Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

PEACEHEALTH ST JOHN MEDICAL CENTER

WA · Facility ID 500041 · FY2026

Total HAC Score

-0.3300

Percentile

30.3th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.3300

Hospital score -0.3300. 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 -0.433
  • CLABSIz -0.868
  • CAUTIz -0.299
  • SSIz 1.618
  • CDIz -1.141
  • MRSAz -0.858

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-0.4331-0.50510.16070.6658
CAUTI-0.2990-0.50000.11750.6175
MRSA-0.8575-0.43000.18370.6137
CDI-1.1408-0.38360.22560.6092
CLABSI-0.8683-0.41970.18800.6078
SSI1.6184-0.8425-0.23780.6047

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 WA (46 scored): 25.0th

Score distributionThreshold 0.3792Hospital -0.3300

Hospital score -0.3300. Penalty threshold 0.3792. Distribution of 46 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 25.5th

Score distributionThreshold 0.3792Hospital -0.3300

Hospital score -0.3300. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.3300; 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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