JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Jefferson Hospital

4 / 5

At a glance

Jefferson Hospital carries a 4-star CMS overall rating — above the national norm. On healthcare-associated infection measures, it performs better than the national average on 18 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 Limit0.033Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit0.653Better than national
Central Line Associated Bloodstream Infection: Number of Device Days9913Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases10.115Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases2Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.198Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.026Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit0.506Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days10790Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases13.064Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases2Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.153Better than national
SSI - Colon Surgery: Lower Confidence Limit0.206Same as national
SSI - Colon Surgery: Upper Confidence Limit2.203Same as national
SSI - Colon Surgery: Number of Procedures150Same as national
SSI - Colon Surgery: Predicted Cases3.706Same as national
SSI - Colon Surgery: Observed Cases3Same as national
SSI - Colon Surgery0.809Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures17Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.148Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence Limit0.012Same as national
MRSA Bacteremia: Upper Confidence Limit1.137Same as national
MRSA Bacteremia: Patient Days76685Same as national
MRSA Bacteremia: Predicted Cases4.337Same as national
MRSA Bacteremia: Observed Cases1Same as national
MRSA Bacteremia0.231Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.155Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.543Better than national
Clostridium Difficile (C.Diff): Patient Days74020Better than national
Clostridium Difficile (C.Diff): Predicted Cases32.854Better than national
Clostridium Difficile (C.Diff): Observed Cases10Better than national
Clostridium Difficile (C.Diff)0.304Better 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 national40
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate3.6Same as national832
Death rate for heart attack patients12.9Same as national126
Death rate for CABG surgery patients2.5Same as national55
Death rate for COPD patients9.1Same as national67
Death rate for heart failure patients10.1Same as national314
Death rate for pneumonia patients19.6Same as national271
Death rate for stroke patients14.5Same as national83
Pressure ulcer rate1.70Worse than national2957
Death rate among surgical inpatients with serious treatable complications174.99Same as national38
Iatrogenic pneumothorax rate0.29Same as national3417
In-hospital fall-associated fracture rate0.24Same as national3527
Postoperative hemorrhage or hematoma rate2.07Same as national899
Postoperative acute kidney injury requiring dialysis rate1.36Same as national378
Postoperative respiratory failure rate5.61Same as national379
Perioperative pulmonary embolism or deep vein thrombosis rate3.29Same as national927
Postoperative sepsis rate4.78Same as national369
Postoperative wound dehiscence rate1.69Same as national180
Abdominopelvic accidental puncture or laceration rate0.92Same as national619
CMS Medicare PSI 90: Patient safety and adverse events composite1.17Same 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 patients23.5Not available115
Hospital return days for heart failure patients-4.2Not available362
Hospital return days for pneumonia patients17.5Not available272
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)15.4Same as national1399
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)12.6Same as national545
Rate of inpatient admissions for patients receiving outpatient chemotherapy10.9Same as national58
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy5.5Same as national58
Ratio of unplanned hospital visits after hospital outpatient surgery1Same as national488
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate15.5Same as national115
Rate of readmission for CABG11.7Same as national53
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients19.1Same as national76
Heart failure (HF) 30-Day Readmission Rate18.8Same as national362
Rate of readmission after hip/knee replacement6.1Same as national38
Pneumonia (PN) 30-Day Readmission Rate15.8Same as national272

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 rating4613
Doctor communication - star rating3613
Communication about medicines - star rating3613
Discharge information - star rating3613
Cleanliness - star rating4613
Quietness - star rating2613
Overall hospital rating - star rating4613
Recommend hospital - star rating4613
Summary star rating3613

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 volumehigh
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 Hypoglycemia13097
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination391826
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 better176499
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 better172467
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better27317
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better23217
Left before being seen052440
Head CT results7427
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients9864
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing142775
Appropriate care for severe sepsis and septic shock70161
Septic Shock 3-Hour Bundle8369
Septic Shock 6-Hour Bundle8649
Severe Sepsis 3-Hour Bundle85161
Severe Sepsis 6-Hour Bundle96105
Discharged on Antithrombotic Therapy98156
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 295129
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 Jefferson Hospital rated?
Jefferson Hospital has a 4 out of 5 CMS overall star rating as of the latest CMS release.
Does Jefferson Hospital have emergency services?
Yes. Jefferson Hospital operates a 24/7 emergency department.
Where is Jefferson Hospital located?
Jefferson Hospital is located at 565 Coal Valley Road, Jefferson Hills, PA 15025.
What type of hospital is Jefferson Hospital?
Jefferson 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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