Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

← All audits

Hospital audit

CHRISTUS GOOD SHEPHERD MEDICAL CENTER

TX · Facility ID 450032 · FY2026

Total HAC Score

-0.5663

Percentile

16.9th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.5663

Hospital score -0.5663. 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 -1.141
  • CLABSIz 0.011
  • CAUTIz -0.870
  • SSIz -0.713
  • CDIz -0.916
  • MRSAz 0.231

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-1.1407-0.62340.04230.6658
CAUTI-0.8703-0.6410-0.02360.6175
MRSA0.2314-0.8478-0.23400.6137
CDI-0.9162-0.6573-0.04810.6092
CLABSI0.0109-0.8026-0.19480.6078
SSI-0.7130-0.6902-0.08550.6047

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 TX (255 scored): 26.9th

Score distributionThreshold 0.3792Hospital -0.5663

Hospital score -0.5663. Penalty threshold 0.3792. Distribution of 255 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 10.8th

Score distributionThreshold 0.3792Hospital -0.5663

Hospital score -0.5663. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.5663; 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.

Scan a hospital system →