JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Montrose Regional Health

4 / 5

At a glance

Montrose Regional Health 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 Days844Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases0.525Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases1Not 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 Days1560Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases0.805Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases1Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards)Not available
SSI - Colon Surgery: Lower Confidence Limit0.044Same as national
SSI - Colon Surgery: Upper Confidence Limit4.353Same as national
SSI - Colon Surgery: Number of Procedures46Same as national
SSI - Colon Surgery: Predicted Cases1.133Same as national
SSI - Colon Surgery: Observed Cases1Same as national
SSI - Colon Surgery0.883Same as national
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 Cases0.082Not 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 Days10361Not available
MRSA Bacteremia: Predicted Cases0.504Not available
MRSA Bacteremia: Observed Cases1Not available
MRSA BacteremiaNot available
Clostridium Difficile (C.Diff): Lower Confidence Limit0.116Same as national
Clostridium Difficile (C.Diff): Upper Confidence Limit1.240Same as national
Clostridium Difficile (C.Diff): Patient Days10302Same as national
Clostridium Difficile (C.Diff): Predicted Cases6.582Same as national
Clostridium Difficile (C.Diff): Observed Cases3Same as national
Clostridium Difficile (C.Diff)0.456Same 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 Rate4.2Same as national396
Death rate for heart attack patients12.3Same as national70
Death rate for CABG surgery patientsNot available
Death rate for COPD patients9.8Same as national37
Death rate for heart failure patients11.7Same as national61
Death rate for pneumonia patients16Same as national33
Death rate for stroke patients13.3Same as national30
Pressure ulcer rate0.46Same as national707
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.26Same as national1269
In-hospital fall-associated fracture rate0.26Same as national1254
Postoperative hemorrhage or hematoma rate2.22Same as national308
Postoperative acute kidney injury requiring dialysis rate1.66Same as national38
Postoperative respiratory failure rate8.97Same as national37
Perioperative pulmonary embolism or deep vein thrombosis rate3.53Same as national323
Postoperative sepsis rate5.12Same as national33
Postoperative wound dehiscence rate1.69Same as national85
Abdominopelvic accidental puncture or laceration rate0.99Same as national167
CMS Medicare PSI 90: Patient safety and adverse events composite0.94Same 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-19.2Not available89
Hospital return days for heart failure patients-28.4Not available83
Hospital return days for pneumonia patients-10.2Not available47
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.7Same as national563
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)13Same as national445
Rate of inpatient admissions for patients receiving outpatient chemotherapy9.7Same as national130
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy6.5Same as national130
Ratio of unplanned hospital visits after hospital outpatient surgery1.2Same as national269
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate12.7Same as national89
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients18.6Same as national43
Heart failure (HF) 30-Day Readmission Rate18.4Same as national83
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate16.1Same as national47

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 rating4356
Doctor communication - star rating4356
Communication about medicines - star rating3356
Discharge information - star rating5356
Cleanliness - star rating5356
Quietness - star rating4356
Overall hospital rating - star rating4356
Recommend hospital - star rating4356
Summary star rating4356

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 Hypoglycemia0315
Hospital Harm - Opioid Related Adverse Events01044
Healthcare workers given influenza vaccination951159
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 better144377
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 better141346
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better15222
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 seen220242
Head CT results6128
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients99112
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing13455
Appropriate care for severe sepsis and septic shock74113
Septic Shock 3-Hour Bundle8843
Septic Shock 6-Hour Bundle9731
Severe Sepsis 3-Hour Bundle88113
Severe Sepsis 6-Hour Bundle9087
Discharged on Antithrombotic Therapy
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 2
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 Montrose Regional Health rated?
Montrose Regional Health has a 4 out of 5 CMS overall star rating as of the latest CMS release.
Does Montrose Regional Health have emergency services?
Yes. Montrose Regional Health operates a 24/7 emergency department.
Where is Montrose Regional Health located?
Montrose Regional Health is located at 800 S 3rd St, Montrose, CO 81401.
What type of hospital is Montrose Regional Health?
Montrose Regional Health 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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