★★★☆☆3 out of 5 StarsWhy 3 stars?Dignity Health – Mercy Hospital Downtown's 3-star rating reflects above-average performance on Timely Care and below-average performance on Patient Experience.
CMS Overall Hospital Quality Star Rating · Dignity Health – Mercy Hospital Downtown
How was Dignity Health – Mercy Hospital Downtown's 3-star rating calculated?
The CMS Overall Hospital Quality Star Rating applies to
acute care hospitals like Dignity Health – Mercy Hospital Downtown. 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 Dignity Health – Mercy Hospital Downtown's rating
Domain
Weight
Measures reported
Hospital performance vs. national
Mortality
22%
6 of 7
0 better6 same0 worse
Safety of Care
22%
18 of 19
1 better17 same0 worse
Readmissions
22%
3 of 6
0 better3 same0 worse
Timely & Effective Care
12%
15 of 22
6 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.
Measures the rate at which patients die within 30 days of hospital admission for specific conditions. A lower mortality rate indicates better outcomes.
Dignity Health – Mercy Hospital…
WorseUS AvgBetter
Underlying measures:Hybrid Hospital-Wide All-Cause Risk Standardized Mortality RateNo Different Than the National RateHospital score: 4.30 95% interval: 3.50 – 5.20 Sample size: 834Reporting period: 07/01/2023 – 06/30/2024CMS measure id: Hybrid_HWMDeath rate for COPD patientsNo Different Than the National RateHospital score: 8.50 95% interval: 5.40 – 12.90 Sample size: 91Reporting period: 07/01/2021 – 06/30/2024CMS measure id: MORT_30_COPDDeath rate for heart attack patientsNo Different Than the National RateHospital score: 11.20 95% interval: 8.20 – 15.00 Sample size: 35Reporting period: 07/01/2021 – 06/30/2024CMS measure id: MORT_30_AMIDeath rate for heart failure patientsNo Different Than the National RateHospital score: 12.70 95% interval: 9.30 – 17.10 Sample size: 152Reporting period: 07/01/2021 – 06/30/2024CMS measure id: MORT_30_HFDeath rate for pneumonia patientsNo Different Than the National RateHospital score: 17.00 95% interval: 13.70 – 20.60 Sample size: 285Reporting period: 07/01/2021 – 06/30/2024CMS measure id: MORT_30_PNDeath rate for stroke patientsNo Different Than the National RateHospital score: 13.90 95% interval: 10.80 – 17.90 Sample size: 104Reporting period: 07/01/2021 – 06/30/2024CMS measure id: MORT_30_STKDeath rate for CABG surgery patientsNot AvailableHospital score: — Reporting period: 07/01/2021 – 06/30/2024CMS measure id: MORT_30_CABG
Safety of Care
Same as National Average
Tracks hospital-acquired infections, surgical complications, and other patient safety indicators. Lower rates indicate better safety practices.
Dignity Health – Mercy Hospital…
WorseUS AvgBetter
Underlying measures:Clostridium Difficile (C.Diff)Better than the National BenchmarkHospital score: 0.10 SIR Reporting period: 07/01/2024 – 06/30/2025CMS measure id: HAI_6_SIRAbdominopelvic accidental puncture or laceration rateNo Different Than the National RateHospital score: 0.82 95% interval: 0.00 – 1.78 Sample size: 851Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_15Catheter Associated Urinary Tract Infections (ICU + select Wards)No Different than National BenchmarkHospital score: 0.28 SIR Reporting period: 07/01/2024 – 06/30/2025CMS measure id: HAI_2_SIRCentral Line Associated Bloodstream Infection (ICU + select Wards)No Different than National BenchmarkHospital score: 0.25 SIR Reporting period: 07/01/2024 – 06/30/2025CMS measure id: HAI_1_SIRIatrogenic pneumothorax rateNo Different Than the National RateHospital score: 0.24 95% interval: 0.02 – 0.46 Sample size: 3,882Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_06In-hospital fall-associated fracture rateNo Different Than the National RateHospital score: 0.24 95% interval: 0.03 – 0.45 Sample size: 3,839Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_08MRSA BacteremiaNo Different than National BenchmarkHospital score: 0.00 SIR Reporting period: 07/01/2024 – 06/30/2025CMS measure id: HAI_5_SIRPostoperative hemorrhage or hematoma rateNo Different Than the National RateHospital score: 2.32 95% interval: 0.70 – 3.93 Sample size: 670Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_09Perioperative pulmonary embolism or deep vein thrombosis rateNo Different Than the National RateHospital score: 3.25 95% interval: 1.02 – 5.49 Sample size: 702Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_12Postoperative acute kidney injury requiring dialysis rateNo Different Than the National RateHospital score: 1.61 95% interval: 0.00 – 3.30 Sample size: 196Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_10Postoperative respiratory failure rateNo Different Than the National RateHospital score: 17.54 95% interval: 8.81 – 26.27 Sample size: 206Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_11Postoperative sepsis rateNo Different Than the National RateHospital score: 5.99 95% interval: 2.01 – 9.98 Sample size: 168Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_13Pressure ulcer rateNo Different Than the National RateHospital score: 0.21 95% interval: 0.00 – 0.98 Sample size: 3,352Reporting 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: 1.09 95% interval: 0.72 – 1.47 Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_90SSI - Abdominal HysterectomyNo Different than National BenchmarkHospital score: 0.00 SIR Reporting period: 07/01/2024 – 06/30/2025CMS measure id: HAI_4_SIRSSI - Colon SurgeryNo Different than National BenchmarkHospital score: 0.39 SIR Reporting period: 07/01/2024 – 06/30/2025CMS measure id: HAI_3_SIRDeath rate among surgical inpatients with serious treatable complicationsNo Different Than the National RateHospital score: 181.24 95% interval: 125.00 – 237.47 Sample size: 39Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_04Postoperative wound dehiscence rateNo Different Than the National RateHospital score: 1.60 95% interval: 0.14 – 3.07 Sample size: 278Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_14Rate of complications for hip/knee replacement patientsNumber of Cases Too SmallHospital score: — Reporting period: 04/01/2021 – 03/31/2024CMS measure id: COMP_HIP_KNEE
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.
Dignity Health – Mercy 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
Dignity'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 Nurses76%
Communication with Doctors70%
Hospital Cleanliness66%
Hospital Quietness43%
Staff ResponsivenessN/A
Discharge Information82%
Overall Hospital Rating (9 or 10)64%
Would Recommend Hospital65%
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.
Dignity Health – Mercy Hospital…
WorseUS AvgBetter
Underlying measures:Head CT resultsBetter than ~75% of hospitalsHospital score: 85.00 % National median: 74.00 % (higher is better)
Sample size: 26Reporting period: 07/01/2024 – 06/30/2025CMS measure id: OP_23Intensive Care Unit Venous Thromboembolism ProphylaxisBetter than ~75% of hospitalsHospital score: 99.00 % National median: 97.00 % (higher is better)
Sample size: 833Reporting period: 01/01/2024 – 12/31/2024CMS measure id: VTE_2Left before being seenBetter than ~75% of hospitalsHospital score: 1.00 % National median: 1.00 % (lower is better)
Sample size: 84,444Reporting period: 01/01/2024 – 12/31/2024CMS measure id: OP_22Septic Shock 3-Hour BundleBetter than ~75% of hospitalsHospital score: 84.00 % National median: 72.00 % (higher is better)
Sample size: 31Reporting period: 07/01/2024 – 06/30/2025CMS measure id: SEP_SH_3HRSevere Sepsis 6-Hour BundleBetter than ~75% of hospitalsHospital score: 99.00 % National median: 94.00 % (higher is better)
Sample size: 77Reporting period: 07/01/2024 – 06/30/2025CMS measure id: SEV_SEP_6HRVenous Thromboembolism ProphylaxisBetter than ~75% of hospitalsHospital score: 97.00 % National median: 90.00 % (higher is better)
Sample size: 5,285Reporting period: 01/01/2024 – 12/31/2024CMS measure id: VTE_1Safe Use of Opioids - Concurrent PrescribingNear the national medianHospital score: 13.00 % National median: 15.00 % (lower is better)
Sample size: 3,027Reporting period: 01/01/2024 – 12/31/2024CMS measure id: SAFE_USE_OF_OPIOIDSAverage (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is betterNear the national medianHospital score: 219.00 min National median: 248.00 min (lower is better)
Sample size: 12Reporting period: 07/01/2024 – 06/30/2025CMS measure id: OP_18cAppropriate care for severe sepsis and septic shockNear the national medianHospital score: 72.00 % National median: 64.00 % (higher is better)
Sample size: 138Reporting period: 07/01/2024 – 06/30/2025CMS measure id: SEP_1Septic Shock 6-Hour BundleNear the national medianHospital score: 87.00 % National median: 89.00 % (higher is better)
Sample size: 23Reporting period: 07/01/2024 – 06/30/2025CMS measure id: SEP_SH_6HRSevere Sepsis 3-Hour BundleNear the national medianHospital score: 83.00 % National median: 81.00 % (higher is better)
Sample size: 139Reporting period: 07/01/2024 – 06/30/2025CMS measure id: SEV_SEP_3HREndoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patientsWorse than ~75% of hospitalsHospital score: 78.00 % National median: 97.00 % (higher is better)
Sample size: 55Reporting period: 01/01/2024 – 12/31/2024CMS measure id: OP_29Average (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 betterWorse than ~75% of hospitalsHospital score: 190.00 min National median: 148.00 min (lower is better)
Sample size: 370Reporting period: 07/01/2024 – 06/30/2025CMS measure id: OP_18bAverage (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 betterWorse than ~75% of hospitalsHospital score: 194.00 min National median: 154.00 min (lower is better)
Sample size: 389Reporting period: 07/01/2024 – 06/30/2025CMS measure id: OP_18aHealthcare workers given influenza vaccinationWorse than ~75% of hospitalsHospital score: 61.00 % National median: 79.00 % (higher is better)
Sample size: 4,226Reporting period: 10/01/2024 – 03/31/2025CMS measure id: IMM_3
Clinical Staff
Dignity Health – Mercy Hospital Downtown has 195 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
Internal Medicine28
Emergency Medicine27
Certified Registered Nurse Anesthetist (Crna)21
Diagnostic Radiology18
General Surgery16
Anesthesiology10
Gastroenterology8
Nephrology7
Self-reported primary specialty in the CMS Doctors & Clinicians dataset. Many clinicians serve multiple facilities.
Practice characteristics
Accept Medicare assignment
189(97%)
Bill Medicare directly at the approved rate — patients only owe co-insurance/deductible.
Offer telehealth
35(18%)
Indicated by the clinician in their CMS profile as routinely providing virtual visits.
Medicare quality scoring (MIPS)
117 of these clinicians have a published
Merit-based Incentive Payment System (MIPS) final score.
Of those, 60
(51%) 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 2026-05-27.
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 195 clinicians affiliated with Dignity Health – Mercy Hospital Downtown.
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 2026-05-27.
A clinician may also practice at other facilities; "affiliated" means this hospital is on their CMS
profile, not that they exclusively work here.
Pricing & Costs
This hospital participates in price transparency under the federal
Hospital Price Transparency Rule. View 805 published procedures
— gross charges, cash prices, and per-payer negotiated rates where available.
Across this hospital's priced procedures:
vs. CA median+0%roughly matches the state median
vs. national median+5%runs 5% above the national median
Median percent difference across the 805 DRGs
where this hospital has a comparable published price and the comparison cohort
has enough hospitals to compute a stable median.
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.