JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Proprietary

Macneal Hospital

3 / 5

At a glance

Macneal 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 Limit0.260Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit1.974Same as national
Central Line Associated Bloodstream Infection: Number of Device Days4645Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases4.887Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases4Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.818Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.111Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit1.191Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days5625Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases6.857Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases3Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.438Same as national
SSI - Colon Surgery: Lower Confidence Limit0.031Same as national
SSI - Colon Surgery: Upper Confidence Limit3.037Same as national
SSI - Colon Surgery: Number of Procedures58Same as national
SSI - Colon Surgery: Predicted Cases1.624Same as national
SSI - Colon Surgery: Observed Cases1Same as national
SSI - Colon Surgery0.616Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures40Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.379Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence Limit0.332Same as national
MRSA Bacteremia: Upper Confidence Limit2.523Same as national
MRSA Bacteremia: Patient Days58536Same as national
MRSA Bacteremia: Predicted Cases3.824Same as national
MRSA Bacteremia: Observed Cases4Same as national
MRSA Bacteremia1.046Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.090Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.314Better than national
Clostridium Difficile (C.Diff): Patient Days58536Better than national
Clostridium Difficile (C.Diff): Predicted Cases56.679Better than national
Clostridium Difficile (C.Diff): Observed Cases10Better than national
Clostridium Difficile (C.Diff)0.176Better 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 national730
Death rate for heart attack patients12.6Same as national82
Death rate for CABG surgery patientsNot available
Death rate for COPD patients8.1Same as national98
Death rate for heart failure patients12.8Same as national236
Death rate for pneumonia patients14.6Same as national221
Death rate for stroke patients11.6Same as national75
Pressure ulcer rate0.80Same as national2807
Death rate among surgical inpatients with serious treatable complications198.01Same as national26
Iatrogenic pneumothorax rate0.18Same as national3481
In-hospital fall-associated fracture rate0.24Same as national3449
Postoperative hemorrhage or hematoma rate2.34Same as national479
Postoperative acute kidney injury requiring dialysis rate2.03Same as national118
Postoperative respiratory failure rate9.03Same as national126
Perioperative pulmonary embolism or deep vein thrombosis rate2.81Same as national515
Postoperative sepsis rate5.42Same as national107
Postoperative wound dehiscence rate2.05Same as national118
Abdominopelvic accidental puncture or laceration rate0.93Same as national600
CMS Medicare PSI 90: Patient safety and adverse events composite1.02Same 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 patients38Not available63
Hospital return days for heart failure patients27.2Not available269
Hospital return days for pneumonia patients22.6Not available238
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)15.9Same as national1184
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)12.1Same as national845
Rate of inpatient admissions for patients receiving outpatient chemotherapy11.6Same as national47
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy5.3Same as national47
Ratio of unplanned hospital visits after hospital outpatient surgery0.9Same as national213
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate14.6Same as national63
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients19.5Same as national119
Heart failure (HF) 30-Day Readmission Rate21Same as national269
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate16.6Same as national238

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 rating2417
Doctor communication - star rating3417
Communication about medicines - star rating2417
Discharge information - star rating2417
Cleanliness - star rating3417
Quietness - star rating3417
Overall hospital rating - star rating3417
Recommend hospital - star rating3417
Summary star rating3417

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 Hypoglycemia
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination932039
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 better212403
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 better208355
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better41436
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better33613
Left before being seen050407
Head CT results7726
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients9984
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing141589
Appropriate care for severe sepsis and septic shock61109
Septic Shock 3-Hour Bundle7247
Septic Shock 6-Hour Bundle9031
Severe Sepsis 3-Hour Bundle83109
Severe Sepsis 6-Hour Bundle9067
Discharged on Antithrombotic Therapy9996
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 29888
Venous Thromboembolism Prophylaxis893737
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 Macneal Hospital rated?
Macneal Hospital has a 3 out of 5 CMS overall star rating as of the latest CMS release.
Does Macneal Hospital have emergency services?
Yes. Macneal Hospital operates a 24/7 emergency department.
Where is Macneal Hospital located?
Macneal Hospital is located at 3249 South Oak Park Avenue, Berwyn, IL 60402.
What type of hospital is Macneal Hospital?
Macneal Hospital is classified by CMS as a Acute Care Hospitals facility (Proprietary).

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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