Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

CHRISTUS ST MICHAEL HEALTH SYSTEM

TX · Facility ID 450801 · FY2026

Total HAC Score

-0.2765

Percentile

33.6th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.2765

Hospital score -0.2765. 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 -1.014
  • CLABSIz 0.421
  • CAUTIz -0.439
  • SSIz -0.514
  • CDIz -0.266
  • MRSAz 0.152

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-1.0135-0.35480.31100.6658
CAUTI-0.4388-0.42310.19440.6175
MRSA0.1520-0.54470.06900.6137
CDI-0.2657-0.47590.13330.6092
CLABSI0.4215-0.58110.02660.6078
SSI-0.5143-0.43350.17120.6047

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): 45.7th

Score distributionThreshold 0.3792Hospital -0.2765

Hospital score -0.2765. Penalty threshold 0.3792. Distribution of 255 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 29.6th

Score distributionThreshold 0.3792Hospital -0.2765

Hospital score -0.2765. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.2765; 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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