JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Duncan Regional Hospital, Inc

3 / 5

At a glance

Duncan Regional Hospital, Inc 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 Limit0.026Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit2.588Same as national
Central Line Associated Bloodstream Infection: Number of Device Days2824Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases1.906Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases1Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.525Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.564Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit4.279Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days3341Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases2.255Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases4Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)1.774Same as national
SSI - Colon Surgery: Lower Confidence LimitNot available
SSI - Colon Surgery: Upper Confidence LimitNot available
SSI - Colon Surgery: Number of Procedures10Not available
SSI - Colon Surgery: Predicted Cases0.260Not 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 Procedures1Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.005Not 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 Days17985Not available
MRSA Bacteremia: Predicted Cases0.668Not available
MRSA Bacteremia: Observed Cases1Not available
MRSA BacteremiaNot available
Clostridium Difficile (C.Diff): Lower Confidence Limit0.487Same as national
Clostridium Difficile (C.Diff): Upper Confidence Limit1.831Same as national
Clostridium Difficile (C.Diff): Patient Days16921Same as national
Clostridium Difficile (C.Diff): Predicted Cases9.021Same as national
Clostridium Difficile (C.Diff): Observed Cases9Same as national
Clostridium Difficile (C.Diff)0.998Same 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 patients3.1Same as national171
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4Same as national792
Death rate for heart attack patients12.4Same as national33
Death rate for CABG surgery patientsNot available
Death rate for COPD patients8.7Same as national151
Death rate for heart failure patients10.8Same as national219
Death rate for pneumonia patients15.3Same as national347
Death rate for stroke patients13.3Same as national70
Pressure ulcer rate0.31Same as national2279
Death rate among surgical inpatients with serious treatable complications173.53Same as national25
Iatrogenic pneumothorax rate0.25Same as national3145
In-hospital fall-associated fracture rate0.29Same as national3152
Postoperative hemorrhage or hematoma rate2.07Same as national614
Postoperative acute kidney injury requiring dialysis rate1.53Same as national300
Postoperative respiratory failure rate8.91Same as national300
Perioperative pulmonary embolism or deep vein thrombosis rate3.99Same as national633
Postoperative sepsis rate5.50Same as national259
Postoperative wound dehiscence rate2.02Same as national100
Abdominopelvic accidental puncture or laceration rate1.24Same as national312
CMS Medicare PSI 90: Patient safety and adverse events composite0.93Same 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 patients-26.7Not available264
Hospital return days for pneumonia patients0.4Not available378
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)15.3Same as national1240
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)16.4Same as national1310
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 national329
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate13.1Same as national27
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients17.3Same as national162
Heart failure (HF) 30-Day Readmission Rate17.9Same as national264
Rate of readmission after hip/knee replacement4.7Same as national171
Pneumonia (PN) 30-Day Readmission Rate16.6Same as national378

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 rating3413
Doctor communication - star rating4413
Communication about medicines - star rating2413
Discharge information - star rating4413
Cleanliness - star rating3413
Quietness - star rating3413
Overall hospital rating - star rating3413
Recommend hospital - star rating3413
Summary star rating3413

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 vaccination90982
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 better153493
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 better148455
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better24120
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better26418
Left before being seen131550
Head CT results6715
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients96290
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing181314
Appropriate care for severe sepsis and septic shock62302
Septic Shock 3-Hour Bundle8170
Septic Shock 6-Hour Bundle6746
Severe Sepsis 3-Hour Bundle78302
Severe Sepsis 6-Hour Bundle88169
Discharged on Antithrombotic Therapy9649
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 2
Venous Thromboembolism Prophylaxis96365
Intensive Care Unit Venous Thromboembolism Prophylaxis98120

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 Duncan Regional Hospital, Inc rated?
Duncan Regional Hospital, Inc has a 3 out of 5 CMS overall star rating as of the latest CMS release.
Does Duncan Regional Hospital, Inc have emergency services?
Yes. Duncan Regional Hospital, Inc operates a 24/7 emergency department.
Where is Duncan Regional Hospital, Inc located?
Duncan Regional Hospital, Inc is located at 1407 Whisenant Drive, Duncan, OK 73533.
What type of hospital is Duncan Regional Hospital, Inc?
Duncan Regional Hospital, Inc 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