Saint Joseph Regional Medical Center

Hospital in Mishawaka, IN, Medicare certification number 150012. CMS publishes 65 quality measures for it.

Medicare certification

Provider of Services

CCN: 150012The number CMS certifies the facility under, not a provider identifier
Status: Active
Provider type: Hospital – Short-term
Listed by Care Compare as: Acute Care Hospitals
Ownership: Voluntary non-profit - Private
Control type: Private (not for profit)
Participating since: Jul 1, 1966
Last certification: Aug 31, 2017
Beds: 301
Overall star rating: 2 of 5Care Compare
Address: 5215 Holy Cross Pkwy
Mishawaka, IN 46545
(574) 335-5000

NPI records for this facility 2

Saint Joseph Regional Medical Center-South Bend Campus, Inc.
- General Acute Care Hospital
- Mishawaka, IN
- NPI 1023965795
Medicare enrollment
Saint Joseph Regional Medical Center-South Bend Campus, Inc.
- General Acute Care Hospital
- Mishawaka, IN
- NPI 1841245594
Medicare enrollment

Patient survey (HCAHPS) 9

Medicare Care Compare

Cleanliness - star rating Worse3 of 5
- State average 3.54 (computed here)
- National average 3.44 (computed here)
- Period from 10/01/2024
Communication about medicines - star rating Worse1 of 5
- State average 2.49 (computed here)
- National average 2.71 (computed here)
- Period from 10/01/2024
Discharge information - star rating Worse3 of 5
- State average 3.57 (computed here)
- National average 3.31 (computed here)
- Period from 10/01/2024
Doctor communication - star rating Worse2 of 5
- State average 3.08 (computed here)
- National average 3.12 (computed here)
- Period from 10/01/2024
Nurse communication - star rating Worse2 of 5
- State average 3.54 (computed here)
- National average 3.43 (computed here)
- Period from 10/01/2024
Overall hospital rating - star rating Worse3 of 5
- State average 3.54 (computed here)
- National average 3.29 (computed here)
- Period from 10/01/2024
Quietness - star rating Worse3 of 5
- State average 3.52 (computed here)
- National average 3.27 (computed here)
- Period from 10/01/2024
Recommend hospital - star rating Worse3 of 5
- State average 3.82 (computed here)
- National average 3.64 (computed here)
- Period from 10/01/2024
Summary star rating Worse2 of 5
- State average 3.38 (computed here)
- National average 3.27 (computed here)
- Period from 10/01/2024

Complications and deaths 19

Medicare Care Compare

Abdominopelvic accidental puncture or laceration rate As expected0.85
- State average 1.05 (computed here)
- National average 1.06
- No different than the national rate
- 992 patients
- Period from 07/01/2022
CMS Medicare PSI 90: Patient safety and adverse events composite As expected1.12
- State average 0.95 (computed here)
- National average 1
- No different than the national value
- Period from 07/01/2022
Death rate among surgical inpatients with serious treatable complications As expected205.79
- State average 180.37 (computed here)
- National average 173.3
- No different than the national rate
- 64 patients
- Period from 07/01/2022
Death rate for COPD patients As expected7.5
- State average 8.63 (computed here)
- National average 8.6
- No different than the national rate
- 132 patients
- Period from 07/01/2022
Death rate for heart attack patients As expected12.9
- State average 12.13 (computed here)
- National average 11.9
- No different than the national rate
- 119 patients
- Period from 07/01/2022
Death rate for heart failure patients As expected13.7
- State average 11.45 (computed here)
- National average 11.1
- No different than the national rate
- 380 patients
- Period from 07/01/2022
Death rate for pneumonia patients As expected18.8
- State average 15.69 (computed here)
- National average 15.2
- No different than the national rate
- 380 patients
- Period from 07/01/2022
Death rate for stroke patients As expected15.9
- State average 12.44 (computed here)
- National average 11.9
- No different than the national rate
- 211 patients
- Period from 07/01/2023
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate As expected4.4
- State average 4.04 (computed here)
- National average 3.9
- No different than the national rate
- 2,552 patients
- Period from 07/01/2024
Iatrogenic pneumothorax rate As expected0.22
- State average 0.22 (computed here)
- National average 0.21
- No different than the national rate
- 5,352 patients
- Period from 07/01/2022
In-hospital fall-associated fracture rate As expected0.3
- State average 0.27 (computed here)
- National average 0.27
- No different than the national rate
- 5,445 patients
- Period from 07/01/2022
Perioperative pulmonary embolism or deep vein thrombosis rate As expected4.13
- State average 3.37 (computed here)
- National average 3.52
- No different than the national rate
- 1,266 patients
- Period from 07/01/2022
Postoperative acute kidney injury requiring dialysis rate As expected1.82
- State average 1.72 (computed here)
- National average 1.67
- No different than the national rate
- 426 patients
- Period from 07/01/2022
Postoperative hemorrhage or hematoma rate As expected1.77
- State average 2.22 (computed here)
- National average 2.34
- No different than the national rate
- 1,210 patients
- Period from 07/01/2022
Postoperative respiratory failure rate As expected13.14
- State average 9.68 (computed here)
- National average 9.42
- No different than the national rate
- 446 patients
- Period from 07/01/2022
Postoperative sepsis rate As expected5.69
- State average 5.19 (computed here)
- National average 5.27
- No different than the national rate
- 391 patients
- Period from 07/01/2022
Postoperative wound dehiscence rate As expected1.96
- State average 1.76 (computed here)
- National average 1.77
- No different than the national rate
- 190 patients
- Period from 07/01/2022
Pressure ulcer rate As expected0.56
- State average 0.49 (computed here)
- National average 0.63
- No different than the national rate
- 4,559 patients
- Period from 07/01/2022
Rate of complications for hip/knee replacement patients As expected5.3
- State average 4.22 (computed here)
- National average 4.1
- No different than the national rate
- 62 patients
- Period from 04/01/2023

Measures CMS does not publish for this facility (1)

Death rate for CABG surgery patients — 1

Infections 5

Medicare Care Compare

Catheter Associated Urinary Tract Infections (ICU + select Wards) Better0
- State average 0.48
- National average 1
- Better than the national benchmark
- Period from 10/01/2024
Central Line Associated Bloodstream Infection (ICU + select Wards) As expected1.02
- State average 0.53
- National average 1
- No different than national benchmark
- Period from 10/01/2024
Clostridium Difficile (C.Diff) Better0.23
- State average 0.37
- National average 1
- Better than the national benchmark
- Period from 10/01/2024
MRSA Bacteremia As expected0.34
- State average 0.64
- National average 1
- No different than national benchmark
- Period from 10/01/2024
SSI - Colon Surgery As expected2.02
- State average 0.65
- National average 1
- No different than national benchmark
- Period from 10/01/2024

Measures CMS does not publish for this facility (1)

SSI - Abdominal Hysterectomy — 13

Outpatient imaging 2

Medicare Care Compare

Abdomen CT Use of Contrast Material 7.4
- State average 5.82 (computed here)
- National average 5.83 (computed here)
- Period from 07/01/2024
Breast Cancer Screening Recall Rates 7.3
- State average 6.04 (computed here)
- National average 8.08 (computed here)
- Period from 07/01/2024

Spending per patient 1

Medicare Care Compare

Medicare hospital spending per patient (Medicare Spending per Beneficiary) 0.96
- State average 1.01
- National average 0.99 (computed here)
- Period from 01/01/2024

Timely and effective care 16

Medicare Care Compare

Anticoagulation Therapy for Atrial Fibrillation/Flutter 74
- State average 72.33 (computed here)
- National average 74.05 (computed here)
- 47 patients
- Period from 01/01/2024
Antithrombotic Therapy by End of Hospital Day 2 100
- State average 94.11 (computed here)
- National average 92.79 (computed here)
- 160 patients
- Period from 01/01/2024
Appropriate care for severe sepsis and septic shock 70
- State average 60
- National average 65
- 153 patients
- Period from 10/01/2024
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 better 195
- State average 150
- National average 168
- 423 patients
- Period from 10/01/2024
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 better 195
- State average 145
- National average 162
- 411 patients
- Period from 10/01/2024
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better 248
- State average 231
- National average 257
- 12 patients
- Period from 10/01/2024
Discharged on Antithrombotic Therapy 100
- State average 96.86 (computed here)
- National average 96.1 (computed here)
- 168 patients
- Period from 01/01/2024
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients 98
- State average 94
- National average 93
- 47 patients
- Period from 01/01/2024
Head CT results 58
- State average 71
- National average 69
- 19 patients
- Period from 10/01/2024
Healthcare workers given influenza vaccination 61
- State average 82
- National average 78
- 3,133 patients
- Period from 10/01/2024
Left before being seen 2
- State average 2
- National average 2
- 37,062 patients
- Period from 01/01/2024
Safe Use of Opioids - Concurrent Prescribing 14
- State average 15
- National average 15
- 2,785 patients
- Period from 01/01/2024
Septic Shock 3-Hour Bundle 71
- State average 66
- National average 73
- 56 patients
- Period from 10/01/2024
Septic Shock 6-Hour Bundle 91
- State average 82
- National average 87
- 33 patients
- Period from 10/01/2024
Severe Sepsis 3-Hour Bundle 84
- State average 81
- National average 81
- 154 patients
- Period from 10/01/2024
Severe Sepsis 6-Hour Bundle 98
- State average 92
- National average 93
- 85 patients
- Period from 10/01/2024

Measures CMS does not publish for this facility (14)

Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better — 7
Emergency department volume — medium
Global Malnutrition Composite Score — 5
Global Malnutrition Composite Score: Malnutrition Diagnosis Documented — 5
Global Malnutrition Composite Score: Malnutrition Risk Screening — 5
Global Malnutrition Composite Score: Nutrition Assessment — 5
Global Malnutrition Composite Score: Nutritional Care Plan — 5
Hospital Harm - Opioid Related Adverse Events — 5
Hospital Harm - Severe Hyperglycemia — 5
Hospital Harm - Severe Hypoglycemia — 5
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery — 5
Intensive Care Unit Venous Thromboembolism Prophylaxis — 5
ST-Segment Elevation Myocardial Infarction (STEMI) — 1
Venous Thromboembolism Prophylaxis — 5

Unplanned visits 13

Medicare Care Compare

Acute Myocardial Infarction (AMI) 30-Day Readmission Rate As expected12.7
- State average 14.24 (computed here)
- National average 14.4
- No different than the national rate
- 215 patients
- Period from 07/01/2023
Heart failure (HF) 30-Day Readmission Rate As expected19.5
- State average 20.96 (computed here)
- National average 21.3
- No different than the national rate
- 583 patients
- Period from 07/01/2023
Hospital return days for heart attack patients -11.4
- State average 3.22 (computed here)
- National average 6.71 (computed here)
- Average days per 100 discharges
- 124 patients
- Period from 07/01/2022
Hospital return days for heart failure patients -0.9
- State average -4.26 (computed here)
- National average 4.02 (computed here)
- Average days per 100 discharges
- 423 patients
- Period from 07/01/2022
Hospital return days for pneumonia patients 9.5
- State average -1.71 (computed here)
- National average 5.65 (computed here)
- Average days per 100 discharges
- 390 patients
- Period from 07/01/2022
Pneumonia (PN) 30-Day Readmission Rate As expected16.7
- State average 16.99 (computed here)
- National average 17.3
- No different than the national rate
- 640 patients
- Period from 07/01/2023
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy As expected5.1
- State average 5.53 (computed here)
- National average 5.4
- No different than the national rate
- 82 patients
- Period from 01/01/2024
Rate of inpatient admissions for patients receiving outpatient chemotherapy As expected10.3
- State average 10.62 (computed here)
- National average 10.7
- No different than the national rate
- 82 patients
- Period from 01/01/2024
Rate of readmission after hip/knee replacement As expected6.1
- State average 5.69 (computed here)
- National average 5.8
- No different than the national rate
- 58 patients
- Period from 07/01/2023
Rate of readmission for CABG As expected11.8
- State average 10.8 (computed here)
- National average 11
- No different than the national rate
- 29 patients
- Period from 07/01/2023
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients As expected18.7
- State average 19.64 (computed here)
- National average 20
- No different than the national rate
- 222 patients
- Period from 07/01/2023
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies) As expected13.4
- State average 12.92 (computed here)
- National average 13
- No different than the national rate
- 100 patients
- Period from 01/01/2022
Ratio of unplanned hospital visits after hospital outpatient surgery As expected1.2
- State average 1.01 (computed here)
- National average 1.01 (computed here)
- No different than expected
- 515 patients
- Period from 01/01/2024

Measures CMS does not publish for this facility (1)

Hybrid Hospital-Wide All-Cause Readmission Measure (HWR) — 4

Sources for this page

Provider of Services: the certification, provider type, beds and status.
Medicare Care Compare: the star rating and every measure on this page, with the state and national rates CMS publishes beside them.
NPPES NPI Registry: the NPI records connected to this certification.

Better and worse are CMS's own comparison with the national rate, not ours: for most measures a low score is the good one (deaths, infections) and for others a high one is, so measures where CMS states no comparison are left uncoloured. The exception is star ratings, which are read against the national average here. Quality measures are published by CMS and are not adjusted or re-scored here. Averages marked “computed here” are the mean of every facility reporting that measure, worked out by NPIMap because CMS publishes no comparison for it. Confirm anything you rely on at Medicare Care Compare.