JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Government - Hospital District or Authority

Northeastern Health System

2 / 5

At a glance

Northeastern Health System carries a 2-star CMS overall rating — below the national norm. On healthcare-associated infection measures, it performs better than the national average on 0 and worse on 6.

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 Limit0.028Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit2.804Same as national
Central Line Associated Bloodstream Infection: Number of Device Days1863Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases1.759Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases1Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.569Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit1.204Worse than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit4.530Worse than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days3399Worse than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases3.646Worse than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases9Worse than national
Catheter Associated Urinary Tract Infections (ICU + select Wards)2.468Worse than national
SSI - Colon Surgery: Lower Confidence LimitSame as national
SSI - Colon Surgery: Upper Confidence Limit2.699Same as national
SSI - Colon Surgery: Number of Procedures42Same as national
SSI - Colon Surgery: Predicted Cases1.110Same 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 Procedures5Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.040Not 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 Days13900Not available
MRSA Bacteremia: Predicted Cases0.805Not available
MRSA Bacteremia: Observed Cases0Not available
MRSA BacteremiaNot available
Clostridium Difficile (C.Diff): Lower Confidence Limit0.145Same as national
Clostridium Difficile (C.Diff): Upper Confidence Limit1.551Same as national
Clostridium Difficile (C.Diff): Patient Days13594Same as national
Clostridium Difficile (C.Diff): Predicted Cases5.264Same as national
Clostridium Difficile (C.Diff): Observed Cases3Same as national
Clostridium Difficile (C.Diff)0.570Same 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 patients3.7Same as national122
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4.2Same as national492
Death rate for heart attack patients13.7Same as national56
Death rate for CABG surgery patientsNot available
Death rate for COPD patients9.2Same as national47
Death rate for heart failure patients12Same as national141
Death rate for pneumonia patients18.9Same as national102
Death rate for stroke patients12.8Same as national62
Pressure ulcer rate0.73Same as national1428
Death rate among surgical inpatients with serious treatable complications172.11Same as national25
Iatrogenic pneumothorax rate0.18Same as national2190
In-hospital fall-associated fracture rate0.33Same as national2238
Postoperative hemorrhage or hematoma rate3.08Same as national647
Postoperative acute kidney injury requiring dialysis rate1.52Same as national346
Postoperative respiratory failure rate13.66Same as national358
Perioperative pulmonary embolism or deep vein thrombosis rate3.56Same as national670
Postoperative sepsis rate6.08Same as national328
Postoperative wound dehiscence rate1.72Same as national99
Abdominopelvic accidental puncture or laceration rate1.26Same as national325
CMS Medicare PSI 90: Patient safety and adverse events composite1.18Same 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 patients24Not available59
Hospital return days for heart failure patients14.5Not available174
Hospital return days for pneumonia patients-19.9Not available117
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)15Same as national743
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)13Same as national601
Rate of inpatient admissions for patients receiving outpatient chemotherapy10.5Same as national44
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy4.8Same as national44
Ratio of unplanned hospital visits after hospital outpatient surgery1.1Same as national132
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate14.4Same as national59
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients18.4Same as national51
Heart failure (HF) 30-Day Readmission Rate21.6Same as national174
Rate of readmission after hip/knee replacement5.2Same as national108
Pneumonia (PN) 30-Day Readmission Rate15.2Same as national117

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 rating3407
Doctor communication - star rating3407
Communication about medicines - star rating2407
Discharge information - star rating3407
Cleanliness - star rating1407
Quietness - star rating3407
Overall hospital rating - star rating3407
Recommend hospital - star rating3407
Summary star rating3407

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 volumelow
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 vaccination571409
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 better136436
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 better124403
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better27615
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better29418
Left before being seen219642
Head CT results
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients100305
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing17929
Appropriate care for severe sepsis and septic shock5898
Septic Shock 3-Hour Bundle5641
Septic Shock 6-Hour Bundle6414
Severe Sepsis 3-Hour Bundle8598
Severe Sepsis 6-Hour Bundle9560
Discharged on Antithrombotic Therapy9649
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 2
Venous Thromboembolism Prophylaxis951642
Intensive Care Unit Venous Thromboembolism Prophylaxis98511

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 Northeastern Health System rated?
Northeastern Health System has a 2 out of 5 CMS overall star rating as of the latest CMS release.
Does Northeastern Health System have emergency services?
Yes. Northeastern Health System operates a 24/7 emergency department.
Where is Northeastern Health System located?
Northeastern Health System is located at 1400 East Downing Street, Tahlequah, OK 74465.
What type of hospital is Northeastern Health System?
Northeastern Health System 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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