Upmc Passavant

Hospital in Pittsburgh, PA, Medicare certification number 390107. CMS publishes 68 quality measures for it.

Medicare certification

CCN: 390107The 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: Jul 17, 2006
Beds: 346
Overall star rating: 4 of 5Care Compare
Address: 9100 Babcock Boulevard
Pittsburgh, PA 15237
(412) 367-6700

NPI records for this facility (CCN to NPI Mapping) 2

Upmc Passavant
- General Acute Care Hospital
- Pittsburgh, PA
- NPI 1225047699
Medicare enrollment
Upmc Passavant
- Ambulatory Surgical Clinic/Center
- Pittsburgh, PA
- NPI 1639218936
Medicare enrollment

Units certified under this facility 1

Parts of this facility that Medicare certifies under a number of their own, such as a psychiatric or rehabilitation unit.

Upmc Passavant Inpatient rehabilitation facility, CCN 39T107, 19 measures, 10 providers

Patient survey (HCAHPS) 9

Medicare Care Compare

Cleanliness - star rating Worse3 of 5
- State average 3.47 (computed here)
- National average 3.44 (computed here)
- Period from 10/01/2024
Communication about medicines - star rating Better3 of 5
- State average 2.77 (computed here)
- National average 2.71 (computed here)
- Period from 10/01/2024
Discharge information - star rating Better4 of 5
- State average 3.59 (computed here)
- National average 3.31 (computed here)
- Period from 10/01/2024
Doctor communication - star rating Better4 of 5
- State average 3.13 (computed here)
- National average 3.12 (computed here)
- Period from 10/01/2024
Nurse communication - star rating Better5 of 5
- State average 3.8 (computed here)
- National average 3.43 (computed here)
- Period from 10/01/2024
Overall hospital rating - star rating Better4 of 5
- State average 3.38 (computed here)
- National average 3.29 (computed here)
- Period from 10/01/2024
Quietness - star rating Worse3 of 5
- State average 2.85 (computed here)
- National average 3.27 (computed here)
- Period from 10/01/2024
Recommend hospital - star rating Better5 of 5
- State average 3.67 (computed here)
- National average 3.64 (computed here)
- Period from 10/01/2024
Summary star rating Better4 of 5
- State average 3.33 (computed here)
- National average 3.27 (computed here)
- Period from 10/01/2024

Affiliated providers 1,289

Page 2 of 52Medicare Care Compare

Clinicians who list this facility as a hospital or facility affiliation in Care Compare.

Raucheline Akindele
- Diagnostic Radiology Physician
- Pittsburgh, PA
- NPI 1043281447
Tawfiq Al Lahham, M.D.
- Neuromuscular Medicine (Psychiatry & Neurology) Physician
- Pittsburgh, PA
- NPI 1457555773
Alhamza Al-Bayati, MD
- Vascular Neurology Physician
- Pittsburgh, PA
- NPI 1104121227
Georges Al-Khoury
- Vascular Surgery Physician
- Pittsburgh, PA
- NPI 1134453616
Fareeha Sarim Alavi
- Internal Medicine Physician
- La Plata, MD
- NPI 1174001226
Kara L Albrecht, PA
- Surgical Physician Assistant
- Pittsburgh, PA
- NPI 1508019878
Mohammad Khizar Ali, MD
- Neurology Physician
- Wexford, PA
- NPI 1023428919
Christina Alimin, M.D.
- Geriatric Medicine (Family Medicine) Physician
- Pittsburgh, PA
- NPI 1215298682
Rafeed Alkawadri, MD
- Epilepsy Physician
- Pittsburgh, PA
- NPI 1679775431
Peter David Allen, MD
- Surgery Physician
- Pittsburgh, PA
- NPI 1821331141
Ricardo Goncalves Alvim, MD
- Urology Physician
- Hermitage, PA
- NPI 1902464324
Pooja Amarapurkar
- Nephrology Physician
- Atlanta, GA
- NPI 1619317146
Avani Amin
- Hospitalist Physician
- Baltimore, MD
- NPI 1609300862
Rajnikant Amin
- Specialist
- Pittsburgh, PA
- NPI 1780656967
Katerina Ancevski Hunter
- Hematology & Oncology Physician
- Greensburg, PA
- NPI 1598023558
Karl Andersen, D.O
- Pulmonary Disease Physician
- Pittsburgh, PA
- NPI 1033564927
Isabelle Grace Anderson, PA-C
- Physician Assistant
- Pittsburgh, PA
- NPI 1023828811
Kelley Anderson, DO
- Sports Medicine (Family Medicine) Physician
- Pittsburgh, PA
- NPI 1528212271
Derek Eugene Andreini, MD
- Orthopaedic Surgery Physician
- Pittsburgh, PA
- NPI 1568923167
Natalie Eve Andresky, PA-C
- Physician Assistant
- Huntingdon, PA
- NPI 1285226324
Gabriel Andrews
- Family Medicine Physician
- Pittsburgh, PA
- NPI 1770522385
Natasha Andrews
- Physician Assistant
- Morgantown, WV
- NPI 1750744330
Katherine Melonakos Anetakis
- Neurology with Special Qualifications in Child Neurology Physician
- Pittsburgh, PA
- NPI 1841585882
Amardeep Angroola, M.D.
- Hospitalist Physician
- Dublin, CA
- NPI 1821253568
Christina Anthony
- Certified Registered Nurse Anesthetist
- Pittsburgh, PA
- NPI 1235843566

Complications and deaths 20

Medicare Care Compare

Abdominopelvic accidental puncture or laceration rate As expected0.99
- State average 1.06 (computed here)
- National average 1.06
- No different than the national rate
- 1,498 patients
- Period from 07/01/2022
CMS Medicare PSI 90: Patient safety and adverse events composite As expected0.79
- State average 0.99 (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 expected214.69
- State average 176.01 (computed here)
- National average 173.3
- No different than the national rate
- 57 patients
- Period from 07/01/2022
Death rate for CABG surgery patients As expected2.3
- State average 2.21 (computed here)
- National average 2.4
- No different than the national rate
- 48 patients
- Period from 07/01/2022
Death rate for COPD patients As expected8.5
- State average 8.11 (computed here)
- National average 8.6
- No different than the national rate
- 73 patients
- Period from 07/01/2022
Death rate for heart attack patients As expected11.1
- State average 11.71 (computed here)
- National average 11.9
- No different than the national rate
- 141 patients
- Period from 07/01/2022
Death rate for heart failure patients As expected10.5
- State average 10.73 (computed here)
- National average 11.1
- No different than the national rate
- 389 patients
- Period from 07/01/2022
Death rate for pneumonia patients As expected14.7
- State average 14.97 (computed here)
- National average 15.2
- No different than the national rate
- 359 patients
- Period from 07/01/2022
Death rate for stroke patients As expected10.6
- State average 11.35 (computed here)
- National average 11.9
- No different than the national rate
- 275 patients
- Period from 07/01/2023
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate As expected3.2
- State average 3.79 (computed here)
- National average 3.9
- No different than the national rate
- 5,464 patients
- Period from 07/01/2024
Iatrogenic pneumothorax rate As expected0.25
- State average 0.21 (computed here)
- National average 0.21
- No different than the national rate
- 5,406 patients
- Period from 07/01/2022
In-hospital fall-associated fracture rate As expected0.29
- State average 0.27 (computed here)
- National average 0.27
- No different than the national rate
- 5,765 patients
- Period from 07/01/2022
Perioperative pulmonary embolism or deep vein thrombosis rate As expected2.7
- State average 3.52 (computed here)
- National average 3.52
- No different than the national rate
- 1,724 patients
- Period from 07/01/2022
Postoperative acute kidney injury requiring dialysis rate As expected1.87
- State average 1.63 (computed here)
- National average 1.67
- No different than the national rate
- 971 patients
- Period from 07/01/2022
Postoperative hemorrhage or hematoma rate As expected2.63
- State average 2.3 (computed here)
- National average 2.34
- No different than the national rate
- 1,622 patients
- Period from 07/01/2022
Postoperative respiratory failure rate As expected7.19
- State average 8.98 (computed here)
- National average 9.42
- No different than the national rate
- 887 patients
- Period from 07/01/2022
Postoperative sepsis rate As expected3.66
- State average 5.24 (computed here)
- National average 5.27
- No different than the national rate
- 900 patients
- Period from 07/01/2022
Postoperative wound dehiscence rate As expected1.55
- State average 1.72 (computed here)
- National average 1.77
- No different than the national rate
- 473 patients
- Period from 07/01/2022
Pressure ulcer rate As expected0.37
- State average 0.63 (computed here)
- National average 0.63
- No different than the national rate
- 4,346 patients
- Period from 07/01/2022
Rate of complications for hip/knee replacement patients As expected4.2
- State average 4.17 (computed here)
- National average 4.1
- No different than the national rate
- 86 patients
- Period from 04/01/2023

Infections 5

Medicare Care Compare

Catheter Associated Urinary Tract Infections (ICU + select Wards) As expected0.72
- State average 0.56
- National average 1
- No different than national benchmark
- Period from 10/01/2024
Central Line Associated Bloodstream Infection (ICU + select Wards) Better0.42
- State average 0.59
- National average 1
- Better than the national benchmark
- Period from 10/01/2024
Clostridium Difficile (C.Diff) Better0.68
- State average 0.44
- National average 1
- Better than the national benchmark
- Period from 10/01/2024
MRSA Bacteremia As expected0.92
- State average 0.77
- National average 1
- No different than national benchmark
- Period from 10/01/2024
SSI - Colon Surgery As expected0.97
- State average 0.84
- 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 6
- State average 6.22 (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) 0.98
- State average 0.98
- National average 0.99 (computed here)
- Period from 01/01/2024

Timely and effective care 19

Medicare Care Compare

Anticoagulation Therapy for Atrial Fibrillation/Flutter 80
- State average 76.12 (computed here)
- National average 74.05 (computed here)
- 59 patients
- Period from 01/01/2024
Antithrombotic Therapy by End of Hospital Day 2 88
- State average 94.33 (computed here)
- National average 92.79 (computed here)
- 178 patients
- Period from 01/01/2024
Appropriate care for severe sepsis and septic shock 63
- State average 60
- National average 65
- 221 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 199
- State average 191
- National average 168
- 618 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 288
- State average 340
- National average 287
- 15 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 197
- State average 186
- National average 162
- 584 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 498
- State average 297
- National average 257
- 20 patients
- Period from 10/01/2024
Discharged on Antithrombotic Therapy 100
- State average 97.94 (computed here)
- National average 96.1 (computed here)
- 182 patients
- Period from 01/01/2024
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients 98
- State average 95
- National average 93
- 336 patients
- Period from 01/01/2024
Head CT results 35
- State average 69
- National average 69
- 17 patients
- Period from 10/01/2024
Healthcare workers given influenza vaccination 93
- State average 83
- National average 78
- 2,975 patients
- Period from 10/01/2024
Intensive Care Unit Venous Thromboembolism Prophylaxis 84
- State average 90.77 (computed here)
- National average 93.49 (computed here)
- 714 patients
- Period from 01/01/2024
Left before being seen 1
- State average 2
- National average 2
- 60,603 patients
- Period from 01/01/2024
Safe Use of Opioids - Concurrent Prescribing 17
- State average 16
- National average 15
- 3,811 patients
- Period from 01/01/2024
Septic Shock 3-Hour Bundle 74
- State average 70
- National average 73
- 77 patients
- Period from 10/01/2024
Septic Shock 6-Hour Bundle 89
- State average 85
- National average 87
- 46 patients
- Period from 10/01/2024
Severe Sepsis 3-Hour Bundle 81
- State average 78
- National average 81
- 221 patients
- Period from 10/01/2024
Severe Sepsis 6-Hour Bundle 88
- State average 93
- National average 93
- 127 patients
- Period from 10/01/2024
ST-Segment Elevation Myocardial Infarction (STEMI) 13
- State average 44.88 (computed here)
- National average 46.51 (computed here)
- 82 patients
- Period from 01/01/2024

Measures CMS does not publish for this facility (11)

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
Venous Thromboembolism Prophylaxis — 5

Unplanned visits 13

Medicare Care Compare

Acute Myocardial Infarction (AMI) 30-Day Readmission Rate As expected12.8
- State average 14.5 (computed here)
- National average 14.4
- No different than the national rate
- 416 patients
- Period from 07/01/2023
Heart failure (HF) 30-Day Readmission Rate As expected20.5
- State average 21.59 (computed here)
- National average 21.3
- No different than the national rate
- 1,106 patients
- Period from 07/01/2023
Hospital return days for heart attack patients -9.1
- State average 0.71 (computed here)
- National average 6.71 (computed here)
- Average days per 100 discharges
- 151 patients
- Period from 07/01/2022
Hospital return days for heart failure patients -4.7
- State average -1.7 (computed here)
- National average 4.02 (computed here)
- Average days per 100 discharges
- 444 patients
- Period from 07/01/2022
Hospital return days for pneumonia patients -21.4
- State average 2.03 (computed here)
- National average 5.65 (computed here)
- Average days per 100 discharges
- 356 patients
- Period from 07/01/2022
Pneumonia (PN) 30-Day Readmission Rate As expected17.8
- State average 17.56 (computed here)
- National average 17.3
- No different than the national rate
- 968 patients
- Period from 07/01/2023
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy As expected4.8
- State average 5.1 (computed here)
- National average 5.4
- No different than the national rate
- 83 patients
- Period from 01/01/2024
Rate of inpatient admissions for patients receiving outpatient chemotherapy As expected7.9
- State average 10.83 (computed here)
- National average 10.7
- No different than the national rate
- 83 patients
- Period from 01/01/2024
Rate of readmission after hip/knee replacement As expected5.2
- State average 5.89 (computed here)
- National average 5.8
- No different than the national rate
- 84 patients
- Period from 07/01/2023
Rate of readmission for CABG As expected10.5
- State average 10.99 (computed here)
- National average 11
- No different than the national rate
- 111 patients
- Period from 07/01/2023
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients As expected19.2
- State average 20.02 (computed here)
- National average 20
- No different than the national rate
- 257 patients
- Period from 07/01/2023
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies) As expected13.2
- State average 12.89 (computed here)
- National average 13
- No different than the national rate
- 2,564 patients
- Period from 01/01/2022
Ratio of unplanned hospital visits after hospital outpatient surgery As expected1.1
- State average 0.97 (computed here)
- National average 1.01 (computed here)
- No different than expected
- 718 patients
- Period from 01/01/2024

Measures CMS does not publish for this facility (1)

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

Other hospitals in Pittsburgh, PA

Select Specialty Hospital - Pittsburgh terminated
St Clair Hospital 1000 Bower Hill Road
St Clair Hospital 1000 Bower Hill Road
Upmc Children's Hospital of Pittsburgh
Upmc Mercy
Upmc Presbyterian Shadyside
Upmc Shadyside terminated
Upmc St Margaret
VA Pittsburgh Healthcare System - Univ Dr
West Penn Hospital

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, and the clinicians who list this facility as an affiliation.
NPPES NPI Registry: the NPI records connected to this certification and the names of the providers listed above.

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.