JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Cape Cod Hospital

2 / 5

At a glance

Cape Cod Hospital carries a 2-star CMS overall rating — below the national norm. On healthcare-associated infection measures, it performs better than the national average on 18 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 LimitBetter than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit0.493Better than national
Central Line Associated Bloodstream Infection: Number of Device Days6010Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases6.077Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases0Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.000Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.147Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit1.116Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days7183Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases8.647Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases4Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.463Same as national
SSI - Colon Surgery: Lower Confidence Limit0.437Same as national
SSI - Colon Surgery: Upper Confidence Limit2.240Same as national
SSI - Colon Surgery: Number of Procedures228Same as national
SSI - Colon Surgery: Predicted Cases5.570Same as national
SSI - Colon Surgery: Observed Cases6Same as national
SSI - Colon Surgery1.077Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures38Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.291Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitBetter than national
MRSA Bacteremia: Upper Confidence Limit0.715Better than national
MRSA Bacteremia: Patient Days81384Better than national
MRSA Bacteremia: Predicted Cases4.190Better than national
MRSA Bacteremia: Observed Cases0Better than national
MRSA Bacteremia0.000Better than national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.148Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.520Better than national
Clostridium Difficile (C.Diff): Patient Days78219Better than national
Clostridium Difficile (C.Diff): Predicted Cases34.306Better than national
Clostridium Difficile (C.Diff): Observed Cases10Better than national
Clostridium Difficile (C.Diff)0.291Better 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 national116
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate3.8Same as national4297
Death rate for heart attack patients11.9Same as national592
Death rate for CABG surgery patients3.6Same as national68
Death rate for COPD patients8.3Same as national301
Death rate for heart failure patients12.8Same as national1087
Death rate for pneumonia patients16.6Same as national1559
Death rate for stroke patients11.6Same as national552
Pressure ulcer rate0.26Same as national13287
Death rate among surgical inpatients with serious treatable complications227.39Worse than national105
Iatrogenic pneumothorax rate0.20Same as national16268
In-hospital fall-associated fracture rate0.31Same as national16235
Postoperative hemorrhage or hematoma rate2.37Same as national3001
Postoperative acute kidney injury requiring dialysis rate2.01Same as national1077
Postoperative respiratory failure rate11.72Same as national1035
Perioperative pulmonary embolism or deep vein thrombosis rate3.84Same as national3144
Postoperative sepsis rate5.54Same as national1061
Postoperative wound dehiscence rate1.48Same as national627
Abdominopelvic accidental puncture or laceration rate1.07Same as national2708
CMS Medicare PSI 90: Patient safety and adverse events composite0.99Same 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 patients21.7Not available652
Hospital return days for heart failure patients13.4Not available1188
Hospital return days for pneumonia patients17.3Not available1548
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)16.5Worse than national7137
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)13.5Same as national1129
Rate of inpatient admissions for patients receiving outpatient chemotherapy11.9Same as national672
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy4.6Same as national672
Ratio of unplanned hospital visits after hospital outpatient surgery1Same as national1867
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate14.7Same as national652
Rate of readmission for CABG11.1Same as national66
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients19Same as national340
Heart failure (HF) 30-Day Readmission Rate21.8Worse than national1188
Rate of readmission after hip/knee replacement6.2Same as national99
Pneumonia (PN) 30-Day Readmission Rate17.5Same as national1548

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 rating31236
Doctor communication - star rating31236
Communication about medicines - star rating21236
Discharge information - star rating41236
Cleanliness - star rating31236
Quietness - star rating21236
Overall hospital rating - star rating31236
Recommend hospital - star rating41236
Summary star rating31236

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 volumevery high
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 vaccination862946
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 better208408
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 better202372
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better65034
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 seen281517
Head CT results8534
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients10071
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing203529
Appropriate care for severe sepsis and septic shock67127
Septic Shock 3-Hour Bundle5744
Septic Shock 6-Hour Bundle9416
Severe Sepsis 3-Hour Bundle86128
Severe Sepsis 6-Hour Bundle9467
Discharged on Antithrombotic Therapy98317
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 297304
Venous Thromboembolism Prophylaxis
Intensive Care Unit Venous Thromboembolism Prophylaxis971879

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 Cape Cod Hospital rated?
Cape Cod Hospital has a 2 out of 5 CMS overall star rating as of the latest CMS release.
Does Cape Cod Hospital have emergency services?
Yes. Cape Cod Hospital operates a 24/7 emergency department.
Where is Cape Cod Hospital located?
Cape Cod Hospital is located at 27 Park Street, Hyannis, MA 02601.
What type of hospital is Cape Cod Hospital?
Cape Cod 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