JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Other

Sutter Santa Rosa Regional Hospital

5 / 5

At a glance

Sutter Santa Rosa Regional Hospital carries a 5-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.

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 Limit0.012Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit1.163Same as national
Central Line Associated Bloodstream Infection: Number of Device Days4794Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases4.240Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases1Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.236Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.163Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit1.746Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days4775Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases4.677Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases3Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.641Same as national
SSI - Colon Surgery: Lower Confidence LimitSame as national
SSI - Colon Surgery: Upper Confidence Limit1.012Same as national
SSI - Colon Surgery: Number of Procedures118Same as national
SSI - Colon Surgery: Predicted Cases2.960Same as national
SSI - Colon Surgery: Observed Cases0Same as national
SSI - Colon Surgery0.000Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures44Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.347Not available
SSI - Abdominal Hysterectomy: Observed Cases1Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence Limit0.103Same as national
MRSA Bacteremia: Upper Confidence Limit2.037Same as national
MRSA Bacteremia: Patient Days44822Same as national
MRSA Bacteremia: Predicted Cases3.244Same as national
MRSA Bacteremia: Observed Cases2Same as national
MRSA Bacteremia0.617Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.067Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.303Better than national
Clostridium Difficile (C.Diff): Patient Days39886Better than national
Clostridium Difficile (C.Diff): Predicted Cases45.671Better than national
Clostridium Difficile (C.Diff): Observed Cases7Better than national
Clostridium Difficile (C.Diff)0.153Better 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 patients2.3Same as national293
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate3.4Better than national1375
Death rate for heart attack patients11.4Same as national187
Death rate for CABG surgery patientsNot available
Death rate for COPD patients7.5Same as national62
Death rate for heart failure patients10.4Same as national301
Death rate for pneumonia patients14.4Same as national243
Death rate for stroke patients13.4Same as national140
Pressure ulcer rate0.18Same as national4064
Death rate among surgical inpatients with serious treatable complications162.53Same as national54
Iatrogenic pneumothorax rate0.26Same as national4946
In-hospital fall-associated fracture rate0.23Same as national4974
Postoperative hemorrhage or hematoma rate2.36Same as national1214
Postoperative acute kidney injury requiring dialysis rate1.50Same as national532
Postoperative respiratory failure rate9.87Same as national558
Perioperative pulmonary embolism or deep vein thrombosis rate4.99Same as national1288
Postoperative sepsis rate8.01Same as national522
Postoperative wound dehiscence rate1.60Same as national337
Abdominopelvic accidental puncture or laceration rate1.03Same as national1147
CMS Medicare PSI 90: Patient safety and adverse events composite1.03Same 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-16.1Not available189
Hospital return days for heart failure patients-6.6Not available337
Hospital return days for pneumonia patients-2.3Not available247
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.4Same as national2133
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)14Same as national1275
Rate of inpatient admissions for patients receiving outpatient chemotherapy11.6Same as national259
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy7.2Same as national259
Ratio of unplanned hospital visits after hospital outpatient surgery1.1Same as national702
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate12.5Same as national189
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients17.9Same as national67
Heart failure (HF) 30-Day Readmission Rate19.2Same as national337
Rate of readmission after hip/knee replacement4.9Same as national280
Pneumonia (PN) 30-Day Readmission Rate15.8Same as national247

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 rating4810
Doctor communication - star rating3810
Communication about medicines - star rating2810
Discharge information - star rating4810
Cleanliness - star rating3810
Quietness - star rating3810
Overall hospital rating - star rating4810
Recommend hospital - star rating5810
Summary star rating3810

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 Hypoglycemia21725
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination731915
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 better230405
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 better224368
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better28328
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 seen245020
Head CT results8217
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients10032
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing202934
Appropriate care for severe sepsis and septic shock69156
Septic Shock 3-Hour Bundle6560
Septic Shock 6-Hour Bundle9225
Severe Sepsis 3-Hour Bundle87156
Severe Sepsis 6-Hour Bundle9996
Discharged on Antithrombotic Therapy
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 210096
Venous Thromboembolism Prophylaxis
Intensive Care Unit Venous Thromboembolism Prophylaxis99861

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 Sutter Santa Rosa Regional Hospital rated?
Sutter Santa Rosa Regional Hospital has a 5 out of 5 CMS overall star rating as of the latest CMS release.
Does Sutter Santa Rosa Regional Hospital have emergency services?
Yes. Sutter Santa Rosa Regional Hospital operates a 24/7 emergency department.
Where is Sutter Santa Rosa Regional Hospital located?
Sutter Santa Rosa Regional Hospital is located at 30 Mark West Springs Road, Santa Rosa, CA 95403.
What type of hospital is Sutter Santa Rosa Regional Hospital?
Sutter Santa Rosa Regional Hospital is classified by CMS as a Acute Care Hospitals facility (Voluntary non-profit - Other).

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