JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Deaconess Medical Center

3 / 5

At a glance

Deaconess Medical Center 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. For 30-day readmissions, it beats the national rate on 1 measure and trails 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 Limit0.222Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit1.137Same as national
Central Line Associated Bloodstream Infection: Number of Device Days10527Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases10.972Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases6Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.547Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.111Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit0.842Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days9340Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases11.454Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases4Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.349Better than national
SSI - Colon Surgery: Lower Confidence Limit0.077Same as national
SSI - Colon Surgery: Upper Confidence Limit1.517Same as national
SSI - Colon Surgery: Number of Procedures168Same as national
SSI - Colon Surgery: Predicted Cases4.355Same as national
SSI - Colon Surgery: Observed Cases2Same as national
SSI - Colon Surgery0.459Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures30Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.267Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence Limit0.335Same as national
MRSA Bacteremia: Upper Confidence Limit2.544Same as national
MRSA Bacteremia: Patient Days54934Same as national
MRSA Bacteremia: Predicted Cases3.792Same as national
MRSA Bacteremia: Observed Cases4Same as national
MRSA Bacteremia1.055Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.271Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.727Better than national
Clostridium Difficile (C.Diff): Patient Days47030Better than national
Clostridium Difficile (C.Diff): Predicted Cases34.999Better than national
Clostridium Difficile (C.Diff): Observed Cases16Better than national
Clostridium Difficile (C.Diff)0.457Better 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 patients3.5Same as national52
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate3.9Same as national1402
Death rate for heart attack patients13.9Same as national187
Death rate for CABG surgery patients2.3Same as national63
Death rate for COPD patients8.6Same as national50
Death rate for heart failure patients13.9Same as national326
Death rate for pneumonia patients17.4Same as national317
Death rate for stroke patients14.1Same as national136
Pressure ulcer rate0.62Same as national3776
Death rate among surgical inpatients with serious treatable complications187.94Same as national102
Iatrogenic pneumothorax rate0.15Same as national5088
In-hospital fall-associated fracture rate0.26Same as national5290
Postoperative hemorrhage or hematoma rate3.90Worse than national1931
Postoperative acute kidney injury requiring dialysis rate1.81Same as national1073
Postoperative respiratory failure rate18.78Worse than national1110
Perioperative pulmonary embolism or deep vein thrombosis rate5.73Worse than national2023
Postoperative sepsis rate9.17Worse than national1099
Postoperative wound dehiscence rate2.14Same as national506
Abdominopelvic accidental puncture or laceration rate2.18Worse than national1341
CMS Medicare PSI 90: Patient safety and adverse events composite1.53Worse than 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 patients4.2Not available245
Hospital return days for heart failure patients-13.4Not available339
Hospital return days for pneumonia patients-16.8Not available317
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)13.2Better than national2080
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)13.2Same as national1733
Rate of inpatient admissions for patients receiving outpatient chemotherapy9.1Same as national279
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy5.6Same as national279
Ratio of unplanned hospital visits after hospital outpatient surgery1.2Same as national655
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate14.2Same as national245
Rate of readmission for CABG9.6Same as national62
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients18.3Same as national51
Heart failure (HF) 30-Day Readmission Rate17.8Same as national339
Rate of readmission after hip/knee replacement4.2Same as national54
Pneumonia (PN) 30-Day Readmission Rate14.3Same as national317

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 rating31950
Doctor communication - star rating31950
Communication about medicines - star rating21950
Discharge information - star rating41950
Cleanliness - star rating21950
Quietness - star rating21950
Overall hospital rating - star rating31950
Recommend hospital - star rating41950
Summary star rating31950

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 Hypoglycemia22269
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination924520
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 better182402
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 better181378
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better20022
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 seen270907
Head CT results4613
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients10076
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing163396
Appropriate care for severe sepsis and septic shock55138
Septic Shock 3-Hour Bundle7253
Septic Shock 6-Hour Bundle8431
Severe Sepsis 3-Hour Bundle74138
Severe Sepsis 6-Hour Bundle9371
Discharged on Antithrombotic Therapy98130
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 292106
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 Deaconess Medical Center rated?
Deaconess Medical Center has a 3 out of 5 CMS overall star rating as of the latest CMS release.
Does Deaconess Medical Center have emergency services?
Yes. Deaconess Medical Center operates a 24/7 emergency department.
Where is Deaconess Medical Center located?
Deaconess Medical Center is located at W 800 Fifth Avenue, Spokane, WA 99210.
What type of hospital is Deaconess Medical Center?
Deaconess Medical Center 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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