JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

UPMC Passavant

4 / 5

At a glance

UPMC Passavant carries a 4-star CMS overall rating — above the national norm. On healthcare-associated infection measures, it performs better than the national average on 18 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 Limit0.170Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit0.873Better than national
Central Line Associated Bloodstream Infection: Number of Device Days13871Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases14.297Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases6Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.420Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.295Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit0.974Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days15792Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases19.624Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases11Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.561Better than national
SSI - Colon Surgery: Lower Confidence Limit0.324Same as national
SSI - Colon Surgery: Upper Confidence Limit1.464Same as national
SSI - Colon Surgery: Number of Procedures365Same as national
SSI - Colon Surgery: Predicted Cases9.458Same as national
SSI - Colon Surgery: Observed Cases7Same as national
SSI - Colon Surgery0.740Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures100Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.822Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence Limit0.432Same as national
MRSA Bacteremia: Upper Confidence Limit1.956Same as national
MRSA Bacteremia: Patient Days86424Same as national
MRSA Bacteremia: Predicted Cases7.080Same as national
MRSA Bacteremia: Observed Cases7Same as national
MRSA Bacteremia0.989Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.434Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.835Better than national
Clostridium Difficile (C.Diff): Patient Days86424Better than national
Clostridium Difficile (C.Diff): Predicted Cases59.014Better than national
Clostridium Difficile (C.Diff): Observed Cases36Better than national
Clostridium Difficile (C.Diff)0.610Better 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 patients2.9Same as national82
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate3.7Same as national1474
Death rate for heart attack patients11.1Same as national151
Death rate for CABG surgery patients2.8Same as national57
Death rate for COPD patients8Same as national76
Death rate for heart failure patients11.6Same as national379
Death rate for pneumonia patients14.8Same as national327
Death rate for stroke patients12.3Same as national92
Pressure ulcer rate0.37Same as national4346
Death rate among surgical inpatients with serious treatable complications214.69Same as national57
Iatrogenic pneumothorax rate0.25Same as national5406
In-hospital fall-associated fracture rate0.29Same as national5765
Postoperative hemorrhage or hematoma rate2.63Same as national1622
Postoperative acute kidney injury requiring dialysis rate1.87Same as national971
Postoperative respiratory failure rate7.19Same as national887
Perioperative pulmonary embolism or deep vein thrombosis rate2.70Same as national1724
Postoperative sepsis rate3.66Same as national900
Postoperative wound dehiscence rate1.55Same as national473
Abdominopelvic accidental puncture or laceration rate0.99Same as national1498
CMS Medicare PSI 90: Patient safety and adverse events composite0.79Same 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 patients7.6Not available166
Hospital return days for heart failure patients-8.9Not available435
Hospital return days for pneumonia patients-15.8Not available327
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.4Same as national2410
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)13.2Same as national2564
Rate of inpatient admissions for patients receiving outpatient chemotherapy7.9Same as national83
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy4.8Same as national83
Ratio of unplanned hospital visits after hospital outpatient surgery1.1Same as national718
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate14Same as national166
Rate of readmission for CABG11.4Same as national55
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients18.2Same as national81
Heart failure (HF) 30-Day Readmission Rate19.9Same as national435
Rate of readmission after hip/knee replacement4.5Same as national78
Pneumonia (PN) 30-Day Readmission Rate15.2Same as national327

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 rating5472
Doctor communication - star rating4472
Communication about medicines - star rating3472
Discharge information - star rating4472
Cleanliness - star rating3472
Quietness - star rating3472
Overall hospital rating - star rating4472
Recommend hospital - star rating5472
Summary star rating4472

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 volumevery high
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 vaccination932975
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 better200618
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 better198580
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better48419
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better25319
Left before being seen160603
Head CT results4613
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients98336
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)1382
Safe Use of Opioids - Concurrent Prescribing173811
Appropriate care for severe sepsis and septic shock64211
Septic Shock 3-Hour Bundle7480
Septic Shock 6-Hour Bundle8946
Severe Sepsis 3-Hour Bundle82211
Severe Sepsis 6-Hour Bundle91127
Discharged on Antithrombotic Therapy100182
Anticoagulation Therapy for Atrial Fibrillation/Flutter8059
Antithrombotic Therapy by End of Hospital Day 288178
Venous Thromboembolism Prophylaxis
Intensive Care Unit Venous Thromboembolism Prophylaxis84714

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 UPMC Passavant rated?
UPMC Passavant has a 4 out of 5 CMS overall star rating as of the latest CMS release.
Does UPMC Passavant have emergency services?
Yes. UPMC Passavant operates a 24/7 emergency department.
Where is UPMC Passavant located?
UPMC Passavant is located at 9100 Babcock Boulevard, Pittsburgh, PA 15237.
What type of hospital is UPMC Passavant?
UPMC Passavant 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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