Trinity Health Muskegon Hospital

Hospital in Muskegon, MI, Medicare certification number 230066. CMS publishes 64 quality measures for it.

Medicare certification

Provider of Services

CCN: 230066The 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: Jun 14, 2018
Beds: 382
Overall star rating: 3 of 5Care Compare
Most recent change of ownership: Jan 1, 2014 (6 total)
Address: 1500 E Sherman Blvd
Muskegon, MI 49441
(231) 726-3511

NPI records for this facility 1

Mercy Health Partners
- General Acute Care Hospital
- Muskegon, MI
- NPI 1831132133
Medicare enrollment

Patient survey (HCAHPS) 9

Medicare Care Compare

Cleanliness - star rating Worse2 of 5
- State average 2.86 (computed here)
- National average 3.44 (computed here)
- Period from 10/01/2024
Communication about medicines - star rating Worse2 of 5
- State average 2.63 (computed here)
- National average 2.71 (computed here)
- Period from 10/01/2024
Discharge information - star rating Worse3 of 5
- State average 3.35 (computed here)
- National average 3.31 (computed here)
- Period from 10/01/2024
Doctor communication - star rating As expected3 of 5
- State average 3.07 (computed here)
- National average 3.12 (computed here)
- Period from 10/01/2024
Nurse communication - star rating Worse3 of 5
- State average 3.5 (computed here)
- National average 3.43 (computed here)
- Period from 10/01/2024
Overall hospital rating - star rating Worse2 of 5
- State average 3.12 (computed here)
- National average 3.29 (computed here)
- Period from 10/01/2024
Quietness - star rating Worse3 of 5
- State average 3.12 (computed here)
- National average 3.27 (computed here)
- Period from 10/01/2024
Recommend hospital - star rating Worse3 of 5
- State average 3.39 (computed here)
- National average 3.64 (computed here)
- Period from 10/01/2024
Summary star rating Worse3 of 5
- State average 3.21 (computed here)
- National average 3.27 (computed here)
- Period from 10/01/2024

Complications and deaths 20

Medicare Care Compare

Abdominopelvic accidental puncture or laceration rate As expected1.09
- State average 1.12 (computed here)
- National average 1.06
- No different than the national rate
- 998 patients
- Period from 07/01/2022
CMS Medicare PSI 90: Patient safety and adverse events composite As expected0.85
- State average 1 (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 expected210.72
- State average 177.85 (computed here)
- National average 173.3
- No different than the national rate
- 95 patients
- Period from 07/01/2022
Death rate for CABG surgery patients As expected2.9
- State average 2.38 (computed here)
- National average 2.4
- No different than the national rate
- 64 patients
- Period from 07/01/2022
Death rate for COPD patients As expected7.4
- State average 8.58 (computed here)
- National average 8.6
- No different than the national rate
- 87 patients
- Period from 07/01/2022
Death rate for heart attack patients As expected11.4
- State average 12 (computed here)
- National average 11.9
- No different than the national rate
- 152 patients
- Period from 07/01/2022
Death rate for heart failure patients As expected13.5
- State average 11.26 (computed here)
- National average 11.1
- No different than the national rate
- 358 patients
- Period from 07/01/2022
Death rate for pneumonia patients As expected13.3
- State average 15.18 (computed here)
- National average 15.2
- No different than the national rate
- 302 patients
- Period from 07/01/2022
Death rate for stroke patients As expected11.4
- State average 11.95 (computed here)
- National average 11.9
- No different than the national rate
- 417 patients
- Period from 07/01/2023
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate As expected3.8
- State average 3.9 (computed here)
- National average 3.9
- No different than the national rate
- 4,399 patients
- Period from 07/01/2024
Iatrogenic pneumothorax rate As expected0.33
- State average 0.22 (computed here)
- National average 0.21
- No different than the national rate
- 5,279 patients
- Period from 07/01/2022
In-hospital fall-associated fracture rate As expected0.32
- State average 0.28 (computed here)
- National average 0.27
- No different than the national rate
- 5,378 patients
- Period from 07/01/2022
Perioperative pulmonary embolism or deep vein thrombosis rate As expected3.26
- State average 3.55 (computed here)
- National average 3.52
- No different than the national rate
- 1,785 patients
- Period from 07/01/2022
Postoperative acute kidney injury requiring dialysis rate As expected1.68
- State average 1.69 (computed here)
- National average 1.67
- No different than the national rate
- 731 patients
- Period from 07/01/2022
Postoperative hemorrhage or hematoma rate As expected2.68
- State average 2.38 (computed here)
- National average 2.34
- No different than the national rate
- 1,586 patients
- Period from 07/01/2022
Postoperative respiratory failure rate As expected9.83
- State average 9.51 (computed here)
- National average 9.42
- No different than the national rate
- 735 patients
- Period from 07/01/2022
Postoperative sepsis rate As expected3.88
- State average 5.25 (computed here)
- National average 5.27
- No different than the national rate
- 695 patients
- Period from 07/01/2022
Postoperative wound dehiscence rate As expected1.98
- State average 1.76 (computed here)
- National average 1.77
- No different than the national rate
- 296 patients
- Period from 07/01/2022
Pressure ulcer rate As expected0.15
- State average 0.61 (computed here)
- National average 0.63
- No different than the national rate
- 4,533 patients
- Period from 07/01/2022
Rate of complications for hip/knee replacement patients As expected4.4
- State average 4.19 (computed here)
- National average 4.1
- No different than the national rate
- 114 patients
- Period from 04/01/2023

Infections 5

Medicare Care Compare

Catheter Associated Urinary Tract Infections (ICU + select Wards) As expected1.09
- State average 0.4
- National average 1
- No different than national benchmark
- Period from 10/01/2024
Central Line Associated Bloodstream Infection (ICU + select Wards) As expected0.34
- State average 0.62
- National average 1
- No different than national benchmark
- Period from 10/01/2024
Clostridium Difficile (C.Diff) Better0.31
- State average 0.33
- National average 1
- Better than the national benchmark
- Period from 10/01/2024
MRSA Bacteremia As expected1.24
- State average 0.65
- National average 1
- No different than national benchmark
- Period from 10/01/2024
SSI - Colon Surgery As expected0.67
- State average 0.99
- 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
- State average 6.1 (computed here)
- National average 5.83 (computed here)
- Period from 07/01/2024
Breast Cancer Screening Recall Rates 4.7
- State average 7.03 (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) 0.92
- State average 0.95
- 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 65
- State average 69.44 (computed here)
- National average 74.05 (computed here)
- 79 patients
- Period from 01/01/2024
Antithrombotic Therapy by End of Hospital Day 2 98
- State average 91.64 (computed here)
- National average 92.79 (computed here)
- 225 patients
- Period from 01/01/2024
Appropriate care for severe sepsis and septic shock 64
- State average 60
- National average 65
- 177 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 222
- State average 166
- National average 168
- 420 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 220
- State average 159
- National average 162
- 392 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 262
- State average 266
- National average 257
- 28 patients
- Period from 10/01/2024
Discharged on Antithrombotic Therapy 98
- State average 94.44 (computed here)
- National average 96.1 (computed here)
- 294 patients
- Period from 01/01/2024
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients 97
- State average 94
- National average 93
- 116 patients
- Period from 01/01/2024
Head CT results 90
- State average 72
- National average 69
- 42 patients
- Period from 10/01/2024
Healthcare workers given influenza vaccination 24
- State average 80
- National average 78
- 5,420 patients
- Period from 10/01/2024
Left before being seen 3
- State average 3
- National average 2
- 82,464 patients
- Period from 01/01/2024
Safe Use of Opioids - Concurrent Prescribing 12
- State average 16
- National average 15
- 4,905 patients
- Period from 01/01/2024
Septic Shock 3-Hour Bundle 65
- State average 71
- National average 73
- 55 patients
- Period from 10/01/2024
Septic Shock 6-Hour Bundle 100
- State average 86
- National average 87
- 25 patients
- Period from 10/01/2024
Severe Sepsis 3-Hour Bundle 78
- State average 77
- National average 81
- 178 patients
- Period from 10/01/2024
Severe Sepsis 6-Hour Bundle 94
- State average 91
- National average 93
- 103 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 — very high
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 11

Medicare Care Compare

Acute Myocardial Infarction (AMI) 30-Day Readmission Rate As expected13.4
- State average 14.28 (computed here)
- National average 14.4
- No different than the national rate
- 427 patients
- Period from 07/01/2023
Heart failure (HF) 30-Day Readmission Rate As expected17.9
- State average 21.19 (computed here)
- National average 21.3
- No different than the national rate
- 879 patients
- Period from 07/01/2023
Hospital return days for heart attack patients -17.9
- State average 9.88 (computed here)
- National average 6.71 (computed here)
- Average days per 100 discharges
- 147 patients
- Period from 07/01/2022
Hospital return days for heart failure patients -21.5
- State average 2.53 (computed here)
- National average 4.02 (computed here)
- Average days per 100 discharges
- 400 patients
- Period from 07/01/2022
Hospital return days for pneumonia patients -28.7
- State average 5.31 (computed here)
- National average 5.65 (computed here)
- Fewer days than average per 100 discharges
- 319 patients
- Period from 07/01/2022
Pneumonia (PN) 30-Day Readmission Rate Better14.4
- State average 17.08 (computed here)
- National average 17.3
- Better than the national rate
- 751 patients
- Period from 07/01/2023
Rate of readmission after hip/knee replacement As expected5.3
- State average 5.98 (computed here)
- National average 5.8
- No different than the national rate
- 115 patients
- Period from 07/01/2023
Rate of readmission for CABG As expected9.1
- State average 10.41 (computed here)
- National average 11
- No different than the national rate
- 164 patients
- Period from 07/01/2023
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients As expected17.8
- State average 19.73 (computed here)
- National average 20
- No different than the national rate
- 303 patients
- Period from 07/01/2023
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies) As expected12.8
- State average 12.94 (computed here)
- National average 13
- No different than the national rate
- 1,098 patients
- Period from 01/01/2022
Ratio of unplanned hospital visits after hospital outpatient surgery As expected1.1
- State average 0.99 (computed here)
- National average 1.01 (computed here)
- No different than expected
- 569 patients
- Period from 01/01/2024

Measures CMS does not publish for this facility (3)

Hybrid Hospital-Wide All-Cause Readmission Measure (HWR) — 4
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy — 1
Rate of inpatient admissions for patients receiving outpatient chemotherapy — 1

Mercy Health Muskegon CCN 230004, Muskegon, MI

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.