JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Proprietary

St Joseph Health System, Llc

4 / 5

At a glance

St Joseph Health System, Llc 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 Days180Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases0.114Not 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 LimitNot available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence LimitNot available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days418Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases0.229Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases0Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards)Not available
SSI - Colon Surgery: Lower Confidence LimitNot available
SSI - Colon Surgery: Upper Confidence LimitNot available
SSI - Colon Surgery: Number of Procedures4Not available
SSI - Colon Surgery: Predicted Cases0.113Not available
SSI - Colon Surgery: Observed Cases0Not available
SSI - Colon SurgeryNot available
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of ProceduresNot available
SSI - Abdominal Hysterectomy: Predicted CasesNot available
SSI - Abdominal Hysterectomy: Observed CasesNot available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitNot available
MRSA Bacteremia: Upper Confidence LimitNot available
MRSA Bacteremia: Patient Days6111Not available
MRSA Bacteremia: Predicted Cases0.176Not available
MRSA Bacteremia: Observed Cases0Not available
MRSA BacteremiaNot available
Clostridium Difficile (C.Diff): Lower Confidence Limit0.019Same as national
Clostridium Difficile (C.Diff): Upper Confidence Limit1.913Same as national
Clostridium Difficile (C.Diff): Patient Days5595Same as national
Clostridium Difficile (C.Diff): Predicted Cases2.578Same as national
Clostridium Difficile (C.Diff): Observed Cases1Same as national
Clostridium Difficile (C.Diff)0.388Same 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 Rate3.8Same as national56
Death rate for heart attack patientsNot available
Death rate for CABG surgery patientsNot available
Death rate for COPD patientsNot available
Death rate for heart failure patients12.4Same as national25
Death rate for pneumonia patients15Same as national37
Death rate for stroke patientsNot available
Pressure ulcer rate0.57Same as national214
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.21Same as national299
In-hospital fall-associated fracture rate0.27Same as national310
Postoperative hemorrhage or hematoma rate2.32Same as national25
Postoperative acute kidney injury requiring dialysis rateNot available
Postoperative respiratory failure rateNot available
Perioperative pulmonary embolism or deep vein thrombosis rate3.48Same as national25
Postoperative sepsis rateNot available
Postoperative wound dehiscence rateNot available
Abdominopelvic accidental puncture or laceration rate1.05Same as national27
CMS Medicare PSI 90: Patient safety and adverse events composite0.96Same 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 patients2Not available25
Hospital return days for pneumonia patients34.1Not available41
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.8Same as national75
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)13.1Same as national114
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 surgeryNot available
Acute Myocardial Infarction (AMI) 30-Day Readmission RateNot available
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patientsNot available
Heart failure (HF) 30-Day Readmission Rate19.6Same as national25
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate15.9Same as national41

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 rating2249
Doctor communication - star rating3249
Communication about medicines - star rating2249
Discharge information - star rating3249
Cleanliness - star rating4249
Quietness - star rating4249
Overall hospital rating - star rating3249
Recommend hospital - star rating4249
Summary star rating3249

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 Hypoglycemia2463
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination66346
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 better134426
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 better131390
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better28718
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better33418
Left before being seen232845
Head CT results5511
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients9463
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing9263
Appropriate care for severe sepsis and septic shock69124
Septic Shock 3-Hour Bundle5831
Septic Shock 6-Hour Bundle7516
Severe Sepsis 3-Hour Bundle86124
Severe Sepsis 6-Hour Bundle9774
Discharged on Antithrombotic Therapy
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 2
Venous Thromboembolism Prophylaxis97745
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 MeasureNot Applicable (our hospital does not provide inpatient labor/delivery care)

Frequently asked questions

How is St Joseph Health System, Llc rated?
St Joseph Health System, Llc has a 4 out of 5 CMS overall star rating as of the latest CMS release.
Does St Joseph Health System, Llc have emergency services?
Yes. St Joseph Health System, Llc operates a 24/7 emergency department.
Where is St Joseph Health System, Llc located?
St Joseph Health System, Llc is located at 702 Van Buren St., Fort Wayne, IN 46802.
What type of hospital is St Joseph Health System, Llc?
St Joseph Health System, Llc 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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