Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

NORTHWESTERN MEDICINE DELNOR COMMUNITY HOSPITAL

IL · Facility ID 140211 · FY2026

Total HAC Score

-0.5048

Percentile

20.3th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.5048

Hospital score -0.5048. Penalty threshold 0.3792. Distribution of 2929 scored hospitals.

Data completeness

Reported on 6 of 6. Missing measures show N/A with the CMS footnote; footnote 18 values are imputed worst-case, not measured performance.

  • PSI-90z -1.483
  • CLABSIz -1.012
  • CAUTIz 0.880
  • SSIz -0.499
  • CDIz -0.029
  • MRSAz -0.885

Fragility

Each reported measure moves the score by 0.1667 points.

Score swing if each reported measure were at its Z floor versus Z cap, holding other measures fixed
MeasureCurrent ZScore @ floorScore @ capAbs swing
PSI-90controls fate-1.4834-0.50480.16100.6657
CAUTI0.8798-0.8712-0.25370.6175
MRSA-0.8846-0.60020.01350.6137
CDI-0.0295-0.7436-0.13430.6092
CLABSI-1.0121-0.57050.03730.6078
SSI-0.4989-0.6644-0.05970.6047

Swing is a mechanics illustration: replace one reported Z with that measure’s observed floor or cap while holding others fixed. Ranked by absolute swing.

Peer context

Percentile within IL (112 scored): 21.0th

Score distributionThreshold 0.3792Hospital -0.5048

Hospital score -0.5048. Penalty threshold 0.3792. Distribution of 112 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 14.7th

Score distributionThreshold 0.3792Hospital -0.5048

Hospital score -0.5048. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.5048; threshold 0.3792).

Reported on 6 of 6 measures; each reported measure moves the equal-weighted score by 0.1667 points.

Describes scoring mechanics only. Not medical or legal advice. Any “would / would not” language is an illustration against the published threshold, not a CMS prediction.

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