Acute Care Hospital

Southwest General Health Center

18697 Bagley Road, Middleburg Heights, OH 44130

Part of Southwest Community Health Systemsee all 3 affiliated facilities

24/7 Emergency Services Nonprofit
4 out of 5 Stars Why 4 stars? Southwest General Health Center's 4-star rating reflects above-average performance on Timely Care and below-average performance on Safety of Care and Readmissions.

CMS Overall Hospital Quality Star Rating · Southwest General Health Center

How was Southwest General Health Center's 4-star rating calculated?

The CMS Overall Hospital Quality Star Rating applies to acute care hospitals like Southwest General Health Center. 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 Southwest General Health Center's rating
Domain Weight Measures reported Hospital performance vs. national
Mortality 22% 6 of 7 0 better 6 same 0 worse
Safety of Care 22% 18 of 19 1 better 14 same 3 worse
Readmissions 22% 5 of 6 0 better 1 same 4 worse
Timely & Effective Care 12% 16 of 22 7 better 5 same 4 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 CareRanks computes ratings → · CMS official methodology ↗

Emergency & urgent care

How this emergency department performs on the measures that matter most when you need care fast.

199 min Typical ER visit before heading home Worse than ~75% of hospitals · national median 148 min
5% Walked out before being seen Worse than ~75% of hospitals · national median 1%
89% Recommended sepsis care given Better than ~75% of hospitals · national median 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.

Underlying measures: Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate No Different Than the National Rate Hospital score: 3.80 95% interval: 3.20 – 4.30 Sample size: 1,828 Reporting period: 07/01/2023 – 06/30/2024 CMS measure id: Hybrid_HWM Death rate for COPD patients No Different Than the National Rate Hospital score: 6.90 95% interval: 4.90 – 9.60 Sample size: 218 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_COPD Death rate for heart attack patients No Different Than the National Rate Hospital score: 11.40 95% interval: 8.90 – 14.40 Sample size: 172 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_AMI Death rate for heart failure patients No Different Than the National Rate Hospital score: 10.60 95% interval: 8.30 – 13.30 Sample size: 392 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_HF Death rate for pneumonia patients No Different Than the National Rate Hospital score: 13.80 95% interval: 11.50 – 16.30 Sample size: 515 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_PN Death rate for stroke patients No Different Than the National Rate Hospital score: 14.40 95% interval: 11.50 – 17.80 Sample size: 187 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_STK Death rate for CABG surgery patients Number of Cases Too Small Hospital score: — Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_CABG

Safety of Care

Below National Average

Tracks hospital-acquired infections, surgical complications, and other patient safety indicators. Lower rates indicate better safety practices.

Underlying measures: Clostridium Difficile (C.Diff) Better than the National Benchmark Hospital score: 0.37 SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_6_SIR Catheter Associated Urinary Tract Infections (ICU + select Wards) No Different than National Benchmark Hospital score: 0.74 SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_2_SIR Central Line Associated Bloodstream Infection (ICU + select Wards) No Different than National Benchmark Hospital score: 0.57 SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_1_SIR Iatrogenic pneumothorax rate No Different Than the National Rate Hospital score: 0.30 95% interval: 0.10 – 0.50 Sample size: 7,102 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_06 Rate of complications for hip/knee replacement patients No Different Than the National Rate Hospital score: 2.20 95% interval: 1.30 – 3.60 Sample size: 263 Reporting period: 04/01/2021 – 03/31/2024 CMS measure id: COMP_HIP_KNEE In-hospital fall-associated fracture rate No Different Than the National Rate Hospital score: 0.32 95% interval: 0.12 – 0.51 Sample size: 7,306 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_08 MRSA Bacteremia No Different than National Benchmark Hospital score: 0.00 SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_5_SIR Postoperative hemorrhage or hematoma rate No Different Than the National Rate Hospital score: 2.49 95% interval: 0.99 – 3.99 Sample size: 1,266 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_09 Perioperative pulmonary embolism or deep vein thrombosis rate No Different Than the National Rate Hospital score: 3.79 95% interval: 1.71 – 5.87 Sample size: 1,216 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_12 Postoperative acute kidney injury requiring dialysis rate No Different Than the National Rate Hospital score: 1.76 95% interval: 0.19 – 3.32 Sample size: 635 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_10 Postoperative respiratory failure rate No Different Than the National Rate Hospital score: 13.44 95% interval: 6.62 – 20.26 Sample size: 672 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_11 Postoperative sepsis rate No Different Than the National Rate Hospital score: 5.39 95% interval: 1.63 – 9.15 Sample size: 436 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_13 SSI - Colon Surgery No Different than National Benchmark Hospital score: 0.31 SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_3_SIR Death rate among surgical inpatients with serious treatable complications No Different Than the National Rate Hospital score: 156.60 95% interval: 106.45 – 206.74 Sample size: 72 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_04 Postoperative wound dehiscence rate No Different Than the National Rate Hospital score: 1.57 95% interval: 0.12 – 3.01 Sample size: 373 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_14 Abdominopelvic accidental puncture or laceration rate Worse Than the National Rate Hospital score: 2.06 95% interval: 1.13 – 3.00 Sample size: 1,423 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_15 Pressure ulcer rate Worse Than the National Rate Hospital score: 1.40 95% interval: 0.78 – 2.02 Sample size: 6,012 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_03 CMS Medicare PSI 90: Patient safety and adverse events composite Worse Than the National Value Hospital score: 1.40 95% interval: 1.09 – 1.71 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_90 SSI - Abdominal Hysterectomy Not Available Hospital score: — SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_4_SIR

Readmissions

Below National Average

Measures how often patients return to the hospital within 30 days of discharge. Lower readmission rates suggest effective treatment and discharge planning.

Underlying measures: 30-day Readmission, COPD As expected Hospital score: 1.00 Sample size: 236 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-COPD-HRRP 30-day Readmission, Heart Attack Worse than expected Hospital score: 1.13 Sample size: 165 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-AMI-HRRP 30-day Readmission, Heart Failure Worse than expected Hospital score: 1.08 Sample size: 427 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-HF-HRRP 30-day Readmission, Hip/Knee Replacement Worse than expected Hospital score: 1.16 Sample size: 255 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-HIP-KNEE-HRRP 30-day Readmission, Pneumonia Worse than expected Hospital score: 1.09 Sample size: 545 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-PN-HRRP 30-day Readmission, Bypass Surgery Hospital score: — Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-CABG-HRRP

Patient Experience

Same as National Average

Based on the HCAHPS survey — patient satisfaction with communication, cleanliness, pain management, and discharge information.

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 Southwest'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 Nurses 80%
  • Communication with Doctors 77%
  • Hospital Cleanliness 63%
  • Hospital Quietness 58%
  • Staff Responsiveness N/A
  • Discharge Information 86%
  • Overall Hospital Rating (9 or 10) 73%
  • Would Recommend Hospital 73%

Percentages represent patients who gave the most positive response. Survey conducted by CMS through the HCAHPS program.

Timely & Effective Care

Better than National Average

Measures how quickly the hospital provides important treatments such as antibiotics for pneumonia or interventions for heart attacks.

Underlying measures: Head CT results Better than ~75% of hospitals Hospital score: 94.00 % National median: 74.00 % (higher is better) Sample size: 31 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: OP_23 Hospital Harm - Opioid Related Adverse Events Better than ~75% of hospitals Hospital score: 0.00 % National median: 0.00 % (lower is better) Sample size: 6,976 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: HH_ORAE Appropriate care for severe sepsis and septic shock Better than ~75% of hospitals Hospital score: 89.00 % National median: 64.00 % (higher is better) Sample size: 319 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: SEP_1 Septic Shock 3-Hour Bundle Better than ~75% of hospitals Hospital score: 92.00 % National median: 72.00 % (higher is better) Sample size: 147 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: SEP_SH_3HR Septic Shock 6-Hour Bundle Better than ~75% of hospitals Hospital score: 99.00 % National median: 89.00 % (higher is better) Sample size: 120 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: SEP_SH_6HR Severe Sepsis 3-Hour Bundle Better than ~75% of hospitals Hospital score: 94.00 % National median: 81.00 % (higher is better) Sample size: 319 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: SEV_SEP_3HR Severe Sepsis 6-Hour Bundle Better than ~75% of hospitals Hospital score: 99.00 % National median: 94.00 % (higher is better) Sample size: 213 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: SEV_SEP_6HR Discharged on Antithrombotic Therapy Near the national median Hospital score: 98.00 % National median: 98.00 % (higher is better) Sample size: 171 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: STK_02 Antithrombotic Therapy by End of Hospital Day 2 Near the national median Hospital score: 94.00 % National median: 94.00 % (higher is better) Sample size: 153 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: STK_05 Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients Near the national median Hospital score: 99.00 % National median: 97.00 % (higher is better) Sample size: 73 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: OP_29 Safe Use of Opioids - Concurrent Prescribing Near the national median Hospital score: 13.00 % National median: 15.00 % (lower is better) Sample size: 2,982 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: SAFE_USE_OF_OPIOIDS Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better Near the national median Hospital score: 188.00 min National median: 248.00 min (lower is better) Sample size: 21 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: OP_18c 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 Worse than ~75% of hospitals Hospital score: 199.00 min National median: 148.00 min (lower is better) Sample size: 378 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: OP_18b 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 Worse than ~75% of hospitals Hospital score: 199.00 min National median: 154.00 min (lower is better) Sample size: 403 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: OP_18a Left before being seen Worse than ~75% of hospitals Hospital score: 5.00 % National median: 1.00 % (lower is better) Sample size: 36,871 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: OP_22 Healthcare workers given influenza vaccination Worse than ~75% of hospitals Hospital score: 53.00 % National median: 79.00 % (higher is better) Sample size: 2,942 Reporting period: 10/01/2024 – 03/31/2025 CMS measure id: IMM_3

Psychiatric Unit Quality (IPFQR)

Southwest General Health Center operates a Medicare-certified inpatient psychiatric unit that reports under the federal IPFQR program. The measures are specific to that unit — not the hospital as a whole. They cover restraint and seclusion use, screening for medication side effects, substance-use and tobacco treatment, transitions of care, follow-up after discharge, and readmissions.

Show the psychiatric unit's 11 reported measures expand ↓
Physical Restraint Use 0.1 hours per 1,000 patient-hours
National median: 0.1 hours Near national median

HBIPS-2 — hours of physical restraint use per 1,000 patient-hours. Lower is better; restraints carry physical and psychological risks.

Seclusion Use 0.0 hours per 1,000 patient-hours
National median: 0.0 hours Near national median

HBIPS-3 — hours of seclusion per 1,000 patient-hours. Lower is better; seclusion is used only when no other intervention works.

Metabolic Screening (SMD) 95.0 %
National median: 92.0 % Near national median

SMD — % of patients on antipsychotics screened for metabolic side effects (BMI, blood glucose, cholesterol). Antipsychotics raise metabolic-syndrome risk; screening catches it early.

Substance-Use Treatment Provided 97.0 %
National median: 74.0 % Better than national median

SUB-2 — % of patients with alcohol/drug use referred for treatment during admission.

Substance-Use Treatment at Discharge 85.0 %
National median: 77.0 % Better than national median

SUB-3 — % of patients with substance-use disorder offered or referred to treatment at discharge.

Tobacco-Use Treatment at Discharge 73.0 %
National median: 64.0 % Better than national median

TOB-3 — % of patients using tobacco who received counseling and/or medication at discharge.

Transition Record Completed 89.0 %
National median: 77.0 % Better than national median

TR-1 — % of discharges with a completed transition record including medications, follow-up plan, and crisis instructions.

Follow-up Within 7 Days 37.9 %
National median: 35.4 % Near national median

FAPH-7 — % of patients with a follow-up outpatient mental-health visit within 7 days of discharge. Predicts lower readmission risk.

Follow-up Within 30 Days 79.3 %
National median: 60.7 % Better than national median

FAPH-30 — % of patients with a follow-up outpatient mental-health visit within 30 days of discharge.

30-Day Readmission Rate 18.4 %
National median: 19.1 % Near national median

READM-30-IPF — risk-standardized 30-day readmission rate. No Different Than the National Rate

Influenza Immunization 95.0 %
National median: 87.0 % Near national median

IMM-2 — % of patients given a flu vaccine during the inpatient stay.

Source: CMS Inpatient Psychiatric Facility Quality Reporting Program. Reporting period ending 12/31/2024.

Clinical Staff

Southwest General Health Center has 613 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

  • Nurse Practitioner 97
  • Internal Medicine 71
  • Family Practice 49
  • Diagnostic Radiology 41
  • Physician Assistant 35
  • Emergency Medicine 25
  • Orthopedic Surgery 21
  • Cardiovascular Disease (Cardiology) 20

Self-reported primary specialty in the CMS Doctors & Clinicians dataset. Many clinicians serve multiple facilities.

Practice characteristics

Accept Medicare assignment
609 (99%)

Bill Medicare directly at the approved rate — patients only owe co-insurance/deductible.

Offer telehealth
103 (17%)

Indicated by the clinician in their CMS profile as routinely providing virtual visits.

Medicare quality scoring (MIPS)

313 of these clinicians have a published Merit-based Incentive Payment System (MIPS) final score. Of those, 105 (34%) 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 613 clinicians affiliated with Southwest General Health Center. 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.

Showing 30 of 613 clinicians (alphabetical)

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

This hospital participates in price transparency under the federal Hospital Price Transparency Rule. View 771 published procedures — gross charges, cash prices, and per-payer negotiated rates where available.

View full pricing →

Facility Information

Licensed beds
346
Facility type
Acute Care Hospitals
Ownership
Voluntary non-profit - Private
Emergency services
Yes — 24/7

Ownership & Finances

Ownership
Nonprofit
Charity care spend (FY2023)
$1.5M
List prices vs. actual cost
≈ 4.5× actual cost

From the hospital's FY2023 Medicare cost report (HCRIS).

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How Southwest General Health Center compares nearby

Compared with the 8 other acute-care hospitals within 25 miles — 9 facilities in all, CMS data only.

Among the 9 acute-care hospitals within 25 miles, Southwest General Health Center's overall star rating is 4★; the median among the 8 peers reporting it is 4★.

Measure This facility Nearby median Best nearby
Overall star rating reported by 8 of 8 nearby peers 4★ 4★ 5★
Patient experience (HCAHPS) star reported by 8 of 8 nearby peers 3★ 3★ 4★
Mortality reported by 8 of 8 nearby peers Same as National Average Same as National Average Better than National Average
Safety of Care reported by 8 of 8 nearby peers Below National Average Same as National Average Better than National Average
Readmissions reported by 8 of 8 nearby peers Below National Average Same as National Average Same as National Average

The comparison group

Cohort: within 25 miles · CMS data period 2026-06 · method cohort-v1 · comparisons are never affected by claiming or payment. How nearby comparisons work

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Skilled nursing facilities nearby

For planning care after discharge — CMS five-star ratings shown; always confirm availability and coverage with the facility and your insurer.

About this data

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.

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