JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Church

St Josephs Hospital

4 / 5

At a glance

St Josephs 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 Days239Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases0.138Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases0Not 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 Days528Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases0.258Not 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 Procedures7Not available
SSI - Colon Surgery: Predicted Cases0.167Not 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 Procedures2Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.015Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitNot available
MRSA Bacteremia: Upper Confidence LimitNot available
MRSA Bacteremia: Patient Days6881Not available
MRSA Bacteremia: Predicted Cases0.150Not available
MRSA Bacteremia: Observed Cases0Not available
MRSA BacteremiaNot available
Clostridium Difficile (C.Diff): Lower Confidence Limit0.030Same as national
Clostridium Difficile (C.Diff): Upper Confidence Limit2.985Same as national
Clostridium Difficile (C.Diff): Patient Days5864Same as national
Clostridium Difficile (C.Diff): Predicted Cases1.652Same as national
Clostridium Difficile (C.Diff): Observed Cases1Same as national
Clostridium Difficile (C.Diff)0.605Same 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 national200
Death rate for heart attack patientsNot available
Death rate for CABG surgery patientsNot available
Death rate for COPD patients8.6Same as national25
Death rate for heart failure patients13.4Same as national94
Death rate for pneumonia patients11.7Better than national157
Death rate for stroke patients13.3Same as national26
Pressure ulcer rate0.51Same as national549
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.21Same as national797
In-hospital fall-associated fracture rate0.31Same as national763
Postoperative hemorrhage or hematoma rate2.31Same as national67
Postoperative acute kidney injury requiring dialysis rateNot available
Postoperative respiratory failure rateNot available
Perioperative pulmonary embolism or deep vein thrombosis rate3.37Same as national70
Postoperative sepsis rateNot available
Postoperative wound dehiscence rateNot available
Abdominopelvic accidental puncture or laceration rate1.03Same as national36
CMS Medicare PSI 90: Patient safety and adverse events composite0.95Same 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 patients0.5Not available100
Hospital return days for pneumonia patients6.1Not available162
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.5Same as national281
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)12Same as national514
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 national66
Acute Myocardial Infarction (AMI) 30-Day Readmission RateNot available
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients18Same as national31
Heart failure (HF) 30-Day Readmission Rate19Same as national100
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate15.9Same as national162

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 rating4193
Doctor communication - star rating4193
Communication about medicines - star rating4193
Discharge information - star rating4193
Cleanliness - star rating3193
Quietness - star rating5193
Overall hospital rating - star rating4193
Recommend hospital - star rating4193
Summary star rating4193

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 volumelow
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 Hyperglycemia10569
Hospital Harm - Severe Hypoglycemia1192
Hospital Harm - Opioid Related Adverse Events0862
Healthcare workers given influenza vaccination75484
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 better138379
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 better130342
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better32833
Left before being seen09727
Head CT results7713
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients91181
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing18310
Appropriate care for severe sepsis and septic shock6170
Septic Shock 3-Hour Bundle7914
Septic Shock 6-Hour Bundle
Severe Sepsis 3-Hour Bundle7070
Severe Sepsis 6-Hour Bundle10035
Discharged on Antithrombotic Therapy
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 2
Venous Thromboembolism Prophylaxis95596
Intensive Care Unit Venous Thromboembolism Prophylaxis0

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 St Josephs Hospital rated?
St Josephs Hospital has a 4 out of 5 CMS overall star rating as of the latest CMS release.
Does St Josephs Hospital have emergency services?
Yes. St Josephs Hospital operates a 24/7 emergency department.
Where is St Josephs Hospital located?
St Josephs Hospital is located at 9515 Holy Cross Ln, Breese, IL 62230.
What type of hospital is St Josephs Hospital?
St Josephs Hospital is classified by CMS as a Acute Care Hospitals facility (Voluntary non-profit - Church).

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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