JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

M Health Fairview Southdale Hospital

5 / 5

At a glance

M Health Fairview Southdale Hospital 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. 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 Limit0.387Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit1.457Same as national
Central Line Associated Bloodstream Infection: Number of Device Days11037Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases11.333Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases9Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.794Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.315Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit1.187Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days11099Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases13.915Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases9Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.647Same as national
SSI - Colon Surgery: Lower Confidence Limit0.254Same as national
SSI - Colon Surgery: Upper Confidence Limit1.302Same as national
SSI - Colon Surgery: Number of Procedures375Same as national
SSI - Colon Surgery: Predicted Cases9.582Same as national
SSI - Colon Surgery: Observed Cases6Same as national
SSI - Colon Surgery0.626Same as national
SSI - Abdominal Hysterectomy: Lower Confidence Limit0.250Same as national
SSI - Abdominal Hysterectomy: Upper Confidence Limit4.924Same as national
SSI - Abdominal Hysterectomy: Number of Procedures178Same as national
SSI - Abdominal Hysterectomy: Predicted Cases1.342Same as national
SSI - Abdominal Hysterectomy: Observed Cases2Same as national
SSI - Abdominal Hysterectomy1.490Same as national
MRSA Bacteremia: Lower Confidence Limit0.191Same as national
MRSA Bacteremia: Upper Confidence Limit1.448Same as national
MRSA Bacteremia: Patient Days98647Same as national
MRSA Bacteremia: Predicted Cases6.665Same as national
MRSA Bacteremia: Observed Cases4Same as national
MRSA Bacteremia0.600Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.232Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.622Better than national
Clostridium Difficile (C.Diff): Patient Days88855Better than national
Clostridium Difficile (C.Diff): Predicted Cases40.907Better than national
Clostridium Difficile (C.Diff): Observed Cases16Better than national
Clostridium Difficile (C.Diff)0.391Better 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 patients4.5Same as national95
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate3Better than national1717
Death rate for heart attack patients11Same as national221
Death rate for CABG surgery patients2Same as national91
Death rate for COPD patients7.3Same as national87
Death rate for heart failure patients8.3Better than national449
Death rate for pneumonia patients12.9Better than national426
Death rate for stroke patients12Same as national325
Pressure ulcer rate0.41Same as national6033
Death rate among surgical inpatients with serious treatable complications158.25Same as national101
Iatrogenic pneumothorax rate0.17Same as national6884
In-hospital fall-associated fracture rate0.30Same as national7050
Postoperative hemorrhage or hematoma rate1.76Same as national1110
Postoperative acute kidney injury requiring dialysis rate1.47Same as national844
Postoperative respiratory failure rate4.72Same as national799
Perioperative pulmonary embolism or deep vein thrombosis rate3.37Same as national2098
Postoperative sepsis rate4.50Same as national832
Postoperative wound dehiscence rate1.85Same as national361
Abdominopelvic accidental puncture or laceration rate0.94Same as national1360
CMS Medicare PSI 90: Patient safety and adverse events composite0.76Same 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-10.2Not available241
Hospital return days for heart failure patients-23.8Not available509
Hospital return days for pneumonia patients-1.3Not available443
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)13.1Better than national2841
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)12.7Same as national979
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 national613
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate12.3Same as national241
Rate of readmission for CABG9.6Same as national90
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients17.2Same as national92
Heart failure (HF) 30-Day Readmission Rate17.6Same as national509
Rate of readmission after hip/knee replacement5.3Same as national94
Pneumonia (PN) 30-Day Readmission Rate14.9Same as national443

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 rating3506
Doctor communication - star rating3506
Communication about medicines - star rating2506
Discharge information - star rating3506
Cleanliness - star rating2506
Quietness - star rating3506
Overall hospital rating - star rating3506
Recommend hospital - star rating4506
Summary star rating3506

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 volumevery high
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 Hypoglycemia14010
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination793785
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 better202405
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 better197355
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better27549
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 seen463063
Head CT results8116
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients99807
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)6531
Safe Use of Opioids - Concurrent Prescribing105113
Appropriate care for severe sepsis and septic shock73106
Septic Shock 3-Hour Bundle8548
Septic Shock 6-Hour Bundle8826
Severe Sepsis 3-Hour Bundle85107
Severe Sepsis 6-Hour Bundle9564
Discharged on Antithrombotic Therapy98533
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 293430
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 M Health Fairview Southdale Hospital rated?
M Health Fairview Southdale Hospital has a 5 out of 5 CMS overall star rating as of the latest CMS release.
Does M Health Fairview Southdale Hospital have emergency services?
Yes. M Health Fairview Southdale Hospital operates a 24/7 emergency department.
Where is M Health Fairview Southdale Hospital located?
M Health Fairview Southdale Hospital is located at 6401 France Avenue South, Edina, MN 55435.
What type of hospital is M Health Fairview Southdale Hospital?
M Health Fairview Southdale 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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