Acute Care Hospital

PeaceHealth St. Joseph Medical Center

2901 Squalicum Parkway, Bellingham, WA 98225
24/7 Emergency Services
4 out of 5 Stars Why 4 stars? PeaceHealth St. Joseph Medical Center's 4-star rating reflects above-average performance on Safety of Care and Readmissions and below-average performance on Timely Care.

CMS Overall Hospital Quality Star Rating · PeaceHealth St. Joseph Medical Center

How was PeaceHealth St. Joseph Medical Center's 4-star rating calculated?

The CMS Overall Hospital Quality Star Rating applies to acute care hospitals like PeaceHealth St. Joseph Medical 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 PeaceHealth St. Joseph Medical Center's rating
Domain Weight Measures reported Hospital performance vs. national
Mortality 22% 7 of 7 1 better 6 same 0 worse
Safety of Care 22% 18 of 19 2 better 16 same 0 worse
Readmissions 22% 6 of 6 4 better 2 same 0 worse
Timely & Effective Care 12% 16 of 22 2 better 7 same 7 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: Death rate for pneumonia patients Better Than the National Rate Hospital score: 12.30 95% interval: 10.00 – 15.00 Sample size: 540 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_PN Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate No Different Than the National Rate Hospital score: 3.80 95% interval: 3.20 – 4.40 Sample size: 2,271 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: 2.40 95% interval: 1.10 – 5.00 Sample size: 115 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: 10.80 95% interval: 7.20 – 15.80 Sample size: 120 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: 12.30 95% interval: 9.90 – 15.10 Sample size: 364 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: 8.70 – 12.80 Sample size: 591 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_HF Death rate for stroke patients No Different Than the National Rate Hospital score: 12.30 95% interval: 9.60 – 15.50 Sample size: 275 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: 0.45 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: 0.20 SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_2_SIR Abdominopelvic accidental puncture or laceration rate No Different Than the National Rate Hospital score: 0.76 95% interval: 0.00 – 1.69 Sample size: 1,554 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: 0.49 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: 0.18 95% interval: 0.00 – 0.37 Sample size: 8,007 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: 3.30 95% interval: 1.80 – 5.60 Sample size: 126 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: 0.24 95% interval: 0.05 – 0.43 Sample size: 8,252 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_08 MRSA Bacteremia No Different than National Benchmark Hospital score: 0.24 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: 1.76 95% interval: 0.35 – 3.17 Sample size: 1,816 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: 3.44 95% interval: 1.54 – 5.35 Sample size: 2,014 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: 1.64 95% interval: 0.12 – 3.15 Sample size: 663 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: 6.02 95% interval: 0.22 – 11.82 Sample size: 673 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_11 Postoperative sepsis rate No Different Than the National Rate Hospital score: 3.31 95% interval: 0.00 – 6.76 Sample size: 665 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_13 Pressure ulcer rate No Different Than the National Rate Hospital score: 0.49 95% interval: 0.00 – 1.14 Sample size: 6,221 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: 0.77 95% interval: 0.47 – 1.06 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_90 SSI - Colon Surgery No Different than National Benchmark Hospital score: 0.43 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: 161.88 95% interval: 111.20 – 212.55 Sample size: 91 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: 1.54 95% interval: 0.11 – 2.98 Sample size: 360 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

Better than 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 Better than expected Hospital score: 0.94 Sample size: 131 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-COPD-HRRP 30-day Readmission, Heart Failure Better than expected Hospital score: 0.88 Sample size: 674 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-HF-HRRP 30-day Readmission, Hip/Knee Replacement Better than expected Hospital score: 0.84 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-HIP-KNEE-HRRP 30-day Readmission, Pneumonia Better than expected Hospital score: 0.92 Sample size: 564 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-PN-HRRP 30-day Readmission, Bypass Surgery As expected Hospital score: 1.00 Sample size: 114 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-CABG-HRRP 30-day Readmission, Heart Attack As expected Hospital score: 0.99 Sample size: 382 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-AMI-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 PeaceHealth'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 78%
  • Communication with Doctors 79%
  • Hospital Cleanliness 62%
  • Hospital Quietness 35%
  • Staff Responsiveness N/A
  • Discharge Information 87%
  • Overall Hospital Rating (9 or 10) 63%
  • Would Recommend Hospital 67%

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.

Underlying measures: Discharged on Antithrombotic Therapy Better than ~75% of hospitals Hospital score: 99.00 % National median: 98.00 % (higher is better) Sample size: 286 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: STK_02 Venous Thromboembolism Prophylaxis Better than ~75% of hospitals Hospital score: 96.00 % National median: 90.00 % (higher is better) Sample size: 8,259 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: VTE_1 Safe Use of Opioids - Concurrent Prescribing Near the national median Hospital score: 15.00 % National median: 15.00 % (lower is better) Sample size: 4,308 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: SAFE_USE_OF_OPIOIDS Head CT results Near the national median Hospital score: 64.00 % National median: 74.00 % (higher is better) Sample size: 33 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: OP_23 Appropriate care for severe sepsis and septic shock Near the national median Hospital score: 57.00 % National median: 64.00 % (higher is better) Sample size: 162 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: SEP_1 Septic Shock 6-Hour Bundle Near the national median Hospital score: 84.00 % National median: 89.00 % (higher is better) Sample size: 25 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: SEP_SH_6HR Severe Sepsis 3-Hour Bundle Near the national median Hospital score: 84.00 % National median: 81.00 % (higher is better) Sample size: 162 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: SEV_SEP_3HR Severe Sepsis 6-Hour Bundle Near the national median Hospital score: 92.00 % National median: 94.00 % (higher is better) Sample size: 106 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: 89.00 % National median: 79.00 % (higher is better) Sample size: 4,831 Reporting period: 10/01/2024 – 03/31/2025 CMS measure id: IMM_3 Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients Worse than ~75% of hospitals Hospital score: 85.00 % National median: 97.00 % (higher is better) Sample size: 39 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: OP_29 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: 386.00 min National median: 248.00 min (lower is better) Sample size: 24 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: 211.00 min National median: 148.00 min (lower is better) Sample size: 344 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: 214.00 min National median: 154.00 min (lower is better) Sample size: 376 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: OP_18a Intensive Care Unit Venous Thromboembolism Prophylaxis Worse than ~75% of hospitals Hospital score: 93.00 % National median: 97.00 % (higher is better) Sample size: 1,696 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: VTE_2 Left before being seen Worse than ~75% of hospitals Hospital score: 3.00 % National median: 1.00 % (lower is better) Sample size: 71,471 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: OP_22 Septic Shock 3-Hour Bundle Worse than ~75% of hospitals Hospital score: 53.00 % National median: 72.00 % (higher is better) Sample size: 62 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: SEP_SH_3HR

Psychiatric Unit Quality (IPFQR)

PeaceHealth St. Joseph Medical Center 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 0.1 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 1.3 hours per 1,000 patient-hours
National median: 0.0 hours Worse than 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) 91.0 %
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 51.0 %
National median: 74.0 % Worse than national median

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

Substance-Use Treatment at Discharge 64.0 %
National median: 77.0 % Worse than national median

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

Tobacco-Use Treatment at Discharge 40.0 %
National median: 64.0 % Worse than national median

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

Transition Record Completed 45.0 %
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.

Follow-up Within 7 Days 31.5 %
National median: 35.4 % Worse than 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 55.6 %
National median: 60.7 % Near national median

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

Medication Continuation 78.6 %
National median: 78.2 % Near national median

MedCont — % of discharged patients with continued antipsychotic / antidepressant medication post-discharge.

30-Day Readmission Rate 17.4 %
National median: 19.1 % Near national median

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

Influenza Immunization 67.0 %
National median: 87.0 % Worse 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

PeaceHealth St. Joseph Medical Center has 509 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

  • Family Practice 78
  • Nurse Practitioner 61
  • Physician Assistant 55
  • Anesthesiology 44
  • Internal Medicine 36
  • Emergency Medicine 29
  • Diagnostic Radiology 17
  • Orthopedic Surgery 15

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

Practice characteristics

Accept Medicare assignment
508 (100%)

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

Offer telehealth
170 (33%)

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, 62 (53%) 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 509 clinicians affiliated with PeaceHealth St. Joseph Medical 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 509 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 - Other
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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