JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Other

Oaklawn Hospital

4 / 5

At a glance

Oaklawn Hospital 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 Days569Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases0.462Not 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 LimitSame as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit1.936Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days1540Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases1.547Same 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 Limit0.035Same as national
SSI - Colon Surgery: Upper Confidence Limit3.408Same as national
SSI - Colon Surgery: Number of Procedures58Same as national
SSI - Colon Surgery: Predicted Cases1.447Same as national
SSI - Colon Surgery: Observed Cases1Same as national
SSI - Colon Surgery0.691Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures14Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.105Not available
SSI - Abdominal Hysterectomy: Observed Cases1Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitNot available
MRSA Bacteremia: Upper Confidence LimitNot available
MRSA Bacteremia: Patient Days12918Not available
MRSA Bacteremia: Predicted Cases0.550Not available
MRSA Bacteremia: Observed Cases1Not available
MRSA BacteremiaNot available
Clostridium Difficile (C.Diff): Lower Confidence Limit0.275Same as national
Clostridium Difficile (C.Diff): Upper Confidence Limit1.663Same as national
Clostridium Difficile (C.Diff): Patient Days11917Same as national
Clostridium Difficile (C.Diff): Predicted Cases6.665Same as national
Clostridium Difficile (C.Diff): Observed Cases5Same as national
Clostridium Difficile (C.Diff)0.750Same 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 Rate4.3Same as national286
Death rate for heart attack patientsNot available
Death rate for CABG surgery patientsNot available
Death rate for COPD patients9.5Same as national43
Death rate for heart failure patients15Same as national53
Death rate for pneumonia patients18.6Same as national71
Death rate for stroke patients12Same as national25
Pressure ulcer rate0.49Same as national544
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.20Same as national1073
In-hospital fall-associated fracture rate0.26Same as national1070
Postoperative hemorrhage or hematoma rate2.12Same as national315
Postoperative acute kidney injury requiring dialysis rate1.62Same as national193
Postoperative respiratory failure rate9.51Same as national193
Perioperative pulmonary embolism or deep vein thrombosis rate3.07Same as national328
Postoperative sepsis rate4.78Same as national189
Postoperative wound dehiscence rate1.75Same as national48
Abdominopelvic accidental puncture or laceration rate1.02Same as national165
CMS Medicare PSI 90: Patient safety and adverse events composite0.92Same 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-13.9Not available73
Hospital return days for pneumonia patients-0.2Not available83
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.1Same as national377
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)14.5Same as national834
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 surgery1Same as national368
Acute Myocardial Infarction (AMI) 30-Day Readmission RateNot available
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients17.5Same as national44
Heart failure (HF) 30-Day Readmission Rate18.5Same as national73
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate16.2Same as national83

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 rating4443
Doctor communication - star rating4443
Communication about medicines - star rating2443
Discharge information - star rating4443
Cleanliness - star rating5443
Quietness - star rating4443
Overall hospital rating - star rating4443
Recommend hospital - star rating4443
Summary star rating4443

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 Hypoglycemia0519
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination871754
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 better162440
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 better158400
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better23423
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better24117
Left before being seen121019
Head CT results
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients9893
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing16876
Appropriate care for severe sepsis and septic shock6075
Septic Shock 3-Hour Bundle5917
Septic Shock 6-Hour Bundle
Severe Sepsis 3-Hour Bundle7375
Severe Sepsis 6-Hour Bundle9435
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 Oaklawn Hospital rated?
Oaklawn Hospital has a 4 out of 5 CMS overall star rating as of the latest CMS release.
Does Oaklawn Hospital have emergency services?
Yes. Oaklawn Hospital operates a 24/7 emergency department.
Where is Oaklawn Hospital located?
Oaklawn Hospital is located at 200 N Madison, Marshall, MI 49068.
What type of hospital is Oaklawn Hospital?
Oaklawn Hospital is classified by CMS as a Acute Care Hospitals facility (Voluntary non-profit - Other).

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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