JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Proprietary

Hackensack Meridian Health Pascack Valley Medical

5 / 5

At a glance

Hackensack Meridian Health Pascack Valley Medical carries a 5-star CMS overall rating — above the national norm. On healthcare-associated infection measures, it performs better than the national average on 6 and worse 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 LimitNot available
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence LimitNot available
Central Line Associated Bloodstream Infection: Number of Device Days799Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases0.510Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases0Not available
Central Line Associated Bloodstream Infection (ICU + select Wards)Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence LimitNot available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence LimitNot available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days1921Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases0.992Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases0Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards)Not available
SSI - Colon Surgery: Lower Confidence LimitSame as national
SSI - Colon Surgery: Upper Confidence Limit2.055Same as national
SSI - Colon Surgery: Number of Procedures59Same as national
SSI - Colon Surgery: Predicted Cases1.458Same as national
SSI - Colon Surgery: Observed Cases0Same as national
SSI - Colon Surgery0.000Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures72Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.526Not 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 Days14387Not available
MRSA Bacteremia: Predicted Cases0.397Not available
MRSA Bacteremia: Observed Cases0Not available
MRSA BacteremiaNot available
Clostridium Difficile (C.Diff): Lower Confidence LimitBetter than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.614Better than national
Clostridium Difficile (C.Diff): Patient Days14102Better than national
Clostridium Difficile (C.Diff): Predicted Cases4.881Better than national
Clostridium Difficile (C.Diff): Observed Cases0Better than national
Clostridium Difficile (C.Diff)0.000Better 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 patients3.4Same as national132
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4.1Same as national649
Death rate for heart attack patients14.3Same as national32
Death rate for CABG surgery patientsNot available
Death rate for COPD patients7.1Same as national66
Death rate for heart failure patients9.9Same as national165
Death rate for pneumonia patients15.4Same as national281
Death rate for stroke patients11.2Same as national63
Pressure ulcer rate0.30Same as national1845
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.19Same as national2419
In-hospital fall-associated fracture rate0.29Same as national2356
Postoperative hemorrhage or hematoma rate2.14Same as national415
Postoperative acute kidney injury requiring dialysis rate1.64Same as national128
Postoperative respiratory failure rate13.29Same as national131
Perioperative pulmonary embolism or deep vein thrombosis rate2.94Same as national426
Postoperative sepsis rate4.98Same as national119
Postoperative wound dehiscence rate1.71Same as national118
Abdominopelvic accidental puncture or laceration rate0.96Same as national312
CMS Medicare PSI 90: Patient safety and adverse events composite0.96Same 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-10.7Not available182
Hospital return days for pneumonia patients-6.5Not available295
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)15.4Same as national1000
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)12.7Same as national434
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 national245
Acute Myocardial Infarction (AMI) 30-Day Readmission RateNot available
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients17.5Same as national68
Heart failure (HF) 30-Day Readmission Rate18.9Same as national182
Rate of readmission after hip/knee replacement4.2Same as national114
Pneumonia (PN) 30-Day Readmission Rate15.5Same as national295

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 rating3414
Doctor communication - star rating2414
Communication about medicines - star rating2414
Discharge information - star rating3414
Cleanliness - star rating3414
Quietness - star rating4414
Overall hospital rating - star rating3414
Recommend hospital - star rating4414
Summary star rating3414

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 volumelow
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 vaccination841478
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 better146422
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 better144414
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better
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 seen019704
Head CT results
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients9276
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing14882
Appropriate care for severe sepsis and septic shock7982
Septic Shock 3-Hour Bundle8234
Septic Shock 6-Hour Bundle9624
Severe Sepsis 3-Hour Bundle9082
Severe Sepsis 6-Hour Bundle9652
Discharged on Antithrombotic Therapy
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 29627
Venous Thromboembolism Prophylaxis921732
Intensive Care Unit Venous Thromboembolism Prophylaxis97336

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 Hackensack Meridian Health Pascack Valley Medical rated?
Hackensack Meridian Health Pascack Valley Medical has a 5 out of 5 CMS overall star rating as of the latest CMS release.
Does Hackensack Meridian Health Pascack Valley Medical have emergency services?
Yes. Hackensack Meridian Health Pascack Valley Medical operates a 24/7 emergency department.
Where is Hackensack Meridian Health Pascack Valley Medical located?
Hackensack Meridian Health Pascack Valley Medical is located at 250 Old Hook Road, Westwood, NJ 07675.
What type of hospital is Hackensack Meridian Health Pascack Valley Medical?
Hackensack Meridian Health Pascack Valley Medical is classified by CMS as a Acute Care Hospitals facility (Proprietary).

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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