JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Government - Local

Major Hospital

4 / 5

At a glance

Major Hospital carries a 4-star CMS overall rating — above the national norm.

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 LimitNot available
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence LimitNot available
Central Line Associated Bloodstream Infection: Number of Device Days1037Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases0.630Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases0Not available
Central Line Associated Bloodstream Infection (ICU + select Wards)Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence LimitNot available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence LimitNot available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days1638Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases0.845Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases2Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards)Not available
SSI - Colon Surgery: Lower Confidence LimitNot available
SSI - Colon Surgery: Upper Confidence LimitNot available
SSI - Colon Surgery: Number of Procedures20Not available
SSI - Colon Surgery: Predicted Cases0.523Not available
SSI - Colon Surgery: Observed Cases1Not available
SSI - Colon SurgeryNot available
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures11Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.085Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitNot available
MRSA Bacteremia: Upper Confidence LimitNot available
MRSA Bacteremia: Patient Days8836Not available
MRSA Bacteremia: Predicted Cases0.282Not available
MRSA Bacteremia: Observed Cases0Not available
MRSA BacteremiaNot available
Clostridium Difficile (C.Diff): Lower Confidence Limit0.363Same as national
Clostridium Difficile (C.Diff): Upper Confidence Limit2.756Same as national
Clostridium Difficile (C.Diff): Patient Days8836Same as national
Clostridium Difficile (C.Diff): Predicted Cases3.501Same as national
Clostridium Difficile (C.Diff): Observed Cases4Same as national
Clostridium Difficile (C.Diff)1.143Same as 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 Rate3.4Same as national290
Death rate for heart attack patientsNot available
Death rate for CABG surgery patientsNot available
Death rate for COPD patients8Same as national71
Death rate for heart failure patients10.6Same as national95
Death rate for pneumonia patients14.9Same as national148
Death rate for stroke patients12.4Same as national26
Pressure ulcer rate0.42Same as national916
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.27Same as national1345
In-hospital fall-associated fracture rate0.26Same as national1347
Postoperative hemorrhage or hematoma rate2.60Same as national130
Postoperative acute kidney injury requiring dialysis rate1.65Same as national37
Postoperative respiratory failure rate7.68Same as national36
Perioperative pulmonary embolism or deep vein thrombosis rate3.25Same as national146
Postoperative sepsis rate5.76Same as national30
Postoperative wound dehiscence rate1.73Same as national36
Abdominopelvic accidental puncture or laceration rate1.02Same as national113
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 patients-10.2Not available103
Hospital return days for pneumonia patients-19.3Not available156
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.1Same as national499
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)13.4Same as national460
Rate of inpatient admissions for patients receiving outpatient chemotherapy10.5Same as national59
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy5.8Same as national59
Ratio of unplanned hospital visits after hospital outpatient surgery1.1Same as national156
Acute Myocardial Infarction (AMI) 30-Day Readmission RateNot available
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients18.7Same as national78
Heart failure (HF) 30-Day Readmission Rate20.2Same as national103
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate15.8Same as national156

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 rating3332
Doctor communication - star rating4332
Communication about medicines - star rating2332
Discharge information - star rating3332
Cleanliness - star rating4332
Quietness - star rating4332
Overall hospital rating - star rating3332
Recommend hospital - star rating4332
Summary star rating3332

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 vaccination941963
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 better141492
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 better136444
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better20416
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better28533
Left before being seen024431
Head CT results
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients94108
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing14651
Appropriate care for severe sepsis and septic shock89224
Septic Shock 3-Hour Bundle9670
Septic Shock 6-Hour Bundle9847
Severe Sepsis 3-Hour Bundle92225
Severe Sepsis 6-Hour Bundle98129
Discharged on Antithrombotic Therapy
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 2
Venous Thromboembolism Prophylaxis951238
Intensive Care Unit Venous Thromboembolism Prophylaxis98387

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 Major Hospital rated?
Major Hospital has a 4 out of 5 CMS overall star rating as of the latest CMS release.
Does Major Hospital have emergency services?
Yes. Major Hospital operates a 24/7 emergency department.
Where is Major Hospital located?
Major Hospital is located at 2451 Intelliplex Dr, Shelbyville, IN 46176.
What type of hospital is Major Hospital?
Major Hospital is classified by CMS as a Acute Care Hospitals facility (Government - Local).

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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