JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Wellstar Douglas Medical Center

3 / 5

At a glance

Wellstar Douglas Medical Center carries a 3-star CMS overall rating — in line with the national norm. On healthcare-associated infection measures, it performs better than the national average on 6 and worse on 12.

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 Limit1.074Worse than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit3.770Worse than national
Central Line Associated Bloodstream Infection: Number of Device Days5272Worse than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases4.728Worse than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases10Worse than national
Central Line Associated Bloodstream Infection (ICU + select Wards)2.115Worse than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.011Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit1.075Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days4533Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases4.588Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases1Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.218Same as national
SSI - Colon Surgery: Lower Confidence Limit1.653Worse than national
SSI - Colon Surgery: Upper Confidence Limit7.477Worse than national
SSI - Colon Surgery: Number of Procedures73Worse than national
SSI - Colon Surgery: Predicted Cases1.852Worse than national
SSI - Colon Surgery: Observed Cases7Worse than national
SSI - Colon Surgery3.780Worse than national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures12Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.130Not available
SSI - Abdominal Hysterectomy: Observed Cases1Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitSame as national
MRSA Bacteremia: Upper Confidence Limit2.165Same as national
MRSA Bacteremia: Patient Days32004Same as national
MRSA Bacteremia: Predicted Cases1.384Same as national
MRSA Bacteremia: Observed Cases0Same as national
MRSA Bacteremia0.000Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.004Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.427Better than national
Clostridium Difficile (C.Diff): Patient Days30374Better than national
Clostridium Difficile (C.Diff): Predicted Cases11.561Better than national
Clostridium Difficile (C.Diff): Observed Cases1Better than national
Clostridium Difficile (C.Diff)0.086Better 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 Rate3.7Same as national501
Death rate for heart attack patients12.2Same as national47
Death rate for CABG surgery patientsNot available
Death rate for COPD patients8Same as national53
Death rate for heart failure patients9.4Same as national225
Death rate for pneumonia patients12.4Better than national205
Death rate for stroke patients13.2Same as national99
Pressure ulcer rate0.53Same as national2085
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.19Same as national2460
In-hospital fall-associated fracture rate0.29Same as national2552
Postoperative hemorrhage or hematoma rate2.23Same as national211
Postoperative acute kidney injury requiring dialysis rate1.64Same as national38
Postoperative respiratory failure rate10.09Same as national45
Perioperative pulmonary embolism or deep vein thrombosis rate3.98Same as national230
Postoperative sepsis rate5.65Same as national40
Postoperative wound dehiscence rate2.05Same as national78
Abdominopelvic accidental puncture or laceration rate0.96Same as national421
CMS Medicare PSI 90: Patient safety and adverse events composite1.02Same 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 patients-15Not available258
Hospital return days for pneumonia patients2.3Not available210
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.3Same as national845
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)12.3Same as national223
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 surgery1.1Same as national175
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate13.6Same as national42
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients17.7Same as national63
Heart failure (HF) 30-Day Readmission Rate19.3Same as national258
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate14.9Same as national210

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 rating2541
Doctor communication - star rating3541
Communication about medicines - star rating2541
Discharge information - star rating2541
Cleanliness - star rating3541
Quietness - star rating3541
Overall hospital rating - star rating3541
Recommend hospital - star rating3541
Summary star rating3541

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 Hyperglycemia914620
Hospital Harm - Severe Hypoglycemia
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination652018
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 better188370
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 better186359
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 better
Left before being seen265679
Head CT results6221
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients9464
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing192220
Appropriate care for severe sepsis and septic shock76170
Septic Shock 3-Hour Bundle7066
Septic Shock 6-Hour Bundle9733
Severe Sepsis 3-Hour Bundle88170
Severe Sepsis 6-Hour Bundle10093
Discharged on Antithrombotic Therapy
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 2
Venous Thromboembolism Prophylaxis1004424
Intensive Care Unit Venous Thromboembolism Prophylaxis1001052

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 Wellstar Douglas Medical Center rated?
Wellstar Douglas Medical Center has a 3 out of 5 CMS overall star rating as of the latest CMS release.
Does Wellstar Douglas Medical Center have emergency services?
Yes. Wellstar Douglas Medical Center operates a 24/7 emergency department.
Where is Wellstar Douglas Medical Center located?
Wellstar Douglas Medical Center is located at 8954 Hospital Drive, Douglasville, GA 30134.
What type of hospital is Wellstar Douglas Medical Center?
Wellstar Douglas Medical Center 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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