JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

St. Mary's Hospital

2 / 5

At a glance

St. Mary's Hospital carries a 2-star CMS overall rating — below 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 0 measures and trails on 1.

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 Limit0.017Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit1.668Same as national
Central Line Associated Bloodstream Infection: Number of Device Days3567Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases2.956Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases1Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.338Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.015Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit1.475Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days3864Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases3.344Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases1Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.299Same as national
SSI - Colon Surgery: Lower Confidence Limit0.302Same as national
SSI - Colon Surgery: Upper Confidence Limit5.948Same as national
SSI - Colon Surgery: Number of Procedures40Same as national
SSI - Colon Surgery: Predicted Cases1.111Same as national
SSI - Colon Surgery: Observed Cases2Same as national
SSI - Colon Surgery1.800Same as national
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 Limit0.249Same as national
MRSA Bacteremia: Upper Confidence Limit2.660Same as national
MRSA Bacteremia: Patient Days40567Same as national
MRSA Bacteremia: Predicted Cases3.070Same as national
MRSA Bacteremia: Observed Cases3Same as national
MRSA Bacteremia0.977Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.166Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.625Better than national
Clostridium Difficile (C.Diff): Patient Days40567Better than national
Clostridium Difficile (C.Diff): Predicted Cases26.407Better than national
Clostridium Difficile (C.Diff): Observed Cases9Better than national
Clostridium Difficile (C.Diff)0.341Better 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 patientsNot available
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4Same as national806
Death rate for heart attack patients13.2Same as national164
Death rate for CABG surgery patients2.4Same as national47
Death rate for COPD patients8.2Same as national35
Death rate for heart failure patients11.9Same as national145
Death rate for pneumonia patients15.2Same as national189
Death rate for stroke patients15.1Same as national151
Pressure ulcer rate0.56Same as national2184
Death rate among surgical inpatients with serious treatable complications181.12Same as national57
Iatrogenic pneumothorax rate0.24Same as national2822
In-hospital fall-associated fracture rate0.28Same as national2969
Postoperative hemorrhage or hematoma rate2.20Same as national750
Postoperative acute kidney injury requiring dialysis rate1.60Same as national60
Postoperative respiratory failure rate7.37Same as national57
Perioperative pulmonary embolism or deep vein thrombosis rate3.83Same as national862
Postoperative sepsis rate5.84Same as national61
Postoperative wound dehiscence rate1.69Same as national135
Abdominopelvic accidental puncture or laceration rate1.50Same as national411
CMS Medicare PSI 90: Patient safety and adverse events composite0.97Same 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-2.3Not available184
Hospital return days for heart failure patients14.6Not available169
Hospital return days for pneumonia patients18.8Not available195
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.3Same as national1193
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)13Same as national71
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 surgery1.5Worse than national232
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate13.8Same as national184
Rate of readmission for CABG10.5Same as national47
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients18.7Same as national40
Heart failure (HF) 30-Day Readmission Rate19.8Same as national169
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate16Same as national195

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 rating21079
Doctor communication - star rating21079
Communication about medicines - star rating11079
Discharge information - star rating21079
Cleanliness - star rating21079
Quietness - star rating21079
Overall hospital rating - star rating21079
Recommend hospital - star rating21079
Summary star rating21079

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 Hyperglycemia215245
Hospital Harm - Severe Hypoglycemia03100
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination90362
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 better190492
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 better186458
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better39317
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better31517
Left before being seen542045
Head CT results8824
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients9985
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing111770
Appropriate care for severe sepsis and septic shock40141
Septic Shock 3-Hour Bundle4730
Septic Shock 6-Hour Bundle
Severe Sepsis 3-Hour Bundle62141
Severe Sepsis 6-Hour Bundle8458
Discharged on Antithrombotic Therapy
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 2
Venous Thromboembolism Prophylaxis765108
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. Mary's Hospital rated?
St. Mary's Hospital has a 2 out of 5 CMS overall star rating as of the latest CMS release.
Does St. Mary's Hospital have emergency services?
Yes. St. Mary's Hospital operates a 24/7 emergency department.
Where is St. Mary's Hospital located?
St. Mary's Hospital is located at 1601 West St Mary's Road, Tucson, AZ 85745.
What type of hospital is St. Mary's Hospital?
St. Mary's 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