JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Proprietary

Baycare Hospital Wesley Chapel

Not rated overall

CMS reports safety and quality measures for this hospital but does not assign an overall star rating. See scores below.

At a glance

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 LimitNot available
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence LimitNot available
Central Line Associated Bloodstream Infection: Number of Device Days579Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases0.335Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases0Not available
Central Line Associated Bloodstream Infection (ICU + select Wards)Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence LimitNot available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence LimitNot available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days765Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases0.402Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases0Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards)Not available
SSI - Colon Surgery: Lower Confidence LimitSame as national
SSI - Colon Surgery: Upper Confidence Limit2.837Same as national
SSI - Colon Surgery: Number of Procedures42Same as national
SSI - Colon Surgery: Predicted Cases1.056Same as national
SSI - Colon Surgery: Observed Cases0Same as national
SSI - Colon Surgery0.000Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of ProceduresNot available
SSI - Abdominal Hysterectomy: Predicted CasesNot available
SSI - Abdominal Hysterectomy: Observed CasesNot available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitNot available
MRSA Bacteremia: Upper Confidence LimitNot available
MRSA Bacteremia: Patient Days15029Not available
MRSA Bacteremia: Predicted Cases0.636Not available
MRSA Bacteremia: Observed Cases0Not available
MRSA BacteremiaNot available
Clostridium Difficile (C.Diff): Lower Confidence Limit0.050Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.983Better than national
Clostridium Difficile (C.Diff): Patient Days15029Better than national
Clostridium Difficile (C.Diff): Predicted Cases6.724Better than national
Clostridium Difficile (C.Diff): Observed Cases2Better than national
Clostridium Difficile (C.Diff)0.297Better 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 Rate4Same as national203
Death rate for heart attack patientsNot available
Death rate for CABG surgery patientsNot available
Death rate for COPD patientsNot available
Death rate for heart failure patientsNot available
Death rate for pneumonia patients15.3Same as national31
Death rate for stroke patientsNot available
Pressure ulcer rate0.54Same as national406
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.21Same as national515
In-hospital fall-associated fracture rate0.27Same as national510
Postoperative hemorrhage or hematoma rate2.32Same as national46
Postoperative acute kidney injury requiring dialysis rateNot available
Postoperative respiratory failure rateNot available
Perioperative pulmonary embolism or deep vein thrombosis rate3.44Same as national48
Postoperative sepsis rateNot available
Postoperative wound dehiscence rateNot available
Abdominopelvic accidental puncture or laceration rate1.04Same as national93
CMS Medicare PSI 90: Patient safety and adverse events composite0.97Same 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 patientsNot available
Hospital return days for heart failure patientsNot available
Hospital return days for pneumonia patients-23.8Not available32
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)16.3Same as national366
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)Not available
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 surgery0.9Same as national41
Acute Myocardial Infarction (AMI) 30-Day Readmission RateNot available
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patientsNot available
Heart failure (HF) 30-Day Readmission RateNot available
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate15.7Same as national32

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 rating4389
Doctor communication - star rating3389
Communication about medicines - star rating2389
Discharge information - star rating3389
Cleanliness - star rating5389
Quietness - star rating5389
Overall hospital rating - star rating4389
Recommend hospital - star rating5389
Summary star rating4389

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 Hypoglycemia
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination35881
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 better157740
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 better153710
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better27217
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better38013
Left before being seen120504
Head CT results
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 Prescribing23791
Appropriate care for severe sepsis and septic shock74152
Septic Shock 3-Hour Bundle7846
Septic Shock 6-Hour Bundle8431
Severe Sepsis 3-Hour Bundle86152
Severe Sepsis 6-Hour Bundle9682
Discharged on Antithrombotic Therapy10041
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 2
Venous Thromboembolism Prophylaxis881345
Intensive Care Unit Venous Thromboembolism Prophylaxis97640

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 MeasureNot Applicable (our hospital does not provide inpatient labor/delivery care)

Frequently asked questions

How is Baycare Hospital Wesley Chapel rated?
CMS does not assign an overall star rating to Baycare Hospital Wesley Chapel, but does publish underlying safety and quality measures shown on this page.
Does Baycare Hospital Wesley Chapel have emergency services?
Yes. Baycare Hospital Wesley Chapel operates a 24/7 emergency department.
Where is Baycare Hospital Wesley Chapel located?
Baycare Hospital Wesley Chapel is located at 4501 Bruce B Downs Blvd, Wesley Chapel, FL 33544.
What type of hospital is Baycare Hospital Wesley Chapel?
Baycare Hospital Wesley Chapel is classified by CMS as a Acute Care Hospitals facility (Proprietary).

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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