★★☆☆☆2 out of 5 StarsWhy 2 stars?Avera St. Mary's Hospital's 2-star rating reflects above-average performance on Timely Care.
CMS Overall Hospital Quality Star Rating · Avera St. Mary's Hospital
How was Avera St. Mary's Hospital's 2-star rating calculated?
The CMS Overall Hospital Quality Star Rating applies to
acute care hospitals like Avera St. Mary's 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 Avera St. Mary's Hospital's rating
Domain
Weight
Measures reported
Hospital performance vs. national
Mortality
22%
5 of 7
0 better4 same1 worse
Safety of Care
22%
13 of 19
0 better13 same0 worse
Readmissions
22%
4 of 6
1 better3 same0 worse
Timely & Effective Care
12%
14 of 22
5 better8 same1 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.
129 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%
81%Recommended sepsis care givenBetter 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.
Avera St. Mary's Hospital
WorseUS AvgBetter
Underlying measures:Hybrid Hospital-Wide All-Cause Risk Standardized Mortality RateNo Different Than the National RateHospital score: 4.10 95% interval: 3.20 – 5.00 Sample size: 262Reporting period: 07/01/2023 – 06/30/2024CMS measure id: Hybrid_HWMDeath rate for COPD patientsNo Different Than the National RateHospital score: 8.80 95% interval: 5.00 – 15.20 Sample size: 36Reporting period: 07/01/2021 – 06/30/2024CMS measure id: MORT_30_COPDDeath rate for pneumonia patientsNo Different Than the National RateHospital score: 20.00 95% interval: 15.00 – 26.00 Sample size: 111Reporting period: 07/01/2021 – 06/30/2024CMS measure id: MORT_30_PNDeath rate for stroke patientsNo Different Than the National RateHospital score: 13.10 95% interval: 9.10 – 18.80 Sample size: 37Reporting period: 07/01/2021 – 06/30/2024CMS measure id: MORT_30_STKDeath rate for heart failure patientsWorse Than the National RateHospital score: 17.30 95% interval: 11.90 – 24.50 Sample size: 48Reporting period: 07/01/2021 – 06/30/2024CMS measure id: MORT_30_HFDeath rate for CABG surgery patientsNot AvailableHospital score: — Reporting period: 07/01/2021 – 06/30/2024CMS measure id: MORT_30_CABGDeath rate for heart attack patientsNumber of Cases Too SmallHospital score: — Reporting period: 07/01/2021 – 06/30/2024CMS measure id: MORT_30_AMI
Safety of Care
Same as National Average
Tracks hospital-acquired infections, surgical complications, and other patient safety indicators. Lower rates indicate better safety practices.
Avera St. Mary's Hospital
WorseUS AvgBetter
Underlying measures:Abdominopelvic accidental puncture or laceration rateNo Different Than the National RateHospital score: 1.02 95% interval: 0.00 – 2.10 Sample size: 121Reporting 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: 0.20 95% interval: 0.00 – 0.44 Sample size: 1,030Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_06Rate of complications for hip/knee replacement patientsNo Different Than the National RateHospital score: 4.50 95% interval: 2.60 – 7.70 Sample size: 90Reporting period: 04/01/2021 – 03/31/2024CMS measure id: COMP_HIP_KNEEIn-hospital fall-associated fracture rateNo Different Than the National RateHospital score: 0.26 95% interval: 0.05 – 0.48 Sample size: 997Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_08Postoperative hemorrhage or hematoma rateNo Different Than the National RateHospital score: 2.27 95% interval: 0.56 – 3.99 Sample size: 233Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_09Perioperative pulmonary embolism or deep vein thrombosis rateNo Different Than the National RateHospital score: 3.15 95% interval: 0.64 – 5.66 Sample size: 247Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_12Postoperative acute kidney injury requiring dialysis rateNo Different Than the National RateHospital score: 1.66 95% interval: 0.00 – 3.38 Sample size: 105Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_10Postoperative respiratory failure rateNo Different Than the National RateHospital score: 11.41 95% interval: 1.58 – 21.23 Sample size: 105Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_11Postoperative sepsis rateNo Different Than the National RateHospital score: 7.77 95% interval: 3.50 – 12.03 Sample size: 93Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_13Pressure ulcer rateNo Different Than the National RateHospital score: 0.46 95% interval: 0.00 – 1.60 Sample size: 761Reporting 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: 1.07 95% interval: 0.60 – 1.54 Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_90Postoperative wound dehiscence rateNo Different Than the National RateHospital score: 1.74 95% interval: 0.22 – 3.26 Sample size: 43Reporting 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.
Avera St. Mary's 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
Avera'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 Nurses82%
Communication with Doctors76%
Hospital Cleanliness80%
Hospital Quietness65%
Staff ResponsivenessN/A
Discharge Information90%
Overall Hospital Rating (9 or 10)69%
Would Recommend Hospital61%
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.
Avera St. Mary's Hospital
WorseUS AvgBetter
Underlying measures:Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is betterBetter than ~75% of hospitalsHospital score: 152.00 min National median: 248.00 min (lower is better)
Sample size: 457Reporting period: 07/01/2024 – 06/30/2025CMS measure id: OP_18cLeft before being seenBetter than ~75% of hospitalsHospital score: 1.00 % National median: 1.00 % (lower is better)
Sample size: 8,559Reporting period: 01/01/2024 – 12/31/2024CMS measure id: OP_22Appropriate care for severe sepsis and septic shockBetter than ~75% of hospitalsHospital score: 81.00 % National median: 64.00 % (higher is better)
Sample size: 151Reporting period: 07/01/2024 – 06/30/2025CMS measure id: SEP_1Septic Shock 3-Hour BundleBetter than ~75% of hospitalsHospital score: 89.00 % National median: 72.00 % (higher is better)
Sample size: 44Reporting period: 07/01/2024 – 06/30/2025CMS measure id: SEP_SH_3HRSevere Sepsis 3-Hour BundleBetter than ~75% of hospitalsHospital score: 91.00 % National median: 81.00 % (higher is better)
Sample size: 151Reporting period: 07/01/2024 – 06/30/2025CMS measure id: SEV_SEP_3HREndoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patientsNear the national medianHospital score: 99.00 % National median: 97.00 % (higher is better)
Sample size: 270Reporting period: 01/01/2024 – 12/31/2024CMS measure id: OP_29Safe Use of Opioids - Concurrent PrescribingNear the national medianHospital score: 17.00 % National median: 15.00 % (lower is better)
Sample size: 370Reporting period: 01/01/2024 – 12/31/2024CMS measure id: SAFE_USE_OF_OPIOIDSAverage (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: 129.00 min National median: 148.00 min (lower is better)
Sample size: 6,811Reporting 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: 279.00 min National median: 294.00 min (lower is better)
Sample size: 329Reporting 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: 133.00 min National median: 154.00 min (lower is better)
Sample size: 7,576Reporting period: 07/01/2024 – 06/30/2025CMS measure id: OP_18aSeptic Shock 6-Hour BundleNear the national medianHospital score: 93.00 % National median: 89.00 % (higher is better)
Sample size: 30Reporting period: 07/01/2024 – 06/30/2025CMS measure id: SEP_SH_6HRSevere Sepsis 6-Hour BundleNear the national medianHospital score: 93.00 % National median: 94.00 % (higher is better)
Sample size: 76Reporting period: 07/01/2024 – 06/30/2025CMS measure id: SEV_SEP_6HRHealthcare workers given influenza vaccinationNear the national medianHospital score: 84.00 % National median: 79.00 % (higher is better)
Sample size: 633Reporting period: 10/01/2024 – 03/31/2025CMS measure id: IMM_3Head CT resultsWorse than ~75% of hospitalsHospital score: 50.00 % National median: 74.00 % (higher is better)
Sample size: 14Reporting period: 07/01/2024 – 06/30/2025CMS measure id: OP_23
Clinical Staff
Avera St. Mary's Hospital has 208 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 Practitioner41
Physician Assistant20
Family Practice17
Certified Registered Nurse Anesthetist (Crna)16
Internal Medicine14
Pathology10
Pulmonary Disease10
Hematology/Oncology10
Self-reported primary specialty in the CMS Doctors & Clinicians dataset. Many clinicians serve multiple facilities.
Practice characteristics
Accept Medicare assignment
204(98%)
Bill Medicare directly at the approved rate — patients only owe co-insurance/deductible.
Offer telehealth
45(22%)
Indicated by the clinician in their CMS profile as routinely providing virtual visits.
Medicare quality scoring (MIPS)
14 of these clinicians have a published
Merit-based Incentive Payment System (MIPS) final score.
Of those, 6
(43%) 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 208 clinicians affiliated with Avera St. Mary's 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
60
Facility type
Acute Care Hospitals
Ownership
Voluntary non-profit - Private
Emergency services
Yes — 24/7
Ownership & Finances
Ownership
Nonprofit (Church-affiliated)
Charity care spend (FY2023)
$2.8M
List prices vs. actual cost
≈ 4.1× 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.
Compared with the 8 other acute-care hospitals within 100 miles
— 9 facilities in all, CMS data only.
Among the 9 acute-care hospitals within 100 miles, CMS rates Avera St. Mary's Hospital's mortality about the same as the national average; the median among the 8 peers reporting it is about the same as the national average.
Cohort: within 100 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.