JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Betsy Johnson Regional Hospital

3 / 5

At a glance

Betsy Johnson Regional Hospital carries a 3-star CMS overall rating — in line with the national norm.

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 Limit0.022Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit2.129Same as national
Central Line Associated Bloodstream Infection: Number of Device Days3266Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases2.316Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases1Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.432Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.906Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit5.484Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days2776Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases2.021Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases5Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)2.474Same as national
SSI - Colon Surgery: Lower Confidence LimitNot available
SSI - Colon Surgery: Upper Confidence LimitNot available
SSI - Colon Surgery: Number of Procedures13Not available
SSI - Colon Surgery: Predicted Cases0.383Not available
SSI - Colon Surgery: Observed Cases0Not available
SSI - Colon SurgeryNot available
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures6Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.059Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitNot available
MRSA Bacteremia: Upper Confidence LimitNot available
MRSA Bacteremia: Patient Days25563Not available
MRSA Bacteremia: Predicted Cases0.930Not available
MRSA Bacteremia: Observed Cases0Not available
MRSA BacteremiaNot available
Clostridium Difficile (C.Diff): Lower Confidence Limit0.266Same as national
Clostridium Difficile (C.Diff): Upper Confidence Limit1.202Same as national
Clostridium Difficile (C.Diff): Patient Days25563Same as national
Clostridium Difficile (C.Diff): Predicted Cases11.518Same as national
Clostridium Difficile (C.Diff): Observed Cases7Same as national
Clostridium Difficile (C.Diff)0.608Same as 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 Rate3.9Same as national417
Death rate for heart attack patients12.4Same as national61
Death rate for CABG surgery patientsNot available
Death rate for COPD patients9.3Same as national78
Death rate for heart failure patients12.7Same as national125
Death rate for pneumonia patients13.2Same as national206
Death rate for stroke patients12.6Same as national74
Pressure ulcer rate0.37Same as national1384
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.20Same as national1869
In-hospital fall-associated fracture rate0.25Same as national1907
Postoperative hemorrhage or hematoma rate2.23Same as national210
Postoperative acute kidney injury requiring dialysis rateNot available
Postoperative respiratory failure rate7.98Same as national28
Perioperative pulmonary embolism or deep vein thrombosis rate3.19Same as national213
Postoperative sepsis rateNot available
Postoperative wound dehiscence rate1.74Same as national30
Abdominopelvic accidental puncture or laceration rate1.04Same as national119
CMS Medicare PSI 90: Patient safety and adverse events composite0.86Same 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 patients54Not available153
Hospital return days for pneumonia patients-13.7Not available207
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.3Same as national629
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)13.1Same as national71
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 surgery1.1Same as national53
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate13.3Same as national44
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients18.2Same as national84
Heart failure (HF) 30-Day Readmission Rate21Same as national153
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate14.4Same as national207

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 rating4441
Doctor communication - star rating3441
Communication about medicines - star rating3441
Discharge information - star rating3441
Cleanliness - star rating3441
Quietness - star rating4441
Overall hospital rating - star rating3441
Recommend hospital - star rating3441
Summary star rating3441

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 vaccination941003
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 better222778
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 better216725
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better29748
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 seen548041
Head CT results7818
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)041
Safe Use of Opioids - Concurrent Prescribing22885
Appropriate care for severe sepsis and septic shock52119
Septic Shock 3-Hour Bundle6232
Septic Shock 6-Hour Bundle8614
Severe Sepsis 3-Hour Bundle67119
Severe Sepsis 6-Hour Bundle9346
Discharged on Antithrombotic Therapy9843
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 29649
Venous Thromboembolism Prophylaxis
Intensive Care Unit Venous Thromboembolism Prophylaxis92383

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 Betsy Johnson Regional Hospital rated?
Betsy Johnson Regional Hospital has a 3 out of 5 CMS overall star rating as of the latest CMS release.
Does Betsy Johnson Regional Hospital have emergency services?
Yes. Betsy Johnson Regional Hospital operates a 24/7 emergency department.
Where is Betsy Johnson Regional Hospital located?
Betsy Johnson Regional Hospital is located at 800 Tilghman Dr, Dunn, NC 28334.
What type of hospital is Betsy Johnson Regional Hospital?
Betsy Johnson Regional Hospital 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