Mercy Behavioral Hospital

After discharge, a random sample of each hospital's adult patients gets the same standardized survey: did nurses and doctors communicate well, was pain addressed, were medicines explained, was the room clean and quiet, would you recommend this place. The numbers shown are 'top-box' percentages — the share of patients who gave the most positive answer, like 'always'. CMS also publishes a summary star for the survey itself. Patient experience isn't the same thing as clinical quality, but it correlates with it, and it's the only measure here that comes straight from the people in the beds.

What to do with this: compare each percentage to the national average shown beside it, and weigh the survey by its size — the response count and rate are listed right below.

Not every patient is surveyed, and not everyone responds — response rates around 20–25% are typical. When too few patients complete the survey, CMS suppresses the scores and shows a footnote instead of a number; that footnote is CMS's own wording, shown here verbatim. A hospital with 'Not reported' survey scores is not a bad hospital — it's usually small, new, or treats patients the survey doesn't cover (like children's or psychiatric hospitals).

What to do with this: trust bigger survey counts more, and never read a blank as a bad sign — it isn't one.

Hospitals track infections patients pick up during care and report them to the CDC. The number shown is a standardized infection ratio (SIR): observed infections divided by the number predicted for a hospital of that size and type. An SIR of 1 means about as many as predicted; 0.5 means half; 2 means double. Because small numbers bounce around, CMS also publishes whether each SIR is statistically better, no different, or worse than the national benchmark — that category is the more reliable signal, and it's shown here verbatim.

What to do with this: put more weight on the category than the raw ratio, and ask any hospital how visitors and family can help with infection precautions — good teams love that question.

For most safety and outcome measures, CMS doesn't just publish a number — it tests whether the hospital's result is statistically better than, no different than, or worse than the national rate, and publishes that category. 'No different' is the honest middle: most hospitals land there on most measures. 'Number of cases too small' means CMS couldn't reliably tell either way. This site shows CMS's category word-for-word and never invents its own verdicts — when you see 'Worse than the national rate' on this page, that's CMS's math, not our opinion.

What to do with this: treat 'better' and 'worse' as CMS's statistically meaningful flags, and treat 'no different' as exactly that — not a hidden good or bad.

A central line is a catheter placed in a large vein, common in ICUs. Because it runs straight to the bloodstream, germs on it cause serious, largely preventable infections. Hospitals prevent CLABSI with strict insertion checklists, daily line reviews, and removing lines as soon as they're not needed.

What to do with this: if your person has a central line, it's fair to ask each day whether it's still needed — that one question mirrors what good hospitals already do.

Urinary catheters are common during surgery and serious illness, and the longer one stays in, the higher the infection risk. Hospitals prevent CAUTI by using catheters only when needed and removing them promptly.

What to do with this: ask whether a catheter is still necessary each day it's in — prompt removal is the main prevention.

Surgical site infections happen where the body was opened, from skin-level to deep tissue. CMS publicly reports them for two tracer operations — colon surgery and abdominal hysterectomy — because they're common enough to measure reliably. Prevention lives in the details: antibiotics timed right before the incision, sterile technique, warming, glucose control, and wound care after.

What to do with this: before a planned surgery, ask what the team does to prevent surgical infections and what warning signs to watch for at home.

MRSA is a strain of staph that standard antibiotics don't kill, which makes bloodstream infections with it dangerous and harder to treat. Hospitals fight it with hand hygiene, screening, isolation when needed, and careful device care.

What to do with this: the single best defense is hand hygiene — it is always okay to ask anyone entering the room, gently, whether they've cleaned their hands.

Clostridioides difficile causes serious diarrhea and gut inflammation, usually after antibiotics have cleared out the normal gut bacteria that keep it in check. It spreads by spores that survive on surfaces, so cleaning and hand-washing with soap and water (sanitizer doesn't kill the spores) matter enormously. It's one of the most common hospital-acquired infections nationwide.

What to do with this: ask whether every antibiotic your person is on is still needed — unnecessary antibiotics are C. diff's best friend.

For conditions like heart attack, heart failure, pneumonia, COPD, stroke, and bypass surgery, CMS tracks the share of Medicare patients who died within 30 days of admission — wherever the death occurred, in the hospital or after discharge. The rates are risk-adjusted for how sick each hospital's patients were, and each comes with CMS's better/no-different/worse-than-national category. The hospital-wide measure rolls all causes together. The complication measures work the same way: serious avoidable problems after procedures like hip or knee replacement.

What to do with this: look first at the condition that matters to your situation — if you're going in for heart surgery, the CABG line matters more than the composite.

A hospital that takes the hardest cases will lose more patients than one that doesn't — that's arithmetic, not quality. So CMS risk-adjusts these measures: each hospital's rate is adjusted for how old and how sick its patients were, so that what's left reflects care, not case mix. It isn't perfect — no adjustment fully captures how sick someone is — but it means a big-city trauma center and a small community hospital can be compared more fairly than raw numbers would allow.

What to do with this: read the rates as adjusted comparisons, not raw odds — and put the most weight on CMS's better/worse-than-national category, which accounts for the statistical uncertainty too.

These measures track how the hospital's processes actually run. ER time is the median minutes patients spent in the emergency department before leaving; 'left before being seen' is the share who gave up waiting. Sepsis care measures how often patients with severe sepsis or septic shock got every step of the recommended treatment bundle — sepsis is a leading cause of hospital death, and the bundle is time-critical. Staff flu vaccination protects patients who can't afford to catch it. CMS publishes these as plain numbers without a better/worse category, so the national average is shown beside each for context — the comparison is yours to make.

What to do with this: ER numbers matter most if you'll actually use this ER — for a planned admission, weigh the sepsis and vaccination numbers more.

CMS labels each emergency department by how many visits it handles per year. It's context, not quality — a 'very high' volume ER sees more of everything (and often has more specialists on hand) but may also have longer waits; a 'low' volume ER may be faster but transfer complex cases elsewhere.

What to do with this: read the ER wait times in light of the volume — and if your person has a complex condition, ask whether this ER typically treats it or transfers it.