JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Northwestern Medicine Delnor Community Hospital

5 / 5

At a glance

Northwestern Medicine Delnor Community 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 Limit0.017Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit1.640Same as national
Central Line Associated Bloodstream Infection: Number of Device Days3551Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases3.007Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases1Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.333Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence LimitSame as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit1.291Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days2444Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases2.321Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases0Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.000Same as national
SSI - Colon Surgery: Lower Confidence Limit0.129Same as national
SSI - Colon Surgery: Upper Confidence Limit2.541Same as national
SSI - Colon Surgery: Number of Procedures107Same as national
SSI - Colon Surgery: Predicted Cases2.600Same as national
SSI - Colon Surgery: Observed Cases2Same as national
SSI - Colon Surgery0.769Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures63Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.513Not available
SSI - Abdominal Hysterectomy: Observed Cases1Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitSame as national
MRSA Bacteremia: Upper Confidence Limit1.562Same as national
MRSA Bacteremia: Patient Days50062Same as national
MRSA Bacteremia: Predicted Cases1.918Same as national
MRSA Bacteremia: Observed Cases0Same as national
MRSA Bacteremia0.000Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.151Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.681Better than national
Clostridium Difficile (C.Diff): Patient Days47190Better than national
Clostridium Difficile (C.Diff): Predicted Cases20.324Better than national
Clostridium Difficile (C.Diff): Observed Cases7Better than national
Clostridium Difficile (C.Diff)0.344Better 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 patients3.6Same as national35
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate3.3Better than national1792
Death rate for heart attack patients12.5Same as national169
Death rate for CABG surgery patientsNot available
Death rate for COPD patients7.8Same as national124
Death rate for heart failure patients8.6Better than national533
Death rate for pneumonia patients15.3Same as national412
Death rate for stroke patients11.2Same as national218
Pressure ulcer rate0.16Same as national5475
Death rate among surgical inpatients with serious treatable complications139.28Same as national43
Iatrogenic pneumothorax rate0.14Same as national7078
In-hospital fall-associated fracture rate0.28Same as national7044
Postoperative hemorrhage or hematoma rate2.64Same as national1077
Postoperative acute kidney injury requiring dialysis rate1.57Same as national383
Postoperative respiratory failure rate5.64Same as national393
Perioperative pulmonary embolism or deep vein thrombosis rate2.83Same as national1201
Postoperative sepsis rate4.29Same as national375
Postoperative wound dehiscence rate1.66Same as national340
Abdominopelvic accidental puncture or laceration rate0.81Same as national1249
CMS Medicare PSI 90: Patient safety and adverse events composite0.69Same 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 patients6.6Not available132
Hospital return days for heart failure patients-18.2Not available611
Hospital return days for pneumonia patients3.7Not available430
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14Same as national2975
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)11Same as national2891
Rate of inpatient admissions for patients receiving outpatient chemotherapy13.3Same as national364
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy4.2Same as national364
Ratio of unplanned hospital visits after hospital outpatient surgery1.1Same as national489
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate14Same as national132
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients18.3Same as national126
Heart failure (HF) 30-Day Readmission Rate17.7Same as national611
Rate of readmission after hip/knee replacement5.2Same as national39
Pneumonia (PN) 30-Day Readmission Rate16.1Same as national430

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 rating4667
Doctor communication - star rating4667
Communication about medicines - star rating4667
Discharge information - star rating4667
Cleanliness - star rating4667
Quietness - star rating4667
Overall hospital rating - star rating4667
Recommend hospital - star rating4667
Summary star rating4667

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 Hypoglycemia11994
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination962878
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 better213403
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 better211384
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better23915
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 seen247387
Head CT results
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients9774
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing182542
Appropriate care for severe sepsis and septic shock71227
Septic Shock 3-Hour Bundle8180
Septic Shock 6-Hour Bundle9143
Severe Sepsis 3-Hour Bundle82228
Severe Sepsis 6-Hour Bundle9585
Discharged on Antithrombotic Therapy97145
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 295136
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 Northwestern Medicine Delnor Community Hospital rated?
Northwestern Medicine Delnor Community Hospital has a 5 out of 5 CMS overall star rating as of the latest CMS release.
Does Northwestern Medicine Delnor Community Hospital have emergency services?
Yes. Northwestern Medicine Delnor Community Hospital operates a 24/7 emergency department.
Where is Northwestern Medicine Delnor Community Hospital located?
Northwestern Medicine Delnor Community Hospital is located at 300 Randall Rd, Geneva, IL 60134.
What type of hospital is Northwestern Medicine Delnor Community Hospital?
Northwestern Medicine Delnor Community 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.

Report an issue with this page