JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Kaiser Foundation Hospital-Santa Rosa

3 / 5

At a glance

Kaiser Foundation Hospital-Santa Rosa 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.

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 Limit0.242Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit1.836Same as national
Central Line Associated Bloodstream Infection: Number of Device Days6017Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases5.255Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases4Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.761Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.009Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit0.932Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days5445Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases5.293Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases1Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.189Better than national
SSI - Colon Surgery: Lower Confidence Limit0.118Same as national
SSI - Colon Surgery: Upper Confidence Limit2.327Same as national
SSI - Colon Surgery: Number of Procedures121Same as national
SSI - Colon Surgery: Predicted Cases2.839Same as national
SSI - Colon Surgery: Observed Cases2Same as national
SSI - Colon Surgery0.704Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures6Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.076Not available
SSI - Abdominal Hysterectomy: Observed Cases1Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence Limit0.143Same as national
MRSA Bacteremia: Upper Confidence Limit2.823Same as national
MRSA Bacteremia: Patient Days47204Same as national
MRSA Bacteremia: Predicted Cases2.341Same as national
MRSA Bacteremia: Observed Cases2Same as national
MRSA Bacteremia0.854Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.284Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.892Better than national
Clostridium Difficile (C.Diff): Patient Days43438Better than national
Clostridium Difficile (C.Diff): Predicted Cases22.862Better than national
Clostridium Difficile (C.Diff): Observed Cases12Better than national
Clostridium Difficile (C.Diff)0.525Better 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 patientsNot available
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4.1Same as national86
Death rate for heart attack patientsNot available
Death rate for CABG surgery patientsNot available
Death rate for COPD patientsNot available
Death rate for heart failure patientsNot available
Death rate for pneumonia patientsNot available
Death rate for stroke patientsNot available
Pressure ulcer rate0.50Same as national344
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.20Same as national467
In-hospital fall-associated fracture rate0.31Same as national474
Postoperative hemorrhage or hematoma rate2.29Same as national68
Postoperative acute kidney injury requiring dialysis rateNot available
Postoperative respiratory failure rateNot available
Perioperative pulmonary embolism or deep vein thrombosis rate3.37Same as national72
Postoperative sepsis rateNot available
Postoperative wound dehiscence rate2.09Same as national26
Abdominopelvic accidental puncture or laceration rate1.03Same as national102
CMS Medicare PSI 90: Patient safety and adverse events composite0.95Same 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 patientsNot available
Hospital return days for pneumonia patientsNot available
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)15.1Same as national127
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)Not available
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 surgeryNot available
Acute Myocardial Infarction (AMI) 30-Day Readmission RateNot available
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patientsNot available
Heart failure (HF) 30-Day Readmission RateNot available
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission RateNot available

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 rating31865
Doctor communication - star rating31865
Communication about medicines - star rating21865
Discharge information - star rating31865
Cleanliness - star rating31865
Quietness - star rating11865
Overall hospital rating - star rating31865
Recommend hospital - star rating41865
Summary star rating31865

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 volume
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 Hyperglycemia89136
Hospital Harm - Severe Hypoglycemia12127
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination604147
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 better
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 better
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 seen
Head CT results
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing132923
Appropriate care for severe sepsis and septic shock61142
Septic Shock 3-Hour Bundle6042
Septic Shock 6-Hour Bundle9020
Severe Sepsis 3-Hour Bundle78142
Severe Sepsis 6-Hour Bundle9259
Discharged on Antithrombotic Therapy97144
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 2
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 Kaiser Foundation Hospital-Santa Rosa rated?
Kaiser Foundation Hospital-Santa Rosa has a 3 out of 5 CMS overall star rating as of the latest CMS release.
Does Kaiser Foundation Hospital-Santa Rosa have emergency services?
Yes. Kaiser Foundation Hospital-Santa Rosa operates a 24/7 emergency department.
Where is Kaiser Foundation Hospital-Santa Rosa located?
Kaiser Foundation Hospital-Santa Rosa is located at 401 Bicentennial Way, Santa Rosa, CA 95403.
What type of hospital is Kaiser Foundation Hospital-Santa Rosa?
Kaiser Foundation Hospital-Santa Rosa 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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