JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Bozeman Health Deaconess Hospital

4 / 5

At a glance

Bozeman Health Deaconess Hospital carries a 4-star CMS overall rating — above 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 Limit0.035Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit3.476Same as national
Central Line Associated Bloodstream Infection: Number of Device Days1677Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases1.419Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases1Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.705Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.219Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit4.313Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days1520Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases1.532Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases2Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)1.305Same as national
SSI - Colon Surgery: Lower Confidence Limit0.020Same as national
SSI - Colon Surgery: Upper Confidence Limit1.956Same as national
SSI - Colon Surgery: Number of Procedures100Same as national
SSI - Colon Surgery: Predicted Cases2.522Same as national
SSI - Colon Surgery: Observed Cases1Same as national
SSI - Colon Surgery0.397Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures89Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.716Not available
SSI - Abdominal Hysterectomy: Observed Cases2Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence Limit0.034Same as national
MRSA Bacteremia: Upper Confidence Limit3.341Same as national
MRSA Bacteremia: Patient Days33412Same as national
MRSA Bacteremia: Predicted Cases1.476Same as national
MRSA Bacteremia: Observed Cases1Same as national
MRSA Bacteremia0.678Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.181Same as national
Clostridium Difficile (C.Diff): Upper Confidence Limit1.096Same as national
Clostridium Difficile (C.Diff): Patient Days29417Same as national
Clostridium Difficile (C.Diff): Predicted Cases10.111Same as national
Clostridium Difficile (C.Diff): Observed Cases5Same as national
Clostridium Difficile (C.Diff)0.495Same 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 patients3.3Same as national206
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate3.6Same as national1056
Death rate for heart attack patients11Same as national86
Death rate for CABG surgery patientsNot available
Death rate for COPD patients7.3Same as national84
Death rate for heart failure patients10.3Same as national196
Death rate for pneumonia patients10.8Better than national203
Death rate for stroke patients14.3Same as national121
Pressure ulcer rate0.58Same as national2571
Death rate among surgical inpatients with serious treatable complications166.44Same as national41
Iatrogenic pneumothorax rate0.23Same as national3574
In-hospital fall-associated fracture rate0.24Same as national3588
Postoperative hemorrhage or hematoma rate2.49Same as national899
Postoperative acute kidney injury requiring dialysis rate1.42Same as national453
Postoperative respiratory failure rate9.86Same as national463
Perioperative pulmonary embolism or deep vein thrombosis rate4.58Same as national938
Postoperative sepsis rate6.07Same as national441
Postoperative wound dehiscence rate1.64Same as national275
Abdominopelvic accidental puncture or laceration rate1.38Same as national844
CMS Medicare PSI 90: Patient safety and adverse events composite1.07Same 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-34Not available106
Hospital return days for heart failure patients0.5Not available215
Hospital return days for pneumonia patients-18.3Not available234
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.4Same as national1596
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)11.7Same as national1538
Rate of inpatient admissions for patients receiving outpatient chemotherapy9.2Same as national313
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy5.9Same as national313
Ratio of unplanned hospital visits after hospital outpatient surgery1.3Same as national621
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate12.7Same as national106
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients18.2Same as national95
Heart failure (HF) 30-Day Readmission Rate19.5Same as national215
Rate of readmission after hip/knee replacement4.2Same as national185
Pneumonia (PN) 30-Day Readmission Rate15.1Same as national234

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 rating4600
Doctor communication - star rating3600
Communication about medicines - star rating3600
Discharge information - star rating4600
Cleanliness - star rating3600
Quietness - star rating4600
Overall hospital rating - star rating4600
Recommend hospital - star rating4600
Summary star rating4600

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 vaccination553660
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 better142423
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 better142385
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better15436
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 seen133768
Head CT results9213
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients9763
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing141917
Appropriate care for severe sepsis and septic shock7975
Septic Shock 3-Hour Bundle9029
Septic Shock 6-Hour Bundle9021
Severe Sepsis 3-Hour Bundle8976
Severe Sepsis 6-Hour Bundle9544
Discharged on Antithrombotic Therapy10075
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 29845
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 Bozeman Health Deaconess Hospital rated?
Bozeman Health Deaconess Hospital has a 4 out of 5 CMS overall star rating as of the latest CMS release.
Does Bozeman Health Deaconess Hospital have emergency services?
Yes. Bozeman Health Deaconess Hospital operates a 24/7 emergency department.
Where is Bozeman Health Deaconess Hospital located?
Bozeman Health Deaconess Hospital is located at 915 Highland Blvd, Bozeman, MT 59715.
What type of hospital is Bozeman Health Deaconess Hospital?
Bozeman Health Deaconess 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.

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