Acute Care Hospital

Providence Mission Hospital

27700 Medical Center Rd, Mission Viejo, CA 92691
24/7 Emergency Services
4 out of 5 Stars Why 4 stars? Providence Mission Hospital's 4-star rating reflects above-average performance on Safety of Care.

CMS Overall Hospital Quality Star Rating · Providence Mission Hospital

How was Providence Mission Hospital's 4-star rating calculated?

The CMS Overall Hospital Quality Star Rating applies to acute care hospitals like Providence Mission 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 Providence Mission Hospital's rating
Domain Weight Measures reported Hospital performance vs. national
Mortality 22% 7 of 7 0 better 7 same 0 worse
Safety of Care 22% 18 of 19 3 better 15 same 0 worse
Readmissions 22% 6 of 6 1 better 5 same 0 worse
Timely & Effective Care 12% 16 of 22 5 better 6 same 5 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 ↗

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: 4.00 95% interval: 3.40 – 4.60 Sample size: 2,527 Reporting period: 07/01/2023 – 06/30/2024 CMS measure id: Hybrid_HWM Death rate for CABG surgery patients No Different Than the National Rate Hospital score: 2.00 95% interval: 0.80 – 4.50 Sample size: 54 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_CABG Death rate for COPD patients No Different Than the National Rate Hospital score: 10.20 95% interval: 6.70 – 14.90 Sample size: 79 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: 12.00 95% interval: 9.70 – 14.90 Sample size: 265 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: 10.30 95% interval: 8.20 – 13.00 Sample size: 417 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: 15.20 95% interval: 13.30 – 17.40 Sample size: 759 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: 13.00 95% interval: 10.50 – 16.00 Sample size: 333 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_STK

Safety of Care

Better than 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: 0.36 SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_6_SIR Catheter Associated Urinary Tract Infections (ICU + select Wards) Better than the National Benchmark Hospital score: 0.36 SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_2_SIR SSI - Colon Surgery Better than the National Benchmark Hospital score: 0.14 SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_3_SIR Abdominopelvic accidental puncture or laceration rate No Different Than the National Rate Hospital score: 1.29 95% interval: 0.40 – 2.18 Sample size: 1,814 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_15 Central Line Associated Bloodstream Infection (ICU + select Wards) No Different than National Benchmark Hospital score: 0.56 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: 0.22 95% interval: 0.03 – 0.41 Sample size: 8,625 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: 2.70 95% interval: 1.40 – 5.00 Sample size: 63 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: 0.29 95% interval: 0.11 – 0.47 Sample size: 8,755 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_08 MRSA Bacteremia No Different than National Benchmark Hospital score: 0.23 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: 2.26 95% interval: 0.90 – 3.61 Sample size: 2,222 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: 2.82 95% interval: 1.09 – 4.54 Sample size: 2,413 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: 2.24 95% interval: 0.77 – 3.71 Sample size: 932 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: 10.47 95% interval: 5.01 – 15.93 Sample size: 872 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_11 Postoperative sepsis rate No Different Than the National Rate Hospital score: 5.72 95% interval: 2.60 – 8.84 Sample size: 861 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_13 Pressure ulcer rate No Different Than the National Rate Hospital score: 0.21 95% interval: 0.00 – 0.74 Sample size: 7,316 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_03 CMS Medicare PSI 90: Patient safety and adverse events composite No Different Than the National Value Hospital score: 0.92 95% interval: 0.66 – 1.19 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_90 Death rate among surgical inpatients with serious treatable complications No Different Than the National Rate Hospital score: 163.98 95% interval: 122.65 – 205.30 Sample size: 165 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: 0.13 – 3.02 Sample size: 610 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_14 SSI - Abdominal Hysterectomy Not Available Hospital score: — SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_4_SIR

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.

Underlying measures: 30-day Readmission, Bypass Surgery Better than expected Hospital score: 0.87 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-CABG-HRRP 30-day Readmission, COPD As expected Hospital score: 1.02 Sample size: 80 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-COPD-HRRP 30-day Readmission, Heart Attack As expected Hospital score: 0.99 Sample size: 253 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-AMI-HRRP 30-day Readmission, Heart Failure As expected Hospital score: 1.00 Sample size: 458 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-HF-HRRP 30-day Readmission, Hip/Knee Replacement As expected Hospital score: 1.01 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-HIP-KNEE-HRRP 30-day Readmission, Pneumonia As expected Hospital score: 1.03 Sample size: 761 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-PN-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 Providence'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 77%
  • Communication with Doctors 75%
  • Hospital Cleanliness 71%
  • Hospital Quietness 48%
  • 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

Same as National Average

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

Underlying measures: Left before being seen Better than ~75% of hospitals Hospital score: 1.00 % National median: 1.00 % (lower is better) Sample size: 90,220 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: OP_22 Appropriate care for severe sepsis and septic shock Better than ~75% of hospitals Hospital score: 82.00 % National median: 64.00 % (higher is better) Sample size: 283 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: 87.00 % National median: 72.00 % (higher is better) Sample size: 84 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: 97.00 % National median: 89.00 % (higher is better) Sample size: 67 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: 90.00 % National median: 81.00 % (higher is better) Sample size: 284 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: SEV_SEP_3HR 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: 296 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: 94.00 % National median: 97.00 % (higher is better) Sample size: 69 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: OP_29 Head CT results Near the national median Hospital score: 65.00 % National median: 74.00 % (higher is better) Sample size: 20 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: OP_23 Intensive Care Unit Venous Thromboembolism Prophylaxis Near the national median Hospital score: 98.00 % National median: 97.00 % (higher is better) Sample size: 2,335 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: VTE_2 Severe Sepsis 6-Hour Bundle Near the national median Hospital score: 95.00 % National median: 94.00 % (higher is better) Sample size: 174 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: SEV_SEP_6HR Healthcare workers given influenza vaccination Near the national median Hospital score: 75.00 % National median: 79.00 % (higher is better) Sample size: 4,889 Reporting period: 10/01/2024 – 03/31/2025 CMS measure id: IMM_3 Discharged on Antithrombotic Therapy Worse than ~75% of hospitals Hospital score: 95.00 % National median: 98.00 % (higher is better) Sample size: 328 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: STK_02 Safe Use of Opioids - Concurrent Prescribing Worse than ~75% of hospitals Hospital score: 19.00 % National median: 15.00 % (lower is better) Sample size: 4,292 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 Worse than ~75% of hospitals Hospital score: 408.00 min National median: 248.00 min (lower is better) Sample size: 29 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: 228.00 min National median: 148.00 min (lower is better) Sample size: 370 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: 238.00 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

Psychiatric Unit Quality (IPFQR)

Providence Mission Hospital operates a Medicare-certified inpatient psychiatric unit that reports under the federal IPFQR program. The measures below 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.

Physical Restraint Use 0.4 hours per 1,000 patient-hours
National median: 0.1 hours Worse than 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) 99.0 %
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 94.0 %
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 92.0 %
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 78.0 %
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 33.0 %
National median: 77.0 % Worse than national median

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

30-Day Readmission Rate 23.0 %
National median: 19.1 % Worse than national median

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

Influenza Immunization 98.0 %
National median: 87.0 % Better than 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

Providence Mission Hospital has 617 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 Medicine 105
  • Family Practice 57
  • Physician Assistant 54
  • Anesthesiology 50
  • Diagnostic Radiology 29
  • Nurse Practitioner 28
  • Orthopedic Surgery 26
  • Cardiovascular Disease (Cardiology) 24

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
279 (45%)

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

Medicare quality scoring (MIPS)

195 of these clinicians have a published Merit-based Incentive Payment System (MIPS) final score. Of those, 73 (37%) 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 617 clinicians affiliated with Providence Mission 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.

Showing 30 of 617 clinicians (alphabetical)

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

Facility Information

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

Nearby Hospitals

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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