JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Baptist Memorial Hospital North Ms

4 / 5

At a glance

Baptist Memorial Hospital North Ms carries a 4-star CMS overall rating — above the national norm. On healthcare-associated infection measures, it performs better than the national average on 12 and worse on 0. For 30-day readmissions, it beats the national rate on 0 measures and trails on 2.

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 Limit0.054Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit1.057Same as national
Central Line Associated Bloodstream Infection: Number of Device Days7048Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases6.251Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases2Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.320Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.008Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit0.781Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days6323Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases6.318Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases1Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.158Better than national
SSI - Colon Surgery: Lower Confidence Limit0.198Same as national
SSI - Colon Surgery: Upper Confidence Limit2.123Same as national
SSI - Colon Surgery: Number of Procedures146Same as national
SSI - Colon Surgery: Predicted Cases3.846Same as national
SSI - Colon Surgery: Observed Cases3Same as national
SSI - Colon Surgery0.780Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures47Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.460Not available
SSI - Abdominal Hysterectomy: Observed Cases1Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitSame as national
MRSA Bacteremia: Upper Confidence Limit1.141Same as national
MRSA Bacteremia: Patient Days54726Same as national
MRSA Bacteremia: Predicted Cases2.625Same as national
MRSA Bacteremia: Observed Cases0Same as national
MRSA Bacteremia0.000Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.105Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.536Better than national
Clostridium Difficile (C.Diff): Patient Days52632Better than national
Clostridium Difficile (C.Diff): Predicted Cases23.268Better than national
Clostridium Difficile (C.Diff): Observed Cases6Better than national
Clostridium Difficile (C.Diff)0.258Better 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 patients3.9Same as national31
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate3.8Same as national1926
Death rate for heart attack patients12.8Same as national289
Death rate for CABG surgery patients3.1Same as national77
Death rate for COPD patients7.6Same as national157
Death rate for heart failure patients12Same as national596
Death rate for pneumonia patients15.7Same as national738
Death rate for stroke patients12.7Same as national165
Pressure ulcer rate0.20Same as national6808
Death rate among surgical inpatients with serious treatable complications136.87Same as national127
Iatrogenic pneumothorax rate0.21Same as national8957
In-hospital fall-associated fracture rate0.24Same as national9052
Postoperative hemorrhage or hematoma rate2.88Same as national1473
Postoperative acute kidney injury requiring dialysis rate1.42Same as national368
Postoperative respiratory failure rate8.37Same as national378
Perioperative pulmonary embolism or deep vein thrombosis rate4.45Same as national1649
Postoperative sepsis rate6.02Same as national351
Postoperative wound dehiscence rate1.47Same as national398
Abdominopelvic accidental puncture or laceration rate0.93Same as national1414
CMS Medicare PSI 90: Patient safety and adverse events composite0.90Same 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 patients0.9Not available307
Hospital return days for heart failure patients16Not available745
Hospital return days for pneumonia patients5.9Not available837
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)16.2Worse than national3395
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)14.3Same as national401
Rate of inpatient admissions for patients receiving outpatient chemotherapyNot available
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapyNot available
Ratio of unplanned hospital visits after hospital outpatient surgery1Same as national604
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate13.4Same as national307
Rate of readmission for CABG11.3Same as national74
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients19Same as national174
Heart failure (HF) 30-Day Readmission Rate22.4Worse than national745
Rate of readmission after hip/knee replacement5.6Same as national33
Pneumonia (PN) 30-Day Readmission Rate16.4Same as national837

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 rating5632
Doctor communication - star rating4632
Communication about medicines - star rating3632
Discharge information - star rating3632
Cleanliness - star rating3632
Quietness - star rating4632
Overall hospital rating - star rating4632
Recommend hospital - star rating5632
Summary star rating4632

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 volumehigh
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 Hypoglycemia
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination891926
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 better155555
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 better153529
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better21814
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better30312
Left before being seen147172
Head CT results7629
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing113072
Appropriate care for severe sepsis and septic shock86670
Septic Shock 3-Hour Bundle84188
Septic Shock 6-Hour Bundle97110
Severe Sepsis 3-Hour Bundle92674
Severe Sepsis 6-Hour Bundle99454
Discharged on Antithrombotic Therapy84143
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 294138
Venous Thromboembolism Prophylaxis996774
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 Memorial Hospital North Ms rated?
Baptist Memorial Hospital North Ms has a 4 out of 5 CMS overall star rating as of the latest CMS release.
Does Baptist Memorial Hospital North Ms have emergency services?
Yes. Baptist Memorial Hospital North Ms operates a 24/7 emergency department.
Where is Baptist Memorial Hospital North Ms located?
Baptist Memorial Hospital North Ms is located at 1100 Belk Blvd, Oxford, MS 38655.
What type of hospital is Baptist Memorial Hospital North Ms?
Baptist Memorial Hospital North Ms 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.

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