JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

West Penn Hospital

3 / 5

At a glance

West Penn Hospital 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 12 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 Limit0.039Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit0.775Better than national
Central Line Associated Bloodstream Infection: Number of Device Days7651Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases8.527Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases2Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.235Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.124Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit1.324Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days4437Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases6.167Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases3Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.486Same as national
SSI - Colon Surgery: Lower Confidence Limit0.801Same as national
SSI - Colon Surgery: Upper Confidence Limit2.401Same as national
SSI - Colon Surgery: Number of Procedures351Same as national
SSI - Colon Surgery: Predicted Cases9.027Same as national
SSI - Colon Surgery: Observed Cases13Same as national
SSI - Colon Surgery1.440Same as national
SSI - Abdominal Hysterectomy: Lower Confidence Limit0.155Same as national
SSI - Abdominal Hysterectomy: Upper Confidence Limit1.658Same as national
SSI - Abdominal Hysterectomy: Number of Procedures591Same as national
SSI - Abdominal Hysterectomy: Predicted Cases4.924Same as national
SSI - Abdominal Hysterectomy: Observed Cases3Same as national
SSI - Abdominal Hysterectomy0.609Same as national
MRSA Bacteremia: Lower Confidence Limit0.170Same as national
MRSA Bacteremia: Upper Confidence Limit1.290Same as national
MRSA Bacteremia: Patient Days79187Same as national
MRSA Bacteremia: Predicted Cases7.480Same as national
MRSA Bacteremia: Observed Cases4Same as national
MRSA Bacteremia0.535Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.250Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.786Better than national
Clostridium Difficile (C.Diff): Patient Days57283Better than national
Clostridium Difficile (C.Diff): Predicted Cases25.957Better than national
Clostridium Difficile (C.Diff): Observed Cases12Better than national
Clostridium Difficile (C.Diff)0.462Better 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 national350
Death rate for heart attack patients11.5Same as national36
Death rate for CABG surgery patientsNot available
Death rate for COPD patientsNot available
Death rate for heart failure patients12.7Same as national53
Death rate for pneumonia patients17.6Same as national59
Death rate for stroke patientsNot available
Pressure ulcer rate0.59Same as national1672
Death rate among surgical inpatients with serious treatable complications159.85Same as national37
Iatrogenic pneumothorax rate0.25Same as national1939
In-hospital fall-associated fracture rate0.25Same as national2152
Postoperative hemorrhage or hematoma rate2.47Same as national684
Postoperative acute kidney injury requiring dialysis rate1.50Same as national360
Postoperative respiratory failure rate11.96Same as national349
Perioperative pulmonary embolism or deep vein thrombosis rate3.52Same as national707
Postoperative sepsis rate5.61Same as national344
Postoperative wound dehiscence rate1.58Same as national341
Abdominopelvic accidental puncture or laceration rate0.95Same as national790
CMS Medicare PSI 90: Patient safety and adverse events composite1.06Same 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-36.9Not available61
Hospital return days for pneumonia patients22.3Not available63
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)16.3Same as national693
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)13Same as national388
Rate of inpatient admissions for patients receiving outpatient chemotherapy14.7Worse than national647
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy6.1Same as national647
Ratio of unplanned hospital visits after hospital outpatient surgery1.1Same as national224
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate13.2Same as national41
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patientsNot available
Heart failure (HF) 30-Day Readmission Rate18.9Same as national61
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate16.1Same as national63

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 rating5449
Doctor communication - star rating3449
Communication about medicines - star rating3449
Discharge information - star rating4449
Cleanliness - star rating3449
Quietness - star rating3449
Overall hospital rating - star rating4449
Recommend hospital - star rating4449
Summary star rating4449

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 volumemedium
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 Hypoglycemia21796
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination502200
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 better206490
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 better203475
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 seen222244
Head CT results
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients9864
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing112966
Appropriate care for severe sepsis and septic shock5567
Septic Shock 3-Hour Bundle7419
Septic Shock 6-Hour Bundle8312
Severe Sepsis 3-Hour Bundle6667
Severe Sepsis 6-Hour Bundle10031
Discharged on Antithrombotic Therapy9738
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 29436
Venous Thromboembolism Prophylaxis
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 MeasureYes

Frequently asked questions

How is West Penn Hospital rated?
West Penn Hospital has a 3 out of 5 CMS overall star rating as of the latest CMS release.
Does West Penn Hospital have emergency services?
Yes. West Penn Hospital operates a 24/7 emergency department.
Where is West Penn Hospital located?
West Penn Hospital is located at 4800 Friendship Avenue, Pittsburgh, PA 15224.
What type of hospital is West Penn Hospital?
West Penn 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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