Hospital
TRISTAR SOUTHERN HILLS MEDICAL CENTER
CCN: 440197 · NASHVILLE, TN 37211 · DAVIDSON County
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Middle
Top quartile
Percentile badges compare this hospital to all 5,426 hospitals nationally.
Overview
- Address
- 391 WALLACE RD, NASHVILLE, TN 37211
- Phone
- (615) 781-4000
- Hospital Type
- Acute Care
- Ownership
- For-Profit
- Emergency Services
- Yes
4 /5
★★★★★
CMS Overall Rating
p63 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 4 of 7 measures reported
30-day death rates for heart attack, heart failure, pneumonia, COPD, stroke, CABG, and kidney disease.
Safety of Care 6 of 8 measures reported
Healthcare-associated infections and patient safety indicators (PSI-90 composite).
Readmission 5 of 11 measures reported
30-day unplanned readmission rates for heart attack, heart failure, pneumonia, COPD, hip/knee replacement, and CABG.
Patient Experience 8 of 8 measures reported
HCAHPS survey scores — patient-reported experience with communication, responsiveness, cleanliness, and discharge planning.
Timely & Effective Care 8 of 12 measures reported
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)
Heart Failure 117 discharges
Pneumonia 120 discharges
COPD
Hip/Knee Replacement
CABG Surgery
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.
19.7 p15
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
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
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: 1.0290
Value-Based Purchasing
19.7 TPS
Below national median
HAC Reduction
No Reduction
HAC Score: -0.5608
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 | 4.00 | No Different Than the National Rate | 349 |
| MORT_30_AMI | 11.30 | No Different Than the National Rate | 32 |
| MORT_30_CABG | — | — | — |
| MORT_30_COPD | — | Number of Cases Too Small | — |
| MORT_30_HF | 11.60 | No Different Than the National Rate | 102 |
| MORT_30_PN | 20.10 | No Different Than the National Rate | 114 |
| MORT_30_STK | 13.80 | No Different Than the National Rate | 51 |
| PSI_03 | 0.36 | No Different Than the National Rate | 1,269 |
| PSI_04 | — | Number of Cases Too Small | — |
| PSI_06 | 0.20 | No Different Than the National Rate | 1,704 |
| PSI_08 | 0.25 | No Different Than the National Rate | 1,683 |
| PSI_09 | 2.17 | No Different Than the National Rate | 333 |
| PSI_10 | 1.65 | No Different Than the National Rate | 162 |
| PSI_11 | 11.66 | No Different Than the National Rate | 178 |
| PSI_12 | 3.06 | No Different Than the National Rate | 329 |
| PSI_13 | 4.75 | No Different Than the National Rate | 155 |
| PSI_14 | 1.73 | No Different Than the National Rate | 104 |
| PSI_15 | 1.01 | No Different Than the National Rate | 234 |
| PSI_90 | 0.93 | 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 | 73% | — |
| H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well | 7% | — |
| H_COMP_1_U_P: Nurses "usually" communicated well | 20% | — |
| 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 | 69% | — |
| H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully | 9% | — |
| H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully | 22% | — |
| H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand | 68% | — |
| H_NURSE_EXPLAIN_SN_P: Nurses "sometimes" or "never" explained things so they could understand | 7% | — |
| H_NURSE_EXPLAIN_U_P: Nurses "usually" explained things so they could understand | 25% | — |
| H_COMP_2_A_P: Doctors "always" communicated well | 76% | — |
| H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well | 5% | — |
| 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 | 83% | — |
| 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 | 15% | — |
| H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully | 73% | — |
| H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully | 8% | — |
| H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully | 19% | — |
| H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand | 71% | — |
| 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 | 23% | — |
| H_COMP_5_A_P: Staff "always" explained | 52% | — |
| H_COMP_5_SN_P: Staff "sometimes" or "never" explained | 27% | — |
| H_COMP_5_U_P: Staff "usually" explained | 21% | — |
| 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 | 67% | — |
| H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications | 15% | — |
| H_MED_FOR_U_P: Staff "usually" explained new medications | 18% | — |
| H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects | 38% | — |
| 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 | 23% | — |
| H_COMP_6_N_P: No, staff "did not" give patients this information | 18% | — |
| H_COMP_6_Y_P: Yes, staff "did" give patients this information | 82% | — |
| 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 | 15% | — |
| H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms | 85% | — |
| H_CLEAN_HSP_A_P: Room was "always" clean | 72% | — |
| H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean | 12% | — |
| 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 | — | 3 |
| H_QUIET_HSP_A_P: "Always" quiet at night | 59% | — |
| H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night | 9% | — |
| 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) | 11% | — |
| 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) | 67% | — |
| 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) | 8% | — |
| H_RECMND_DY: "YES", patients would definitely recommend the hospital | 61% | — |
| 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 | — | 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 | 0.027 | No Different than National Benchmark |
| HAI_1_CIUPPER | 2.676 | No Different than National Benchmark |
| HAI_1_DOPC | 2026.000 | No Different than National Benchmark |
| HAI_1_ELIGCASES | 1.843 | No Different than National Benchmark |
| HAI_1_NUMERATOR | 1.000 | No Different than National Benchmark |
| HAI_1_SIR | 0.543 | No Different than National Benchmark |
| HAI_2_CILOWER | N/A | No Different than National Benchmark |
| HAI_2_CIUPPER | 1.112 | No Different than National Benchmark |
| HAI_2_DOPC | 2629.000 | No Different than National Benchmark |
| HAI_2_ELIGCASES | 2.694 | No Different than National Benchmark |
| HAI_2_NUMERATOR | 0.000 | No Different than National Benchmark |
| HAI_2_SIR | 0.000 | No Different than National Benchmark |
| HAI_3_CILOWER | 0.034 | No Different than National Benchmark |
| HAI_3_CIUPPER | 3.341 | No Different than National Benchmark |
| HAI_3_DOPC | 51.000 | No Different than National Benchmark |
| HAI_3_ELIGCASES | 1.476 | No Different than National Benchmark |
| HAI_3_NUMERATOR | 1.000 | No Different than National Benchmark |
| HAI_3_SIR | 0.678 | No Different than National Benchmark |
| HAI_4_CILOWER | — | — |
| HAI_4_CIUPPER | — | — |
| HAI_4_DOPC | — | — |
| HAI_4_ELIGCASES | — | — |
| HAI_4_NUMERATOR | — | — |
| HAI_4_SIR | — | — |
| HAI_5_CILOWER | 0.041 | No Different than National Benchmark |
| HAI_5_CIUPPER | 4.049 | No Different than National Benchmark |
| HAI_5_DOPC | 23215.000 | No Different than National Benchmark |
| HAI_5_ELIGCASES | 1.218 | No Different than National Benchmark |
| HAI_5_NUMERATOR | 1.000 | No Different than National Benchmark |
| HAI_5_SIR | 0.821 | No Different than National Benchmark |
| HAI_6_CILOWER | 0.005 | Better than the National Benchmark |
| HAI_6_CIUPPER | 0.496 | Better than the National Benchmark |
| HAI_6_DOPC | 23215.000 | Better than the National Benchmark |
| HAI_6_ELIGCASES | 9.940 | Better than the National Benchmark |
| HAI_6_NUMERATOR | 1.000 | Better than the National Benchmark |
| HAI_6_SIR | 0.101 | 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 | 38.0 | Healthcare Personnel Vaccination |
| OP_18a | 127.0 | Emergency Department |
| OP_18b | 122.0 | Emergency Department |
| OP_18c | 353.0 | Emergency Department |
| OP_18d | 236.0 | Emergency Department |
| OP_22 | 0.0 | Emergency Department |
| OP_23 | 73.0 | Emergency Department |
| OP_29 | 99.0 | Colonoscopy care |
| OP_31 | — | Cataract surgery outcome |
| OP_40 | — | Electronic Clinical Quality Measure |
| SAFE_USE_OF_OPIOIDS | 17.0 | Electronic Clinical Quality Measure |
| SEP_1 | 72.0 | Sepsis Care |
| SEP_SH_3HR | 72.0 | Sepsis Care |
| SEP_SH_6HR | 96.0 | Sepsis Care |
| SEV_SEP_3HR | 85.0 | Sepsis Care |
| SEV_SEP_6HR | 96.0 | Sepsis Care |
| STK_02 | — | Electronic Clinical Quality Measure |
| STK_03 | — | Electronic Clinical Quality Measure |
| STK_05 | 93.0 | Electronic Clinical Quality Measure |
| VTE_1 | 92.0 | Electronic Clinical Quality Measure |
| VTE_2 | 94.0 | 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 | 19.80 | More Days Than Average per 100 Discharges |
| EDAC_30_PN | -34.00 | Fewer Days Than Average per 100 Discharges |
| Hybrid_HWR | 14.80 | No Different Than the National Rate |
| OP_32 | 12.20 | No Different Than the National Rate |
| OP_35_ADM | — | — |
| OP_35_ED | — | — |
| OP_36 | 1.00 | No Different than expected |
| READM_30_AMI | 13.10 | No Different Than the National Rate |
| READM_30_CABG | — | — |
| READM_30_COPD | — | Number of Cases Too Small |
| READM_30_HF | 20.20 | No Different Than the National Rate |
| READM_30_HIP_KNEE | — | Number of Cases Too Small |
| READM_30_PN | 15.00 | 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
1.08
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.
Show 81 rows
| Source | Metric | Value | National Median | Pctl. | Raw key |
|---|---|---|---|---|---|
| Cost Report | Cost-to-Charge Ratio | 0.09 | — | metrics.cost_to_charge_ratio | |
| Cost Report | Current Ratio | 2.82 | — | metrics.current_ratio | |
| Cost Report | Employees per Bed | 4.25 | — | metrics.employees_per_bed | |
| Cost Report | fiscal_year | 2,024 | — | fiscal_year | |
| Cost Report | Fund Balance ($) | $165,876,965 | — | metrics.fund_balance | |
| Cost Report | Net Income ($) | $27,651,290 | — | metrics.net_income | |
| Cost Report | Net Patient Revenue ($) | $154,667,034 | — | metrics.net_patient_revenue | |
| Cost Report | Operating Margin (%) | 17.0% | — | metrics.operating_margin | |
| Cost Report | Total Assets ($) | $147,268,028 | — | metrics.total_assets | |
| Cost Report | Total Costs ($) | $108,956,189 | — | metrics.total_costs | |
| Cost Report | Total Liabilities ($) | $-18,608,937 | — | metrics.total_liabilities | |
| Cost Report | Total Margin (%) | 17.7% | — | metrics.total_margin | |
| Cost Report | Uncompensated Care (%) | 18.2% | — | metrics.uncompensated_care_pct | |
| General Information | Address | 391 WALLACE RD | — | Address | |
| General Information | City/Town | NASHVILLE | — | City/Town | |
| General Information | Count of Facility MORT Measures | 4 | — | 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 | 8 | — | 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 | 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 | 1 | — | Count of READM Measures Better | |
| General Information | Count of READM Measures No Different | 4 | — | 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 | 5 | — | 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 | 440197 | — | Facility ID | |
| General Information | Facility Name | TRISTAR SOUTHERN HILLS MEDICAL CENTER | — | Facility Name | |
| General Information | Hospital overall rating | 4 | — | Hospital overall rating | |
| General Information | Hospital overall rating footnote | — | — | Hospital overall rating footnote | |
| General Information | Hospital Ownership | Proprietary | — | 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 | 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) 781-4000 | — | Telephone Number | |
| General Information | ZIP Code | 37211 | — | ZIP Code | |
| HAC Reduction Program | fiscal_year | 2,026 | — | fiscal_year | |
| HAC Reduction Program | measures — cauti — sir | 0 | — | measures.cauti.sir | |
| HAC Reduction Program | measures — cdi — sir | 0.09 | — | measures.cdi.sir | |
| HAC Reduction Program | measures — clabsi — sir | 0.26 | — | measures.clabsi.sir | |
| HAC Reduction Program | measures — mrsa — sir | 1.22 | — | measures.mrsa.sir | |
| HAC Reduction Program | measures — ssi — sir | 0.38 | — | measures.ssi.sir | |
| HAC Reduction Program | payment_reduction | No | — | payment_reduction | |
| HAC Reduction Program | total_hac_score | -0.56 | — | 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 | 1.08 | — | Value | |
| Readmissions (HRRP) | Acute Myocardial Infarction (Heart Attack) — Excess readmission ratio | 0.96 | 0.9995 | p24 | READM-30-AMI-HRRP.excess_readmission_ratio |
| Readmissions (HRRP) | Acute Myocardial Infarction (Heart Attack) — Expected readmission rate | 12.6% | — | READM-30-AMI-HRRP.expected_readmission_rate | |
| Readmissions (HRRP) | Acute Myocardial Infarction (Heart Attack) — Predicted readmission rate | 12.0% | — | READM-30-AMI-HRRP.predicted_readmission_rate | |
| Readmissions (HRRP) | Heart Failure — Excess readmission ratio | 1.03 | 0.9983 | p69 | READM-30-HF-HRRP.excess_readmission_ratio |
| Readmissions (HRRP) | Heart Failure — Expected readmission rate | 18.2% | — | READM-30-HF-HRRP.expected_readmission_rate | |
| Readmissions (HRRP) | Heart Failure — Number of discharges | 117 | — | READM-30-HF-HRRP.num_discharges | |
| Readmissions (HRRP) | Heart Failure — Number of readmissions | 24 | — | READM-30-HF-HRRP.num_readmissions | |
| Readmissions (HRRP) | Heart Failure — Predicted readmission rate | 18.8% | — | READM-30-HF-HRRP.predicted_readmission_rate | |
| Readmissions (HRRP) | Pneumonia — Excess readmission ratio | 0.94 | 0.9955 | p15 | READM-30-PN-HRRP.excess_readmission_ratio |
| Readmissions (HRRP) | Pneumonia — Expected readmission rate | 14.1% | — | READM-30-PN-HRRP.expected_readmission_rate | |
| Readmissions (HRRP) | Pneumonia — Number of discharges | 120 | — | READM-30-PN-HRRP.num_discharges | |
| Readmissions (HRRP) | Pneumonia — Number of readmissions | 12 | — | READM-30-PN-HRRP.num_readmissions | |
| Readmissions (HRRP) | Pneumonia — Predicted readmission rate | 13.3% | — | 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 | 3.00 | 8.75 | p5 | person_community_score |
| Value-Based Purchasing | Safety | 11.67 | 10.00 | p59 | safety_score |
| Value-Based Purchasing | Total Performance Score | 19.67 | 29.50 | p15 | total_performance_score |
Methodology
- Hospital General Information (dataset:
xubh-q36u, vintage: 2026, downloaded: 2026-04-13) - Hospital Readmissions Reduction Program (dataset:
hrrp, vintage: FY2026, downloaded: 2026-04-13) - Hospital Value-Based Purchasing TPS (dataset:
hvbp-tps, vintage: FY2026, downloaded: 2026-04-13) - Timely and Effective Care — Hospital (dataset:
hosp-timely-care, vintage: 2026, downloaded: 2026-04-13) - Complications and Deaths — Hospital (dataset:
hosp-complications, vintage: 2026, downloaded: 2026-04-13) - Patient Survey (HCAHPS) — Hospital (dataset:
hosp-hcahps, vintage: 2026, downloaded: 2026-04-13) - Healthcare Associated Infections — Hospital (dataset:
hosp-hai, vintage: 2026, downloaded: 2026-04-13) - Unplanned Hospital Visits — Hospital (dataset:
hosp-unplanned-visits, vintage: 2026, downloaded: 2026-04-13) - Medicare Spending Per Beneficiary — Hospital (dataset:
hosp-mspb, vintage: 2026, downloaded: 2026-04-13) - Hospital Provider Cost Report (dataset:
hosp-cost-report, vintage: 2024, downloaded: 2026-04-13) - Hospital-Acquired Condition (HAC) Reduction Program (dataset:
hac-reduction, vintage: FY2026, downloaded: 2026-04-13)