JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Church

Bethesda North

3 / 5

At a glance

Bethesda North carries a 3-star CMS overall rating — in line with the national norm. On healthcare-associated infection measures, it performs better than the national average on 12 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 Limit0.005Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit0.507Better than national
Central Line Associated Bloodstream Infection: Number of Device Days10537Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases9.724Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases1Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.103Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.163Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit1.239Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days7422Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases7.787Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases4Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.514Same as national
SSI - Colon Surgery: Lower Confidence Limit0.942Same as national
SSI - Colon Surgery: Upper Confidence Limit2.954Same as national
SSI - Colon Surgery: Number of Procedures271Same as national
SSI - Colon Surgery: Predicted Cases6.905Same as national
SSI - Colon Surgery: Observed Cases12Same as national
SSI - Colon Surgery1.738Same as national
SSI - Abdominal Hysterectomy: Lower Confidence Limit0.033Same as national
SSI - Abdominal Hysterectomy: Upper Confidence Limit3.245Same as national
SSI - Abdominal Hysterectomy: Number of Procedures177Same as national
SSI - Abdominal Hysterectomy: Predicted Cases1.520Same as national
SSI - Abdominal Hysterectomy: Observed Cases1Same as national
SSI - Abdominal Hysterectomy0.658Same as national
MRSA Bacteremia: Lower Confidence Limit0.417Same as national
MRSA Bacteremia: Upper Confidence Limit1.704Same as national
MRSA Bacteremia: Patient Days130546Same as national
MRSA Bacteremia: Predicted Cases8.913Same as national
MRSA Bacteremia: Observed Cases8Same as national
MRSA Bacteremia0.898Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.215Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.532Better than national
Clostridium Difficile (C.Diff): Patient Days121352Better than national
Clostridium Difficile (C.Diff): Predicted Cases54.703Better than national
Clostridium Difficile (C.Diff): Observed Cases19Better than national
Clostridium Difficile (C.Diff)0.347Better 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 patients3.2Same as national70
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4.4Same as national2947
Death rate for heart attack patients12Same as national383
Death rate for CABG surgery patients2.6Same as national180
Death rate for COPD patients10.4Same as national205
Death rate for heart failure patients11.1Same as national706
Death rate for pneumonia patients18.7Worse than national746
Death rate for stroke patients12.8Same as national290
Pressure ulcer rate0.20Same as national8174
Death rate among surgical inpatients with serious treatable complications167.21Same as national134
Iatrogenic pneumothorax rate0.12Same as national10801
In-hospital fall-associated fracture rate0.32Same as national11165
Postoperative hemorrhage or hematoma rate2.53Same as national2666
Postoperative acute kidney injury requiring dialysis rate1.44Same as national1146
Postoperative respiratory failure rate8.53Same as national1066
Perioperative pulmonary embolism or deep vein thrombosis rate3.22Same as national2945
Postoperative sepsis rate5.10Same as national1114
Postoperative wound dehiscence rate2.43Same as national516
Abdominopelvic accidental puncture or laceration rate0.88Same as national2206
CMS Medicare PSI 90: Patient safety and adverse events composite0.82Same 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 patients-4.8Not available422
Hospital return days for heart failure patients5.7Not available837
Hospital return days for pneumonia patients13.4Not available775
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)15.5Same as national4770
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)13.4Same as national2130
Rate of inpatient admissions for patients receiving outpatient chemotherapy10.5Same as national38
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy5.4Same as national38
Ratio of unplanned hospital visits after hospital outpatient surgery0.9Same as national751
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate14Same as national422
Rate of readmission for CABG10.5Same as national174
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients19.1Same as national232
Heart failure (HF) 30-Day Readmission Rate20.5Same as national837
Rate of readmission after hip/knee replacement5.9Same as national76
Pneumonia (PN) 30-Day Readmission Rate17.6Same as national775

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 rating41737
Doctor communication - star rating31737
Communication about medicines - star rating21737
Discharge information - star rating41737
Cleanliness - star rating31737
Quietness - star rating31737
Overall hospital rating - star rating31737
Recommend hospital - star rating41737
Summary star rating31737

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 vaccination744236
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 better154383
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 better151365
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better28612
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better
Left before being seen159295
Head CT results7744
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients96651
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing138159
Appropriate care for severe sepsis and septic shock52269
Septic Shock 3-Hour Bundle5585
Septic Shock 6-Hour Bundle7540
Severe Sepsis 3-Hour Bundle75269
Severe Sepsis 6-Hour Bundle95148
Discharged on Antithrombotic Therapy98416
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 296312
Venous Thromboembolism Prophylaxis9212469
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 Bethesda North rated?
Bethesda North has a 3 out of 5 CMS overall star rating as of the latest CMS release.
Does Bethesda North have emergency services?
Yes. Bethesda North operates a 24/7 emergency department.
Where is Bethesda North located?
Bethesda North is located at 10500 Montgomery Road, Cincinnati, OH 45242.
What type of hospital is Bethesda North?
Bethesda North is classified by CMS as a Acute Care Hospitals facility (Voluntary non-profit - Church).

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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