★★★★☆4 out of 5 StarsWhy 4 stars?Jack Hughston Memorial Hospital's 4-star rating reflects below-average performance on Timely Care.
CMS Overall Hospital Quality Star Rating · Jack Hughston Memorial Hospital
How was Jack Hughston Memorial Hospital's 4-star rating calculated?
The CMS Overall Hospital Quality Star Rating applies to
acute care hospitals like Jack Hughston Memorial Hospital. CMS standardizes
every underlying measure against the national rate, computes
a weighted score for each of five domains, sums them by the
fixed weights below, and assigns 1–5 stars using k-means
clustering across all reporting hospitals.
Domains that fed Jack Hughston Memorial Hospital's rating
Domain
Weight
Measures reported
Hospital performance vs. national
Mortality
22%
1 of 7
0 better1 same0 worse
Safety of Care
22%
13 of 19
0 better13 same0 worse
Readmissions
22%
1 of 6
0 better1 same0 worse
Timely & Effective Care
12%
11 of 22
2 better5 same4 worse
Patient Experience
22%
HCAHPS
See HCAHPS detail below
How star meaning varies by hospital type.
This CMS Overall Star Rating only applies to acute care
hospitals. Children's hospitals (Pediatric Quality), psychiatric
hospitals (IPFQR), inpatient rehabilitation facilities (IRF QRP),
long-term acute care hospitals (LTACH QRP), and VA medical centers
each use separate quality programs designed for their patient
populations. Comparing star ratings across these facility types
isn't meaningful — see the methodology page for the full mapping
of which program applies to which facility.
How this emergency department performs on the measures that
matter most when you need care fast.
123 minTypical ER visit before heading homeNear the national median of 148 min
1%Walked out before being seenBetter than ~75% of hospitals · national median 1%
65%Recommended sepsis care givenNear the national median of 64%
From CMS Timely & Effective Care reporting.
Quality measures
Mortality
Same as National Average
Measures the rate at which patients die within 30 days of hospital admission for specific conditions. A lower mortality rate indicates better outcomes.
Jack Hughston Memorial Hospital
WorseUS AvgBetter
Underlying measures:Hybrid Hospital-Wide All-Cause Risk Standardized Mortality RateNo Different Than the National RateHospital score: 3.90 95% interval: 2.50 – 5.90 Sample size: 280Reporting period: 07/01/2023 – 06/30/2024CMS measure id: Hybrid_HWMDeath rate for CABG surgery patientsNot AvailableHospital score: — Reporting period: 07/01/2021 – 06/30/2024CMS measure id: MORT_30_CABGDeath rate for COPD patientsNumber of Cases Too SmallHospital score: — Reporting period: 07/01/2021 – 06/30/2024CMS measure id: MORT_30_COPDDeath rate for heart attack patientsNumber of Cases Too SmallHospital score: — Reporting period: 07/01/2021 – 06/30/2024CMS measure id: MORT_30_AMIDeath rate for heart failure patientsNumber of Cases Too SmallHospital score: — Reporting period: 07/01/2021 – 06/30/2024CMS measure id: MORT_30_HFDeath rate for pneumonia patientsNumber of Cases Too SmallHospital score: — Reporting period: 07/01/2021 – 06/30/2024CMS measure id: MORT_30_PNDeath rate for stroke patientsNumber of Cases Too SmallHospital score: — Reporting period: 07/01/2021 – 06/30/2024CMS measure id: MORT_30_STK
Safety of Care
Same as National Average
Tracks hospital-acquired infections, surgical complications, and other patient safety indicators. Lower rates indicate better safety practices.
Jack Hughston Memorial Hospital
WorseUS AvgBetter
Underlying measures:Abdominopelvic accidental puncture or laceration rateNo Different Than the National RateHospital score: 1.04 95% interval: 0.00 – 2.12 Sample size: 241Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_15Clostridium Difficile (C.Diff)No Different than National BenchmarkHospital score: 0.00 SIR Reporting period: 07/01/2024 – 06/30/2025CMS measure id: HAI_6_SIRIatrogenic pneumothorax rateNo Different Than the National RateHospital score: 0.27 95% interval: 0.03 – 0.50 Sample size: 996Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_06Rate of complications for hip/knee replacement patientsNo Different Than the National RateHospital score: 3.70 95% interval: 2.40 – 5.80 Sample size: 276Reporting period: 04/01/2021 – 03/31/2024CMS measure id: COMP_HIP_KNEEIn-hospital fall-associated fracture rateNo Different Than the National RateHospital score: 0.30 95% interval: 0.09 – 0.51 Sample size: 904Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_08Postoperative hemorrhage or hematoma rateNo Different Than the National RateHospital score: 2.65 95% interval: 1.02 – 4.29 Sample size: 814Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_09Perioperative pulmonary embolism or deep vein thrombosis rateNo Different Than the National RateHospital score: 4.18 95% interval: 1.89 – 6.47 Sample size: 844Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_12Postoperative acute kidney injury requiring dialysis rateNo Different Than the National RateHospital score: 1.60 95% interval: 0.00 – 3.30 Sample size: 775Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_10Postoperative respiratory failure rateNo Different Than the National RateHospital score: 5.76 95% interval: 0.00 – 13.73 Sample size: 777Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_11Postoperative sepsis rateNo Different Than the National RateHospital score: 5.96 95% interval: 1.98 – 9.93 Sample size: 701Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_13Pressure ulcer rateNo Different Than the National RateHospital score: 0.54 95% interval: 0.00 – 1.79 Sample size: 412Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_03CMS Medicare PSI 90: Patient safety and adverse events compositeNo Different Than the National ValueHospital score: 0.95 95% interval: 0.48 – 1.41 Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_90Postoperative wound dehiscence rateNo Different Than the National RateHospital score: 1.76 95% interval: 0.23 – 3.29 Sample size: 126Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_14Catheter Associated Urinary Tract Infections (ICU + select Wards)Not AvailableHospital score: — SIR Reporting period: 07/01/2024 – 06/30/2025CMS measure id: HAI_2_SIRCentral Line Associated Bloodstream Infection (ICU + select Wards)Not AvailableHospital score: — SIR Reporting period: 07/01/2024 – 06/30/2025CMS measure id: HAI_1_SIRMRSA BacteremiaNot AvailableHospital score: — SIR Reporting period: 07/01/2024 – 06/30/2025CMS measure id: HAI_5_SIRSSI - Abdominal HysterectomyNot AvailableHospital score: — SIR Reporting period: 07/01/2024 – 06/30/2025CMS measure id: HAI_4_SIRSSI - Colon SurgeryNot AvailableHospital score: — SIR Reporting period: 07/01/2024 – 06/30/2025CMS measure id: HAI_3_SIRDeath rate among surgical inpatients with serious treatable complicationsNumber of Cases Too SmallHospital score: — Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_04
Readmissions
Same as National Average
Measures how often patients return to the hospital within 30 days of discharge. Lower readmission rates suggest effective treatment and discharge planning.
Based on the HCAHPS survey — patient satisfaction with communication, cleanliness, pain management, and discharge information.
Jack Hughston Memorial Hospital
WorseUS AvgBetter
Patient survey detail — the questions feeding the Patient Experience domain above
expand ↓
CMS computes the Patient Experience domain from the federal HCAHPS survey.
Each bar below is one survey question; the percentage is the share of
Jack's recent patients who gave the most positive
response. HCAHPS percentages aren't directly comparable across all measures —
see the methodology page for how CMS weights them.
Communication with Nurses86%
Communication with Doctors84%
Hospital Cleanliness76%
Hospital Quietness77%
Staff ResponsivenessN/A
Discharge Information86%
Overall Hospital Rating (9 or 10)86%
Would Recommend Hospital88%
Percentages represent patients who gave the most positive response. Survey conducted by CMS through the HCAHPS program.
Timely & Effective Care
Below National Average
Measures how quickly the hospital provides important treatments such as antibiotics for pneumonia or interventions for heart attacks.
Jack Hughston Memorial Hospital
WorseUS AvgBetter
Underlying measures:Left before being seenBetter than ~75% of hospitalsHospital score: 1.00 % National median: 1.00 % (lower is better)
Sample size: 17,625Reporting period: 01/01/2024 – 12/31/2024CMS measure id: OP_22Severe Sepsis 3-Hour BundleBetter than ~75% of hospitalsHospital score: 92.00 % National median: 81.00 % (higher is better)
Sample size: 26Reporting period: 07/01/2024 – 06/30/2025CMS measure id: SEV_SEP_3HRAverage (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 betterNear the national medianHospital score: 123.00 min National median: 148.00 min (lower is better)
Sample size: 412Reporting period: 07/01/2024 – 06/30/2025CMS measure id: OP_18bAverage (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is betterNear the national medianHospital score: 325.00 min National median: 294.00 min (lower is better)
Sample size: 12Reporting period: 07/01/2024 – 06/30/2025CMS measure id: OP_18dAverage (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 betterNear the national medianHospital score: 128.00 min National median: 154.00 min (lower is better)
Sample size: 428Reporting period: 07/01/2024 – 06/30/2025CMS measure id: OP_18aAppropriate care for severe sepsis and septic shockNear the national medianHospital score: 65.00 % National median: 64.00 % (higher is better)
Sample size: 26Reporting period: 07/01/2024 – 06/30/2025CMS measure id: SEP_1Severe Sepsis 6-Hour BundleNear the national medianHospital score: 95.00 % National median: 94.00 % (higher is better)
Sample size: 20Reporting period: 07/01/2024 – 06/30/2025CMS measure id: SEV_SEP_6HRSafe Use of Opioids - Concurrent PrescribingWorse than ~75% of hospitalsHospital score: 19.00 % National median: 15.00 % (lower is better)
Sample size: 568Reporting period: 01/01/2024 – 12/31/2024CMS measure id: SAFE_USE_OF_OPIOIDSIntensive Care Unit Venous Thromboembolism ProphylaxisWorse than ~75% of hospitalsHospital score: 87.00 % National median: 97.00 % (higher is better)
Sample size: 131Reporting period: 01/01/2024 – 12/31/2024CMS measure id: VTE_2Healthcare workers given influenza vaccinationWorse than ~75% of hospitalsHospital score: 41.00 % National median: 79.00 % (higher is better)
Sample size: 540Reporting period: 10/01/2024 – 03/31/2025CMS measure id: IMM_3Venous Thromboembolism ProphylaxisWorse than ~75% of hospitalsHospital score: 66.00 % National median: 90.00 % (higher is better)
Sample size: 930Reporting period: 01/01/2024 – 12/31/2024CMS measure id: VTE_1
Clinical Staff
Jack Hughston Memorial Hospital has 99 CMS-affiliated
clinicians on its roster — physicians, advanced practice providers, and other
Medicare-enrolled professionals who list this hospital as an affiliated facility.
Top specialties
Certified Registered Nurse Anesthetist (Crna)19
Orthopedic Surgery19
Family Practice13
Physician Assistant9
Nurse Practitioner6
Internal Medicine5
Sports Medicine4
Neurology4
Self-reported primary specialty in the CMS Doctors & Clinicians dataset. Many clinicians serve multiple facilities.
Practice characteristics
Accept Medicare assignment
99(100%)
Bill Medicare directly at the approved rate — patients only owe co-insurance/deductible.
Offer telehealth
7(7%)
Indicated by the clinician in their CMS profile as routinely providing virtual visits.
Medicare quality scoring (MIPS)
54 of these clinicians have a published
Merit-based Incentive Payment System (MIPS) final score.
Of those, 13
(24%) score above the national median of 85.5.
MIPS scoring is heavily compressed at the top of the 0–100 range, so individual scores
are not a reliable consumer signal. We surface roster-level coverage and the share
above the national median instead.
Source: CMS Doctors and Clinicians (Care Compare) national downloadable file
and MIPS Performance Year final scores, as of 2026-07-18.
Affiliations from the CMS Facility Affiliations dataset. About 16% of small
facilities (critical access, rural emergency, freestanding psych, IRF/LTCH)
do not appear in the affiliations file and therefore have no panel.
Find a Doctor
Search the 99 clinicians affiliated with Jack Hughston Memorial Hospital.
Each name links to that clinician's official Medicare Care Compare profile, where you can see
their credentials, secondary specialties, group affiliations, and (when applicable) MIPS quality scores.
No clinicians match that search. Try a broader term like "internal medicine" or just a last name.
Roster from CMS Doctors and Clinicians (Care Compare), updated 2026-07-18.
A clinician may also practice at other facilities; "affiliated" means this hospital is on their CMS
profile, not that they exclusively work here.
Procedure volumes are Medicare fee-for-service counts from the CMS
clinician utilization file (all practice locations, not just this
hospital). Industry payment totals are from CMS Open Payments,
program year 2024, and include meals, travel, consulting, and
speaking fees; payments are legal and common — we show them for
transparency, not as a quality judgment.
Pricing & Costs
Facility Information
Licensed beds
70
Facility type
Acute Care Hospitals
Ownership
Government - State
Emergency services
Yes — 24/7
Ownership & Finances
Ownership
For-profit (Partnership)
Charity care spend (FY2023)
$19K
List prices vs. actual cost
≈ 3.5× actual cost
From the hospital's FY2023 Medicare cost report (HCRIS).
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Claim this listing free to add your logo, correct details, and
publish a statement.
How Jack Hughston Memorial Hospital compares nearby
Compared with the 7 other acute-care hospitals within 50 miles
— 8 facilities in all, CMS data only.
Among the 8 acute-care hospitals within 50 miles, Jack Hughston Memorial Hospital's overall star rating is 4★; the median among the 5 peers reporting it is 3★.
Measure
This facility
Nearby median
Overall star rating
reported by 5 of 7 nearby peers
4★
3★
Patient experience (HCAHPS) star
reported by 6 of 7 nearby peers
Cohort: within 50 miles · CMS data period 2026-06 · method cohort-v1
· comparisons are never affected by claiming or payment.
How nearby comparisons work
Quality and ratings data are sourced from the U.S. Centers for
Medicare & Medicaid Services (CMS) Hospital Compare program.
Star ratings are CMS's own calculation; CareRanks does not modify
or re-weight them. Facility-level details (address, beds,
ownership, teaching status) come from CMS provider files and the
CMS Provider of Services file.
Pricing data, where shown, is drawn from the hospital's own
Machine-Readable File (MRF) published under the federal Hospital
Price Transparency Rule. See our methodology for the full update
cadence and limitations.