JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Baptist Health Deaconess Madisonville

2 / 5

At a glance

Baptist Health Deaconess Madisonville carries a 2-star CMS overall rating — below the national norm. On healthcare-associated infection measures, it performs better than the national average on 6 and worse on 0.

Healthcare-Associated Infections

lower is better · 36 measures reported

Rates of infections patients can acquire while receiving care, such as central-line and catheter-associated infections, MRSA, and C. difficile.

MeasureScoreCompared to national
Central Line Associated Bloodstream Infection (ICU + select Wards): Lower Confidence LimitSame as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit1.874Same as national
Central Line Associated Bloodstream Infection: Number of Device Days1878Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases1.599Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases0Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.000Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.323Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit3.455Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days2331Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases2.363Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases3Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)1.270Same as national
SSI - Colon Surgery: Lower Confidence Limit0.022Same as national
SSI - Colon Surgery: Upper Confidence Limit2.156Same as national
SSI - Colon Surgery: Number of Procedures78Same as national
SSI - Colon Surgery: Predicted Cases2.287Same as national
SSI - Colon Surgery: Observed Cases1Same as national
SSI - Colon Surgery0.437Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures21Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.265Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence Limit0.257Same as national
MRSA Bacteremia: Upper Confidence Limit2.746Same as national
MRSA Bacteremia: Patient Days39658Same as national
MRSA Bacteremia: Predicted Cases2.973Same as national
MRSA Bacteremia: Observed Cases3Same as national
MRSA Bacteremia1.009Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.003Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.323Better than national
Clostridium Difficile (C.Diff): Patient Days37486Better than national
Clostridium Difficile (C.Diff): Predicted Cases15.271Better than national
Clostridium Difficile (C.Diff): Observed Cases1Better than national
Clostridium Difficile (C.Diff)0.065Better than national

Complications & Deaths

lower is better · 20 measures reported

Rates of serious complications (like hip/knee replacement problems or accidental cuts during surgery) and 30-day mortality rates for common conditions.

MeasureScoreCompared to nationalSample
Rate of complications for hip/knee replacement patientsNot available
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate5Same as national572
Death rate for heart attack patients14.7Same as national95
Death rate for CABG surgery patients6.1Worse than national28
Death rate for COPD patients7.1Same as national75
Death rate for heart failure patients17.2Worse than national155
Death rate for pneumonia patients20.9Worse than national272
Death rate for stroke patients12.9Same as national75
Pressure ulcer rate0.62Same as national2019
Death rate among surgical inpatients with serious treatable complications171.80Same as national31
Iatrogenic pneumothorax rate0.18Same as national2427
In-hospital fall-associated fracture rate0.25Same as national2464
Postoperative hemorrhage or hematoma rate2.05Same as national485
Postoperative acute kidney injury requiring dialysis rate1.92Same as national170
Postoperative respiratory failure rate11.16Same as national157
Perioperative pulmonary embolism or deep vein thrombosis rate3.71Same as national494
Postoperative sepsis rate5.21Same as national151
Postoperative wound dehiscence rate1.65Same as national108
Abdominopelvic accidental puncture or laceration rate0.91Same as national453
CMS Medicare PSI 90: Patient safety and adverse events composite1.04Same as national

Unplanned Hospital Visits & Readmissions

lower is better · 14 measures reported

How often patients return to the hospital unexpectedly within 30 days of discharge — a marker of care quality and discharge planning.

MeasureScoreCompared to nationalSample
Hospital return days for heart attack patients69.3Not available80
Hospital return days for heart failure patients12.9Not available164
Hospital return days for pneumonia patients-26.1Not available268
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.7Same as national866
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)10.4Same as national1265
Rate of inpatient admissions for patients receiving outpatient chemotherapy9.5Same as national88
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy4.9Same as national88
Ratio of unplanned hospital visits after hospital outpatient surgery1Same as national258
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate13.5Same as national80
Rate of readmission for CABG10.6Same as national27
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients18.3Same as national84
Heart failure (HF) 30-Day Readmission Rate19.3Same as national164
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate14.4Same as national268

Patient Experience (HCAHPS)

higher is better · 9 measures reported

What patients say about their hospital stay — communication with nurses and doctors, responsiveness, cleanliness, pain management, and whether they would recommend the hospital.

MeasureScoreSample
Nurse communication - star rating4536
Doctor communication - star rating3536
Communication about medicines - star rating2536
Discharge information - star rating3536
Cleanliness - star rating3536
Quietness - star rating3536
Overall hospital rating - star rating3536
Recommend hospital - star rating3536
Summary star rating3536

Timely & Effective Care

higher is better (unless a wait time) · 30 measures reported

How consistently hospitals follow recommended care processes — for example, giving heart-attack patients aspirin on arrival, or the average time spent in the emergency department.

MeasureScoreSample
Emergency department volumemedium
Global Malnutrition Composite Score
Global Malnutrition Composite Score: Malnutrition Diagnosis Documented
Global Malnutrition Composite Score: Malnutrition Risk Screening
Global Malnutrition Composite Score: Nutrition Assessment
Global Malnutrition Composite Score: Nutritional Care Plan
Hospital Harm - Severe Hyperglycemia
Hospital Harm - Severe Hypoglycemia11703
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination881933
Average (median) time all patients spent in the emergency department before leaving from the visit, including psychiatric/mental health patients and patients who were transferred to another facility. A lower number of minutes is better194405
Average (median) time patients spent in the emergency department before leaving from the visit, excluding patients transferred to another facility or psychiatric care/mental health patients. A lower number of minutes is better187376
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better35212
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better44217
Left before being seen128808
Head CT results4511
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients9976
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing131536
Appropriate care for severe sepsis and septic shock50225
Septic Shock 3-Hour Bundle5483
Septic Shock 6-Hour Bundle5040
Severe Sepsis 3-Hour Bundle78225
Severe Sepsis 6-Hour Bundle96123
Discharged on Antithrombotic Therapy10069
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 29471
Venous Thromboembolism Prophylaxis
Intensive Care Unit Venous Thromboembolism Prophylaxis

Maternal Health

lower is better · 4 measures reported

Measures of maternal outcomes and safe delivery practices, including severe complications during childbirth.

MeasureScoreSample
Cesarean Birth
Risk Adjusted Severe Obstetric Complications (All)
Risk Adjusted Severe Obstetric Complications (excluding blood-transfusion-only cases)
Maternal Morbidity Structural MeasureYes

Frequently asked questions

How is Baptist Health Deaconess Madisonville rated?
Baptist Health Deaconess Madisonville has a 2 out of 5 CMS overall star rating as of the latest CMS release.
Does Baptist Health Deaconess Madisonville have emergency services?
Yes. Baptist Health Deaconess Madisonville operates a 24/7 emergency department.
Where is Baptist Health Deaconess Madisonville located?
Baptist Health Deaconess Madisonville is located at 900 Hospital Drive, Madisonville, KY 42431.
What type of hospital is Baptist Health Deaconess Madisonville?
Baptist Health Deaconess Madisonville is classified by CMS as a Acute Care Hospitals facility (Voluntary non-profit - Private).

Data as of 2026-06-14. Source: CMS Provider Data Catalog. This is public data provided for informational purposes only and is not medical advice. See our methodology and editorial policy.

Report an issue with this page