JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Sentara Martha Jefferson Hospital

4 / 5

At a glance

Sentara Martha Jefferson Hospital 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. For 30-day readmissions, it beats the national rate on 1 measure and trails 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 Limit0.128Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit2.525Same as national
Central Line Associated Bloodstream Infection: Number of Device Days3847Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases2.617Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases2Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.764Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.445Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit4.766Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days2369Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases1.713Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases3Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)1.751Same as national
SSI - Colon Surgery: Lower Confidence Limit0.017Same as national
SSI - Colon Surgery: Upper Confidence Limit1.661Same as national
SSI - Colon Surgery: Number of Procedures116Same as national
SSI - Colon Surgery: Predicted Cases2.970Same as national
SSI - Colon Surgery: Observed Cases1Same as national
SSI - Colon Surgery0.337Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures51Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.417Not available
SSI - Abdominal Hysterectomy: Observed Cases2Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence Limit0.029Same as national
MRSA Bacteremia: Upper Confidence Limit2.815Same as national
MRSA Bacteremia: Patient Days38400Same as national
MRSA Bacteremia: Predicted Cases1.752Same as national
MRSA Bacteremia: Observed Cases1Same as national
MRSA Bacteremia0.571Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.050Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.535Better than national
Clostridium Difficile (C.Diff): Patient Days36116Better than national
Clostridium Difficile (C.Diff): Predicted Cases15.264Better than national
Clostridium Difficile (C.Diff): Observed Cases3Better than national
Clostridium Difficile (C.Diff)0.197Better 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 patients4.8Same as national80
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate3.9Same as national1685
Death rate for heart attack patients10.9Same as national280
Death rate for CABG surgery patientsNot available
Death rate for COPD patients10.1Same as national82
Death rate for heart failure patients10.6Same as national498
Death rate for pneumonia patients16.3Same as national437
Death rate for stroke patients11.9Same as national313
Pressure ulcer rate0.17Same as national4599
Death rate among surgical inpatients with serious treatable complications185.76Same as national69
Iatrogenic pneumothorax rate0.21Same as national5762
In-hospital fall-associated fracture rate0.25Same as national5712
Postoperative hemorrhage or hematoma rate2.77Same as national1257
Postoperative acute kidney injury requiring dialysis rate1.54Same as national440
Postoperative respiratory failure rate5.99Same as national427
Perioperative pulmonary embolism or deep vein thrombosis rate3.97Same as national1340
Postoperative sepsis rate7.00Same as national402
Postoperative wound dehiscence rate1.59Same as national291
Abdominopelvic accidental puncture or laceration rate1.07Same as national998
CMS Medicare PSI 90: Patient safety and adverse events composite0.86Same 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-1.9Not available255
Hospital return days for heart failure patients-9.6Not available540
Hospital return days for pneumonia patients-19.8Not available437
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)13.1Better than national2481
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)14.1Same as national2403
Rate of inpatient admissions for patients receiving outpatient chemotherapy10.4Same as national252
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy6Same as national252
Ratio of unplanned hospital visits after hospital outpatient surgery0.9Same as national914
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate13.1Same as national255
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients18.2Same as national83
Heart failure (HF) 30-Day Readmission Rate17.6Same as national540
Rate of readmission after hip/knee replacement4.3Same as national77
Pneumonia (PN) 30-Day Readmission Rate14.7Same as national437

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 rating4784
Doctor communication - star rating4784
Communication about medicines - star rating3784
Discharge information - star rating4784
Cleanliness - star rating4784
Quietness - star rating4784
Overall hospital rating - star rating4784
Recommend hospital - star rating5784
Summary star rating4784

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 Hypoglycemia11873
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination831705
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 better1481928
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 better1441842
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better26838
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better23550
Left before being seen355443
Head CT results4613
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients96132
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing141941
Appropriate care for severe sepsis and septic shock76279
Septic Shock 3-Hour Bundle7889
Septic Shock 6-Hour Bundle9454
Severe Sepsis 3-Hour Bundle90279
Severe Sepsis 6-Hour Bundle93176
Discharged on Antithrombotic Therapy100145
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 296118
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 Sentara Martha Jefferson Hospital rated?
Sentara Martha Jefferson Hospital has a 4 out of 5 CMS overall star rating as of the latest CMS release.
Does Sentara Martha Jefferson Hospital have emergency services?
Yes. Sentara Martha Jefferson Hospital operates a 24/7 emergency department.
Where is Sentara Martha Jefferson Hospital located?
Sentara Martha Jefferson Hospital is located at 500 Martha Jefferson Drive, Charlottesville, VA 22911.
What type of hospital is Sentara Martha Jefferson Hospital?
Sentara Martha Jefferson 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