SCORE: Recommend hospital - linear mean score — —
H_RECMND_STAR_RATING: Recommend hospital - star rating — 3
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 0.174 Better than the National Benchmark
HAI_1_CIUPPER 0.894 Better than the National Benchmark
HAI_1_DOPC 9058.000 Better than the National Benchmark
HAI_1_ELIGCASES 13.966 Better than the National Benchmark
HAI_1_NUMERATOR 6.000 Better than the National Benchmark
HAI_1_SIR 0.430 Better than the National Benchmark
HAI_2_CILOWER 0.092 Better than the National Benchmark
HAI_2_CIUPPER 0.558 Better than the National Benchmark
HAI_2_DOPC 9117.000 Better than the National Benchmark
HAI_2_ELIGCASES 19.870 Better than the National Benchmark
HAI_2_NUMERATOR 5.000 Better than the National Benchmark
HAI_2_SIR 0.252 Better than the National Benchmark
HAI_3_CILOWER 0.208 No Different than National Benchmark
HAI_3_CIUPPER 1.260 No Different than National Benchmark
HAI_3_DOPC 238.000 No Different than National Benchmark
HAI_3_ELIGCASES 8.797 No Different than National Benchmark
HAI_3_NUMERATOR 5.000 No Different than National Benchmark
HAI_3_SIR 0.568 No Different than National Benchmark
HAI_4_CILOWER — —
HAI_4_CIUPPER — —
HAI_4_DOPC 57.000 —
HAI_4_ELIGCASES 0.644 —
HAI_4_NUMERATOR 0.000 —
HAI_4_SIR — —
HAI_5_CILOWER 1.837 Worse than the National Benchmark
HAI_5_CIUPPER 3.977 Worse than the National Benchmark
HAI_5_DOPC 98122.000 Worse than the National Benchmark
HAI_5_ELIGCASES 9.443 Worse than the National Benchmark
HAI_5_NUMERATOR 26.000 Worse than the National Benchmark
HAI_5_SIR 2.753 Worse than the National Benchmark
HAI_6_CILOWER 0.137 Better than the National Benchmark
HAI_6_CIUPPER 0.480 Better than the National Benchmark
HAI_6_DOPC 85270.000 Better than the National Benchmark
HAI_6_ELIGCASES 37.158 Better than the National Benchmark
HAI_6_NUMERATOR 10.000 Better than the National Benchmark
HAI_6_SIR 0.269 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 99.0 Healthcare Personnel Vaccination
OP_18a 299.0 Emergency Department
OP_18b 294.0 Emergency Department
OP_18c 429.0 Emergency Department
OP_18d — Emergency Department
OP_22 3.0 Emergency Department
OP_23 — Emergency Department
OP_29 97.0 Colonoscopy care
OP_31 — Cataract surgery outcome
OP_40 — Electronic Clinical Quality Measure
SAFE_USE_OF_OPIOIDS 9.0 Electronic Clinical Quality Measure
SEP_1 35.0 Sepsis Care
SEP_SH_3HR 25.0 Sepsis Care
SEP_SH_6HR 92.0 Sepsis Care
SEV_SEP_3HR 59.0 Sepsis Care
SEV_SEP_6HR 78.0 Sepsis Care
STK_02 89.0 Electronic Clinical Quality Measure
STK_03 — Electronic Clinical Quality Measure
STK_05 81.0 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 — Number of Cases Too Small
EDAC_30_PN — Number of Cases Too Small
Hybrid_HWR 16.20 No Different Than the National Rate
OP_32 12.80 No Different Than the National Rate
OP_35_ADM 11.70 No Different Than the National Rate
OP_35_ED 5.60 No Different Than the National Rate
OP_36 1.00 No Different than expected
READM_30_AMI — Number of Cases Too Small
READM_30_CABG — —
READM_30_COPD — Number of Cases Too Small
READM_30_HF — Number of Cases Too Small
READM_30_HIP_KNEE — —
READM_30_PN — Number of Cases Too Small

Medicare Spending Per Beneficiary

MSPB ratio: values > 1.0 mean this hospital's episode spending is higher than the national median hospital.

Value
1.14

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 0.25 — metrics.cost_to_charge_ratio
Cost Report Employees per Bed 10.51 — metrics.employees_per_bed
Cost Report fiscal_year 2,024 — fiscal_year
Cost Report Fund Balance ($) $142,058,860 — metrics.fund_balance
Cost Report Net Income ($) $-1,150,753 — metrics.net_income
Cost Report Net Patient Revenue ($) $440,382,933 — metrics.net_patient_revenue
Cost Report Occupancy Rate (%) 4.2% — metrics.occupancy_rate
Cost Report Operating Margin (%) -72.3% — metrics.operating_margin
Cost Report Total Assets ($) $400,618,766 — metrics.total_assets
Cost Report Total Costs ($) $459,265,764 — metrics.total_costs
Cost Report Total Liabilities ($) $258,559,906 — metrics.total_liabilities
Cost Report Total Margin (%) -0.1% — metrics.total_margin
Cost Report Uncompensated Care (%) 14.5% — metrics.uncompensated_care_pct
General Information Address 877 JEFFERSON AVENUE — Address
General Information City/Town MEMPHIS — City/Town
General Information Count of Facility MORT Measures 1 — 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 5 — 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 1 — 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 5 — 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 4 — 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 1 — Count of Safety Measures Worse
General Information County/Parish SHELBY — County/Parish
General Information Emergency Services Yes — Emergency Services
General Information Facility ID 440152 — Facility ID
General Information Facility Name REGIONAL ONE HEALTH — 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 Government - Hospital District or Authority — 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 (901) 545-7928 — Telephone Number
General Information ZIP Code 38103 — ZIP Code
HAC Reduction Program fiscal_year 2,026 — fiscal_year
HAC Reduction Program measures — cauti — sir 0.19 — measures.cauti.sir
HAC Reduction Program measures — cdi — sir 0.23 — measures.cdi.sir
HAC Reduction Program measures — clabsi — sir 0.48 — measures.clabsi.sir
HAC Reduction Program measures — mrsa — sir 2.61 — measures.mrsa.sir
HAC Reduction Program measures — ssi — sir 0.24 — measures.ssi.sir
HAC Reduction Program payment_reduction No — payment_reduction
HAC Reduction Program total_hac_score 0.15 — 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 1.14 — Value
Readmissions (HRRP) Hip/Knee Replacement — Number of discharges 0 — READM-30-HIP-KNEE-HRRP.num_discharges
Value-Based Purchasing Efficiency & Cost Reduction 0.00 2.50 p0 efficiency_score
Value-Based Purchasing Person & Community Engagement 6.33 8.75 p31 person_community_score
Value-Based Purchasing Safety 11.11 10.00 p56 safety_score
Value-Based Purchasing Total Performance Score 17.44 29.50 p9 total_performance_score
Methodology

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