JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Self Regional Healthcare

4 / 5

At a glance

Self Regional Healthcare carries a 4-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 Limit0.242Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit1.840Same as national
Central Line Associated Bloodstream Infection: Number of Device Days5366Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases5.245Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases4Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.763Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.060Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit1.175Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days5448Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases5.626Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases2Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.355Same as national
SSI - Colon Surgery: Lower Confidence Limit0.324Same as national
SSI - Colon Surgery: Upper Confidence Limit2.463Same as national
SSI - Colon Surgery: Number of Procedures148Same as national
SSI - Colon Surgery: Predicted Cases3.918Same as national
SSI - Colon Surgery: Observed Cases4Same as national
SSI - Colon Surgery1.021Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures88Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.815Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence Limit0.015Same as national
MRSA Bacteremia: Upper Confidence Limit1.496Same as national
MRSA Bacteremia: Patient Days65282Same as national
MRSA Bacteremia: Predicted Cases3.297Same as national
MRSA Bacteremia: Observed Cases1Same as national
MRSA Bacteremia0.303Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.112Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.506Better than national
Clostridium Difficile (C.Diff): Patient Days61054Better than national
Clostridium Difficile (C.Diff): Predicted Cases27.390Better than national
Clostridium Difficile (C.Diff): Observed Cases7Better than national
Clostridium Difficile (C.Diff)0.256Better 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 patients3.3Same as national92
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4.9Same as national1459
Death rate for heart attack patients12.1Same as national200
Death rate for CABG surgery patients2.9Same as national87
Death rate for COPD patients8.7Same as national121
Death rate for heart failure patients13Same as national357
Death rate for pneumonia patients16.7Same as national353
Death rate for stroke patients14.2Same as national194
Pressure ulcer rate0.22Same as national4401
Death rate among surgical inpatients with serious treatable complications164.64Same as national41
Iatrogenic pneumothorax rate0.22Same as national5155
In-hospital fall-associated fracture rate0.34Same as national5216
Postoperative hemorrhage or hematoma rate2.26Same as national1148
Postoperative acute kidney injury requiring dialysis rate1.36Same as national535
Postoperative respiratory failure rate11.41Same as national554
Perioperative pulmonary embolism or deep vein thrombosis rate6.06Worse than national1252
Postoperative sepsis rate3.83Same as national526
Postoperative wound dehiscence rate1.61Same as national324
Abdominopelvic accidental puncture or laceration rate0.87Same as national896
CMS Medicare PSI 90: Patient safety and adverse events composite0.98Same 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 patients20.5Not available197
Hospital return days for heart failure patients2.2Not available382
Hospital return days for pneumonia patients5.3Not available353
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.3Same as national2220
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)12.6Same as national93
Rate of inpatient admissions for patients receiving outpatient chemotherapy11.4Same as national279
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy5.3Same as national279
Ratio of unplanned hospital visits after hospital outpatient surgery1.2Same as national672
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate14.1Same as national197
Rate of readmission for CABG9.6Same as national86
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients17.4Same as national125
Heart failure (HF) 30-Day Readmission Rate19.2Same as national382
Rate of readmission after hip/knee replacement5.4Same as national86
Pneumonia (PN) 30-Day Readmission Rate16Same as national353

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 rating4941
Doctor communication - star rating4941
Communication about medicines - star rating3941
Discharge information - star rating3941
Cleanliness - star rating3941
Quietness - star rating4941
Overall hospital rating - star rating4941
Recommend hospital - star rating4941
Summary star rating4941

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 Hypoglycemia12811
Hospital Harm - Opioid Related Adverse Events06142
Healthcare workers given influenza vaccination953370
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 better205398
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 better204380
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better24214
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 seen354371
Head CT results7434
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)6070
Safe Use of Opioids - Concurrent Prescribing132960
Appropriate care for severe sepsis and septic shock66483
Septic Shock 3-Hour Bundle79272
Septic Shock 6-Hour Bundle89150
Severe Sepsis 3-Hour Bundle87483
Severe Sepsis 6-Hour Bundle92336
Discharged on Antithrombotic Therapy98200
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 294176
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 Self Regional Healthcare rated?
Self Regional Healthcare has a 4 out of 5 CMS overall star rating as of the latest CMS release.
Does Self Regional Healthcare have emergency services?
Yes. Self Regional Healthcare operates a 24/7 emergency department.
Where is Self Regional Healthcare located?
Self Regional Healthcare is located at 1325 Spring Street, Greenwood, SC 29646.
What type of hospital is Self Regional Healthcare?
Self Regional Healthcare 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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