JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Government - Hospital District or Authority

Memorial Hospital Miramar

5 / 5

At a glance

Memorial Hospital Miramar 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 LimitSame as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit1.301Same as national
Central Line Associated Bloodstream Infection: Number of Device Days2355Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases2.303Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases0Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.000Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.040Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit3.905Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days1187Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases1.263Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases1Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.792Same as national
SSI - Colon Surgery: Lower Confidence Limit0.358Same as national
SSI - Colon Surgery: Upper Confidence Limit3.833Same as national
SSI - Colon Surgery: Number of Procedures87Same as national
SSI - Colon Surgery: Predicted Cases2.130Same as national
SSI - Colon Surgery: Observed Cases3Same as national
SSI - Colon Surgery1.408Same as national
SSI - Abdominal Hysterectomy: Lower Confidence Limit0.659Same as national
SSI - Abdominal Hysterectomy: Upper Confidence Limit2.982Same as national
SSI - Abdominal Hysterectomy: Number of Procedures581Same as national
SSI - Abdominal Hysterectomy: Predicted Cases4.644Same as national
SSI - Abdominal Hysterectomy: Observed Cases7Same as national
SSI - Abdominal Hysterectomy1.507Same as national
MRSA Bacteremia: Lower Confidence Limit0.140Same as national
MRSA Bacteremia: Upper Confidence Limit2.756Same as national
MRSA Bacteremia: Patient Days57884Same as national
MRSA Bacteremia: Predicted Cases2.398Same as national
MRSA Bacteremia: Observed Cases2Same as national
MRSA Bacteremia0.834Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.211Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.661Better than national
Clostridium Difficile (C.Diff): Patient Days45791Better than national
Clostridium Difficile (C.Diff): Predicted Cases30.846Better than national
Clostridium Difficile (C.Diff): Observed Cases12Better than national
Clostridium Difficile (C.Diff)0.389Better 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 national306
Death rate for heart attack patientsNot available
Death rate for CABG surgery patientsNot available
Death rate for COPD patients8.6Same as national25
Death rate for heart failure patients10.9Same as national99
Death rate for pneumonia patients14.9Same as national109
Death rate for stroke patients13.1Same as national34
Pressure ulcer rate0.39Same as national1524
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.20Same as national1776
In-hospital fall-associated fracture rate0.26Same as national1822
Postoperative hemorrhage or hematoma rate2.58Same as national179
Postoperative acute kidney injury requiring dialysis rate1.66Same as national36
Postoperative respiratory failure rate8.90Same as national37
Perioperative pulmonary embolism or deep vein thrombosis rate3.77Same as national186
Postoperative sepsis rate6.08Same as national33
Postoperative wound dehiscence rate1.75Same as national78
Abdominopelvic accidental puncture or laceration rate0.99Same as national305
CMS Medicare PSI 90: Patient safety and adverse events composite0.95Same 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 patients26.3Not available115
Hospital return days for pneumonia patients-4.6Not available115
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.7Same as national570
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)Not available
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 national76
Acute Myocardial Infarction (AMI) 30-Day Readmission RateNot available
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients17.6Same as national30
Heart failure (HF) 30-Day Readmission Rate20.5Same as national115
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate15.2Same as national115

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 rating41329
Doctor communication - star rating41329
Communication about medicines - star rating31329
Discharge information - star rating31329
Cleanliness - star rating41329
Quietness - star rating41329
Overall hospital rating - star rating41329
Recommend hospital - star rating41329
Summary star rating41329

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 Hypoglycemia01736
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination912448
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 better164378
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 better162347
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better19027
Left before being seen166474
Head CT results
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients10016
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing92867
Appropriate care for severe sepsis and septic shock8872
Septic Shock 3-Hour Bundle9134
Septic Shock 6-Hour Bundle9623
Severe Sepsis 3-Hour Bundle9472
Severe Sepsis 6-Hour Bundle9851
Discharged on Antithrombotic Therapy10086
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 210076
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 Memorial Hospital Miramar rated?
Memorial Hospital Miramar has a 5 out of 5 CMS overall star rating as of the latest CMS release.
Does Memorial Hospital Miramar have emergency services?
Yes. Memorial Hospital Miramar operates a 24/7 emergency department.
Where is Memorial Hospital Miramar located?
Memorial Hospital Miramar is located at 1901 Sw 172nd Ave, Miramar, FL 33029.
What type of hospital is Memorial Hospital Miramar?
Memorial Hospital Miramar is classified by CMS as a Acute Care Hospitals facility (Government - Hospital District or Authority).

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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