JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Marymount Hospital

5 / 5

At a glance

Marymount 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.

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 Limit0.091Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit1.785Same as national
Central Line Associated Bloodstream Infection: Number of Device Days4102Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases3.701Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases2Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.540Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.056Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit1.096Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days6392Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases6.031Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases2Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.332Same as national
SSI - Colon Surgery: Lower Confidence LimitSame as national
SSI - Colon Surgery: Upper Confidence Limit2.105Same as national
SSI - Colon Surgery: Number of Procedures58Same as national
SSI - Colon Surgery: Predicted Cases1.423Same as national
SSI - Colon Surgery: Observed Cases0Same as national
SSI - Colon Surgery0.000Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures10Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.090Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence Limit0.020Same as national
MRSA Bacteremia: Upper Confidence Limit1.955Same as national
MRSA Bacteremia: Patient Days43318Same as national
MRSA Bacteremia: Predicted Cases2.523Same as national
MRSA Bacteremia: Observed Cases1Same as national
MRSA Bacteremia0.396Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.161Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.728Better than national
Clostridium Difficile (C.Diff): Patient Days43318Better than national
Clostridium Difficile (C.Diff): Predicted Cases19.010Better than national
Clostridium Difficile (C.Diff): Observed Cases7Better than national
Clostridium Difficile (C.Diff)0.368Better 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 patients3.4Same as national26
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate3.2Better than national754
Death rate for heart attack patientsNot available
Death rate for CABG surgery patientsNot available
Death rate for COPD patients8.8Same as national84
Death rate for heart failure patients9.5Same as national346
Death rate for pneumonia patients13.7Same as national306
Death rate for stroke patients11.2Same as national73
Pressure ulcer rate0.24Same as national2777
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.18Same as national3334
In-hospital fall-associated fracture rate0.24Same as national3336
Postoperative hemorrhage or hematoma rate2.10Same as national338
Postoperative acute kidney injury requiring dialysis rate1.62Same as national106
Postoperative respiratory failure rate7.63Same as national114
Perioperative pulmonary embolism or deep vein thrombosis rate3.77Same as national368
Postoperative sepsis rate4.82Same as national113
Postoperative wound dehiscence rate1.69Same as national80
Abdominopelvic accidental puncture or laceration rate0.95Same as national528
CMS Medicare PSI 90: Patient safety and adverse events composite0.81Same 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-21.6Not available380
Hospital return days for pneumonia patients22.9Not available324
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)15.3Same as national1315
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)13.2Same as national393
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 surgery0.9Same as national576
Acute Myocardial Infarction (AMI) 30-Day Readmission RateNot available
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients18.3Same as national96
Heart failure (HF) 30-Day Readmission Rate18.6Same as national380
Rate of readmission after hip/knee replacement4.8Same as national32
Pneumonia (PN) 30-Day Readmission Rate18Same as national324

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 rating3842
Doctor communication - star rating4842
Communication about medicines - star rating2842
Discharge information - star rating3842
Cleanliness - star rating3842
Quietness - star rating2842
Overall hospital rating - star rating3842
Recommend hospital - star rating3842
Summary star rating3842

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 vaccination873864
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 better204386
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 better193343
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better36231
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better37214
Left before being seen343871
Head CT results8015
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients9574
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing111126
Appropriate care for severe sepsis and septic shock58127
Septic Shock 3-Hour Bundle6138
Septic Shock 6-Hour Bundle7919
Severe Sepsis 3-Hour Bundle77127
Severe Sepsis 6-Hour Bundle9361
Discharged on Antithrombotic Therapy98118
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 298110
Venous Thromboembolism Prophylaxis
Intensive Care Unit Venous Thromboembolism Prophylaxis93910

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 Marymount Hospital rated?
Marymount Hospital has a 5 out of 5 CMS overall star rating as of the latest CMS release.
Does Marymount Hospital have emergency services?
Yes. Marymount Hospital operates a 24/7 emergency department.
Where is Marymount Hospital located?
Marymount Hospital is located at 12300 Mccracken Road, Garfield Heights, OH 44125.
What type of hospital is Marymount Hospital?
Marymount 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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