JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Proprietary

Southern Hills Hospital and Medical Center

4 / 5

At a glance

Southern Hills Hospital and Medical Center carries a 4-star CMS overall rating — above the national norm. On healthcare-associated infection measures, it performs better than the national average on 18 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 Limit0.008Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit0.749Better than national
Central Line Associated Bloodstream Infection: Number of Device Days6192Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases6.586Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases1Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.152Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.008Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit0.822Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days4874Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases5.998Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases1Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.167Better than national
SSI - Colon Surgery: Lower Confidence Limit0.184Same as national
SSI - Colon Surgery: Upper Confidence Limit1.968Same as national
SSI - Colon Surgery: Number of Procedures161Same as national
SSI - Colon Surgery: Predicted Cases4.148Same as national
SSI - Colon Surgery: Observed Cases3Same as national
SSI - Colon Surgery0.723Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures78Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.626Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence Limit0.499Same as national
MRSA Bacteremia: Upper Confidence Limit3.791Same as national
MRSA Bacteremia: Patient Days63042Same as national
MRSA Bacteremia: Predicted Cases2.545Same as national
MRSA Bacteremia: Observed Cases4Same as national
MRSA Bacteremia1.572Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.031Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.337Better than national
Clostridium Difficile (C.Diff): Patient Days55132Better than national
Clostridium Difficile (C.Diff): Predicted Cases24.251Better than national
Clostridium Difficile (C.Diff): Observed Cases3Better than national
Clostridium Difficile (C.Diff)0.124Better 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 patients2.7Same as national71
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate3.8Same as national1230
Death rate for heart attack patients11.7Same as national91
Death rate for CABG surgery patientsNot available
Death rate for COPD patients8.6Same as national85
Death rate for heart failure patients7.7Better than national231
Death rate for pneumonia patients14.2Same as national413
Death rate for stroke patients14.5Same as national156
Pressure ulcer rate0.35Same as national4322
Death rate among surgical inpatients with serious treatable complications118.27Better than national94
Iatrogenic pneumothorax rate0.20Same as national5430
In-hospital fall-associated fracture rate0.22Same as national5602
Postoperative hemorrhage or hematoma rate1.71Same as national1318
Postoperative acute kidney injury requiring dialysis rate1.52Same as national665
Postoperative respiratory failure rate9.62Same as national683
Perioperative pulmonary embolism or deep vein thrombosis rate3.40Same as national1346
Postoperative sepsis rate5.93Same as national671
Postoperative wound dehiscence rate1.57Same as national487
Abdominopelvic accidental puncture or laceration rate0.82Same as national1244
CMS Medicare PSI 90: Patient safety and adverse events composite0.91Same 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 patients13.3Not available73
Hospital return days for heart failure patients-5.4Not available267
Hospital return days for pneumonia patients20.3Not available444
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)16Same as national2011
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)13Same as national246
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 surgery1.2Same as national370
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate12.9Same as national73
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients17.8Same as national90
Heart failure (HF) 30-Day Readmission Rate19.1Same as national267
Rate of readmission after hip/knee replacement4.7Same as national69
Pneumonia (PN) 30-Day Readmission Rate17.8Same as national444

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 rating2681
Doctor communication - star rating2681
Communication about medicines - star rating2681
Discharge information - star rating2681
Cleanliness - star rating4681
Quietness - star rating3681
Overall hospital rating - star rating3681
Recommend hospital - star rating4681
Summary star rating3681

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 volumevery high
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 vaccination792787
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 better108444
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 better106416
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better16025
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 seen082759
Head CT results
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients9670
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing165020
Appropriate care for severe sepsis and septic shock76161
Septic Shock 3-Hour Bundle6641
Septic Shock 6-Hour Bundle9226
Severe Sepsis 3-Hour Bundle90161
Severe Sepsis 6-Hour Bundle98128
Discharged on Antithrombotic Therapy
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 289206
Venous Thromboembolism Prophylaxis846913
Intensive Care Unit Venous Thromboembolism Prophylaxis971305

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 Southern Hills Hospital and Medical Center rated?
Southern Hills Hospital and Medical Center has a 4 out of 5 CMS overall star rating as of the latest CMS release.
Does Southern Hills Hospital and Medical Center have emergency services?
Yes. Southern Hills Hospital and Medical Center operates a 24/7 emergency department.
Where is Southern Hills Hospital and Medical Center located?
Southern Hills Hospital and Medical Center is located at 9300 West Sunset Rd, Las Vegas, NV 89148.
What type of hospital is Southern Hills Hospital and Medical Center?
Southern Hills Hospital and Medical Center is classified by CMS as a Acute Care Hospitals facility (Proprietary).

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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