JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

UCSF Health St. Mary's Hospital

4 / 5

At a glance

UCSF Health St. Mary's Hospital carries a 4-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 LimitSame as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit2.166Same as national
Central Line Associated Bloodstream Infection: Number of Device Days1699Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases1.383Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases0Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.000Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence LimitSame as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit2.511Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days1503Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases1.193Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases0Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.000Same as national
SSI - Colon Surgery: Lower Confidence LimitNot available
SSI - Colon Surgery: Upper Confidence LimitNot available
SSI - Colon Surgery: Number of Procedures13Not available
SSI - Colon Surgery: Predicted Cases0.302Not 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 Procedures8Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.048Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitSame as national
MRSA Bacteremia: Upper Confidence Limit1.824Same as national
MRSA Bacteremia: Patient Days24633Same as national
MRSA Bacteremia: Predicted Cases1.642Same as national
MRSA Bacteremia: Observed Cases0Same as national
MRSA Bacteremia0.000Same as national
Clostridium Difficile (C.Diff): Lower Confidence LimitBetter than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.279Better than national
Clostridium Difficile (C.Diff): Patient Days24633Better than national
Clostridium Difficile (C.Diff): Predicted Cases10.742Better than national
Clostridium Difficile (C.Diff): Observed Cases0Better than national
Clostridium Difficile (C.Diff)0.000Better 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 patients4.2Same as national84
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate3.5Same as national617
Death rate for heart attack patients11.9Same as national50
Death rate for CABG surgery patientsNot available
Death rate for COPD patients8.9Same as national39
Death rate for heart failure patients8.5Better than national210
Death rate for pneumonia patients9.5Better than national122
Death rate for stroke patients12.1Same as national84
Pressure ulcer rate0.21Same as national2258
Death rate among surgical inpatients with serious treatable complications146.74Same as national30
Iatrogenic pneumothorax rate0.24Same as national2530
In-hospital fall-associated fracture rate0.32Same as national2519
Postoperative hemorrhage or hematoma rate2.07Same as national554
Postoperative acute kidney injury requiring dialysis rate1.63Same as national238
Postoperative respiratory failure rate12.70Same as national259
Perioperative pulmonary embolism or deep vein thrombosis rate3.02Same as national590
Postoperative sepsis rate5.67Same as national203
Postoperative wound dehiscence rate1.70Same as national168
Abdominopelvic accidental puncture or laceration rate0.95Same as national413
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 patients2.3Not available244
Hospital return days for pneumonia patients17.1Not available135
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)15.2Same as national1045
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)13.1Same as national192
Rate of inpatient admissions for patients receiving outpatient chemotherapy12Same as national30
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy5.7Same as national30
Ratio of unplanned hospital visits after hospital outpatient surgery1Same as national113
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate14.4Same as national47
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients19.1Same as national44
Heart failure (HF) 30-Day Readmission Rate19.1Same as national244
Rate of readmission after hip/knee replacement3.9Same as national86
Pneumonia (PN) 30-Day Readmission Rate16.5Same as national135

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 rating2561
Doctor communication - star rating3561
Communication about medicines - star rating2561
Discharge information - star rating3561
Cleanliness - star rating3561
Quietness - star rating1561
Overall hospital rating - star rating2561
Recommend hospital - star rating2561
Summary star rating2561

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 Hyperglycemia
Hospital Harm - Severe Hypoglycemia
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination611492
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 better167388
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 better165353
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better19735
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 seen115484
Head CT results
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients9623
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing21854
Appropriate care for severe sepsis and septic shock75169
Septic Shock 3-Hour Bundle8050
Septic Shock 6-Hour Bundle9328
Severe Sepsis 3-Hour Bundle83171
Severe Sepsis 6-Hour Bundle10090
Discharged on Antithrombotic Therapy
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 29447
Venous Thromboembolism Prophylaxis932371
Intensive Care Unit Venous Thromboembolism Prophylaxis95349

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 UCSF Health St. Mary's Hospital rated?
UCSF Health St. Mary's Hospital has a 4 out of 5 CMS overall star rating as of the latest CMS release.
Does UCSF Health St. Mary's Hospital have emergency services?
Yes. UCSF Health St. Mary's Hospital operates a 24/7 emergency department.
Where is UCSF Health St. Mary's Hospital located?
UCSF Health St. Mary's Hospital is located at 450 Stanyan St, San Francisco, CA 94117.
What type of hospital is UCSF Health St. Mary's Hospital?
UCSF Health 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.

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