JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Lutheran Medical Center

4 / 5

At a glance

Lutheran Medical Center carries a 4-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. For 30-day readmissions, it beats the national rate on 1 measure and trails 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 Limit0.154Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit1.645Same as national
Central Line Associated Bloodstream Infection: Number of Device Days6209Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases4.963Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases3Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.604Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.224Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit1.703Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days5033Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases5.665Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases4Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.706Same as national
SSI - Colon Surgery: Lower Confidence Limit0.295Same as national
SSI - Colon Surgery: Upper Confidence Limit3.156Same as national
SSI - Colon Surgery: Number of Procedures101Same as national
SSI - Colon Surgery: Predicted Cases2.587Same as national
SSI - Colon Surgery: Observed Cases3Same as national
SSI - Colon Surgery1.160Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures52Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.394Not available
SSI - Abdominal Hysterectomy: Observed Cases1Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitSame as national
MRSA Bacteremia: Upper Confidence Limit1.145Same as national
MRSA Bacteremia: Patient Days61779Same as national
MRSA Bacteremia: Predicted Cases2.617Same as national
MRSA Bacteremia: Observed Cases0Same as national
MRSA Bacteremia0.000Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.050Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.376Better than national
Clostridium Difficile (C.Diff): Patient Days57318Better than national
Clostridium Difficile (C.Diff): Predicted Cases25.642Better than national
Clostridium Difficile (C.Diff): Observed Cases4Better than national
Clostridium Difficile (C.Diff)0.156Better 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 Rate3.8Same as national795
Death rate for heart attack patients10.9Same as national86
Death rate for CABG surgery patientsNot available
Death rate for COPD patients11.6Same as national77
Death rate for heart failure patients13.7Same as national235
Death rate for pneumonia patients18.3Same as national209
Death rate for stroke patients12.7Same as national168
Pressure ulcer rate0.48Same as national2761
Death rate among surgical inpatients with serious treatable complications177.19Same as national47
Iatrogenic pneumothorax rate0.29Same as national3352
In-hospital fall-associated fracture rate0.24Same as national3375
Postoperative hemorrhage or hematoma rate2.16Same as national791
Postoperative acute kidney injury requiring dialysis rate2.31Same as national239
Postoperative respiratory failure rate10.57Same as national218
Perioperative pulmonary embolism or deep vein thrombosis rate3.13Same as national858
Postoperative sepsis rate5.21Same as national219
Postoperative wound dehiscence rate1.67Same as national156
Abdominopelvic accidental puncture or laceration rate0.92Same as national678
CMS Medicare PSI 90: Patient safety and adverse events composite0.99Same 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 patients-11.3Not available104
Hospital return days for heart failure patients-31.4Not available264
Hospital return days for pneumonia patients-20.2Not available191
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)13.4Better than national1256
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)12.9Same as national178
Rate of inpatient admissions for patients receiving outpatient chemotherapy10.4Same as national65
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy6.1Same as national65
Ratio of unplanned hospital visits after hospital outpatient surgery1Same as national177
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate13.3Same as national104
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients17.3Same as national83
Heart failure (HF) 30-Day Readmission Rate16.9Same as national264
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate14.8Same as national191

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 rating41211
Doctor communication - star rating41211
Communication about medicines - star rating31211
Discharge information - star rating41211
Cleanliness - star rating41211
Quietness - star rating41211
Overall hospital rating - star rating41211
Recommend hospital - star rating51211
Summary star rating41211

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 Hyperglycemia913028
Hospital Harm - Severe Hypoglycemia
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination933591
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 better204400
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 better192365
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better27833
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 seen159570
Head CT results5714
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients9543
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing133158
Appropriate care for severe sepsis and septic shock76400
Septic Shock 3-Hour Bundle79135
Septic Shock 6-Hour Bundle9582
Severe Sepsis 3-Hour Bundle87400
Severe Sepsis 6-Hour Bundle97259
Discharged on Antithrombotic Therapy98356
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 295255
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 Lutheran Medical Center rated?
Lutheran Medical Center has a 4 out of 5 CMS overall star rating as of the latest CMS release.
Does Lutheran Medical Center have emergency services?
Yes. Lutheran Medical Center operates a 24/7 emergency department.
Where is Lutheran Medical Center located?
Lutheran Medical Center is located at 8300 W 38th Ave, Wheat Ridge, CO 80033.
What type of hospital is Lutheran Medical Center?
Lutheran Medical Center 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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