JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Lutheran Hospital

3 / 5

At a glance

Lutheran Hospital 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 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 LimitSame as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit2.486Same as national
Central Line Associated Bloodstream Infection: Number of Device Days1766Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases1.205Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases0Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.000Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.030Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit2.962Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days2395Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases1.665Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases1Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.601Same as national
SSI - Colon Surgery: Lower Confidence LimitNot available
SSI - Colon Surgery: Upper Confidence LimitNot available
SSI - Colon Surgery: Number of ProceduresNot available
SSI - Colon Surgery: Predicted CasesNot available
SSI - Colon Surgery: Observed CasesNot available
SSI - Colon SurgeryNot available
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of ProceduresNot available
SSI - Abdominal Hysterectomy: Predicted CasesNot available
SSI - Abdominal Hysterectomy: Observed CasesNot available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitNot available
MRSA Bacteremia: Upper Confidence LimitNot available
MRSA Bacteremia: Patient Days21871Not available
MRSA Bacteremia: Predicted Cases0.927Not available
MRSA Bacteremia: Observed Cases2Not available
MRSA BacteremiaNot available
Clostridium Difficile (C.Diff): Lower Confidence Limit0.042Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.823Better than national
Clostridium Difficile (C.Diff): Patient Days21871Better than national
Clostridium Difficile (C.Diff): Predicted Cases8.025Better than national
Clostridium Difficile (C.Diff): Observed Cases2Better than national
Clostridium Difficile (C.Diff)0.249Better 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 patients3.8Same as national59
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4Same as national278
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 patients10.8Same as national32
Death rate for pneumonia patients16.1Same as national43
Death rate for stroke patientsNot available
Pressure ulcer rate0.45Same as national786
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.27Same as national1058
In-hospital fall-associated fracture rate0.30Same as national1042
Postoperative hemorrhage or hematoma rate2.43Same as national417
Postoperative acute kidney injury requiring dialysis rate1.59Same as national356
Postoperative respiratory failure rate7.84Same as national358
Perioperative pulmonary embolism or deep vein thrombosis rate3.25Same as national438
Postoperative sepsis rate5.29Same as national348
Postoperative wound dehiscence rate1.75Same as national178
Abdominopelvic accidental puncture or laceration rate1.03Same as national245
CMS Medicare PSI 90: Patient safety and adverse events composite0.91Same 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 patients41.7Not available41
Hospital return days for pneumonia patients30.8Not available39
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)15.1Same as national376
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 surgery1Same as national666
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 Rate19.7Same as national41
Rate of readmission after hip/knee replacement5Same as national56
Pneumonia (PN) 30-Day Readmission Rate16.5Same as national39

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 rating2412
Doctor communication - star rating2412
Communication about medicines - star rating2412
Discharge information - star rating3412
Cleanliness - star rating3412
Quietness - star rating2412
Overall hospital rating - star rating2412
Recommend hospital - star rating2412
Summary star rating2412

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 vaccination873135
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 better154387
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 better150340
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better21640
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 seen336673
Head CT results
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients10018
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing101255
Appropriate care for severe sepsis and septic shock6894
Septic Shock 3-Hour Bundle6715
Septic Shock 6-Hour Bundle
Severe Sepsis 3-Hour Bundle7994
Severe Sepsis 6-Hour Bundle9345
Discharged on Antithrombotic Therapy10029
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 29628
Venous Thromboembolism Prophylaxis
Intensive Care Unit Venous Thromboembolism Prophylaxis93411

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 MeasureNot Applicable (our hospital does not provide inpatient labor/delivery care)

Frequently asked questions

How is Lutheran Hospital rated?
Lutheran Hospital has a 3 out of 5 CMS overall star rating as of the latest CMS release.
Does Lutheran Hospital have emergency services?
Yes. Lutheran Hospital operates a 24/7 emergency department.
Where is Lutheran Hospital located?
Lutheran Hospital is located at 1730 West 25th Street, Cleveland, OH 44113.
What type of hospital is Lutheran Hospital?
Lutheran 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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