Baptist Health Deaconess Madisonville

Hospital in Madisonville, KY, Medicare certification number 180093. CMS publishes 63 quality measures for it.

Medicare certification

Provider of Services

CCN: 180093The 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: Apr 17, 2009
Beds: 390
Overall star rating: 2 of 5Care Compare
Address: 900 Hospital Drive
Madisonville, KY 42431
(270) 825-5100

NPI records for this facility 1

Baptist Health Deaconess Madisonville Inc
- Rural Acute Care Hospital
- Madisonville, KY
- NPI 1447231956
Medicare enrollment

Patient survey (HCAHPS) 9

Medicare Care Compare

Cleanliness - star rating Better4 of 5
- State average 3.53 (computed here)
- National average 3.44 (computed here)
- Period from 10/01/2024
Communication about medicines - star rating Worse2 of 5
- State average 2.83 (computed here)
- National average 2.71 (computed here)
- Period from 10/01/2024
Discharge information - star rating Worse3 of 5
- State average 3.32 (computed here)
- National average 3.31 (computed here)
- Period from 10/01/2024
Doctor communication - star rating As expected3 of 5
- State average 3.42 (computed here)
- National average 3.12 (computed here)
- Period from 10/01/2024
Nurse communication - star rating Worse3 of 5
- State average 3.8 (computed here)
- National average 3.43 (computed here)
- Period from 10/01/2024
Overall hospital rating - star rating Worse3 of 5
- State average 3.33 (computed here)
- National average 3.29 (computed here)
- Period from 10/01/2024
Quietness - star rating Worse3 of 5
- State average 3.63 (computed here)
- National average 3.27 (computed here)
- Period from 10/01/2024
Recommend hospital - star rating Worse3 of 5
- State average 3.6 (computed here)
- National average 3.64 (computed here)
- Period from 10/01/2024
Summary star rating Worse3 of 5
- State average 3.43 (computed here)
- National average 3.27 (computed here)
- Period from 10/01/2024

Complications and deaths 18

Medicare Care Compare

Abdominopelvic accidental puncture or laceration rate As expected0.91
- State average 1.08 (computed here)
- National average 1.06
- No different than the national rate
- 453 patients
- Period from 07/01/2022
CMS Medicare PSI 90: Patient safety and adverse events composite As expected1.04
- State average 1.02 (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 expected171.8
- State average 185.49 (computed here)
- National average 173.3
- No different than the national rate
- 31 patients
- Period from 07/01/2022
Death rate for COPD patients As expected8.5
- State average 9.15 (computed here)
- National average 8.6
- No different than the national rate
- 60 patients
- Period from 07/01/2022
Death rate for heart attack patients As expected13
- State average 12.11 (computed here)
- National average 11.9
- No different than the national rate
- 127 patients
- Period from 07/01/2022
Death rate for heart failure patients Worse19.7
- State average 11.98 (computed here)
- National average 11.1
- Worse than the national rate
- 166 patients
- Period from 07/01/2022
Death rate for pneumonia patients As expected18.9
- State average 16.6 (computed here)
- National average 15.2
- No different than the national rate
- 290 patients
- Period from 07/01/2022
Death rate for stroke patients As expected10.9
- State average 12.38 (computed here)
- National average 11.9
- No different than the national rate
- 92 patients
- Period from 07/01/2023
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate As expected3.9
- State average 4.54 (computed here)
- National average 3.9
- No different than the national rate
- 1,440 patients
- Period from 07/01/2024
Iatrogenic pneumothorax rate As expected0.18
- State average 0.21 (computed here)
- National average 0.21
- No different than the national rate
- 2,427 patients
- Period from 07/01/2022
In-hospital fall-associated fracture rate As expected0.25
- State average 0.28 (computed here)
- National average 0.27
- No different than the national rate
- 2,464 patients
- Period from 07/01/2022
Perioperative pulmonary embolism or deep vein thrombosis rate As expected3.71
- State average 3.44 (computed here)
- National average 3.52
- No different than the national rate
- 494 patients
- Period from 07/01/2022
Postoperative acute kidney injury requiring dialysis rate As expected1.92
- State average 1.71 (computed here)
- National average 1.67
- No different than the national rate
- 170 patients
- Period from 07/01/2022
Postoperative hemorrhage or hematoma rate As expected2.05
- State average 2.31 (computed here)
- National average 2.34
- No different than the national rate
- 485 patients
- Period from 07/01/2022
Postoperative respiratory failure rate As expected11.16
- State average 10.2 (computed here)
- National average 9.42
- No different than the national rate
- 157 patients
- Period from 07/01/2022
Postoperative sepsis rate As expected5.21
- State average 5.85 (computed here)
- National average 5.27
- No different than the national rate
- 151 patients
- Period from 07/01/2022
Postoperative wound dehiscence rate As expected1.65
- State average 1.76 (computed here)
- National average 1.77
- No different than the national rate
- 108 patients
- Period from 07/01/2022
Pressure ulcer rate As expected0.62
- State average 0.61 (computed here)
- National average 0.63
- No different than the national rate
- 2,019 patients
- Period from 07/01/2022

Measures CMS does not publish for this facility (2)

Death rate for CABG surgery patients — 1
Rate of complications for hip/knee replacement patients — 1

Infections 5

Medicare Care Compare

Catheter Associated Urinary Tract Infections (ICU + select Wards) As expected1.65
- State average 0.61
- National average 1
- No different than national benchmark
- Period from 10/01/2024
Central Line Associated Bloodstream Infection (ICU + select Wards) As expected0
- State average 0.84
- National average 1
- No different than national benchmark
- Period from 10/01/2024
Clostridium Difficile (C.Diff) Better0.13
- State average 0.32
- National average 1
- Better than the national benchmark
- Period from 10/01/2024
MRSA Bacteremia As expected0.98
- State average 0.87
- National average 1
- No different than national benchmark
- Period from 10/01/2024
SSI - Colon Surgery As expected0.86
- State average 1.07
- 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 1

Medicare Care Compare

Abdomen CT Use of Contrast Material 4.2
- State average 7.25 (computed here)
- National average 5.83 (computed here)
- Period from 07/01/2024

Measures CMS does not publish for this facility (1)

Breast Cancer Screening Recall Rates — 7

Spending per patient 1

Medicare Care Compare

Medicare hospital spending per patient (Medicare Spending per Beneficiary) 1.04
- State average 1.01
- National average 0.99 (computed here)
- Period from 01/01/2024

Timely and effective care 17

Medicare Care Compare

Antithrombotic Therapy by End of Hospital Day 2 94
- State average 92.33 (computed here)
- National average 92.79 (computed here)
- 71 patients
- Period from 01/01/2024
Appropriate care for severe sepsis and septic shock 49
- State average 68
- National average 65
- 237 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 194
- State average 155
- National average 168
- 409 patients
- Period from 10/01/2024
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better 468
- State average 277
- National average 287
- 16 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 190
- State average 150
- National average 162
- 382 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 408
- State average 210
- National average 257
- 11 patients
- Period from 10/01/2024
Discharged on Antithrombotic Therapy 100
- State average 96.88 (computed here)
- National average 96.1 (computed here)
- 69 patients
- Period from 01/01/2024
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients 99
- State average 96
- National average 93
- 76 patients
- Period from 01/01/2024
Head CT results 64
- State average 68
- National average 69
- 11 patients
- Period from 10/01/2024
Healthcare workers given influenza vaccination 88
- State average 80
- National average 78
- 1,933 patients
- Period from 10/01/2024
Hospital Harm - Severe Hypoglycemia 1
- State average 1.13 (computed here)
- National average 1.09 (computed here)
- 1,703 patients
- Period from 01/01/2024
Left before being seen 1
- State average 2
- National average 2
- 28,808 patients
- Period from 01/01/2024
Safe Use of Opioids - Concurrent Prescribing 13
- State average 15
- National average 15
- 1,536 patients
- Period from 01/01/2024
Septic Shock 3-Hour Bundle 60
- State average 77
- National average 73
- 87 patients
- Period from 10/01/2024
Septic Shock 6-Hour Bundle 50
- State average 88
- National average 87
- 46 patients
- Period from 10/01/2024
Severe Sepsis 3-Hour Bundle 76
- State average 82
- National average 81
- 237 patients
- Period from 10/01/2024
Severe Sepsis 6-Hour Bundle 96
- State average 95
- National average 93
- 127 patients
- Period from 10/01/2024

Measures CMS does not publish for this facility (13)

Anticoagulation Therapy for Atrial Fibrillation/Flutter — 5
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
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 12

Medicare Care Compare

Acute Myocardial Infarction (AMI) 30-Day Readmission Rate As expected14.5
- State average 14.42 (computed here)
- National average 14.4
- No different than the national rate
- 199 patients
- Period from 07/01/2023
Heart failure (HF) 30-Day Readmission Rate As expected21.9
- State average 21.36 (computed here)
- National average 21.3
- No different than the national rate
- 305 patients
- Period from 07/01/2023
Hospital return days for heart attack patients 68.8
- State average 13.02 (computed here)
- National average 6.71 (computed here)
- Average days per 100 discharges
- 116 patients
- Period from 07/01/2022
Hospital return days for heart failure patients 6.7
- State average 9.52 (computed here)
- National average 4.02 (computed here)
- Average days per 100 discharges
- 173 patients
- Period from 07/01/2022
Hospital return days for pneumonia patients -2.8
- State average 12.61 (computed here)
- National average 5.65 (computed here)
- Average days per 100 discharges
- 281 patients
- Period from 07/01/2022
Pneumonia (PN) 30-Day Readmission Rate As expected17.7
- State average 17.37 (computed here)
- National average 17.3
- No different than the national rate
- 452 patients
- Period from 07/01/2023
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy As expected4.9
- State average 5.4 (computed here)
- National average 5.4
- No different than the national rate
- 88 patients
- Period from 01/01/2024
Rate of inpatient admissions for patients receiving outpatient chemotherapy As expected9.5
- State average 10.97 (computed here)
- National average 10.7
- No different than the national rate
- 88 patients
- Period from 01/01/2024
Rate of readmission for CABG As expected10.4
- State average 10.55 (computed here)
- National average 11
- No different than the national rate
- 36 patients
- Period from 07/01/2023
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients As expected20.1
- State average 19.89 (computed here)
- National average 20
- No different than the national rate
- 105 patients
- Period from 07/01/2023
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies) As expected10.4
- State average 13.03 (computed here)
- National average 13
- No different than the national rate
- 1,265 patients
- Period from 01/01/2022
Ratio of unplanned hospital visits after hospital outpatient surgery As expected1
- State average 1.03 (computed here)
- National average 1.01 (computed here)
- No different than expected
- 258 patients
- Period from 01/01/2024

Measures CMS does not publish for this facility (2)

Hybrid Hospital-Wide All-Cause Readmission Measure (HWR) — 4
Rate of readmission after hip/knee replacement — 1

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.