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Baptist Health Brookwood Hospital
AI-generated illustrative exterior for Baptist Health Brookwood Hospital profile, not an official facility photograph
AI-generated illustrative exterior. Not an official photograph of Baptist Health Brookwood Hospital. AI Visuals Policy
Hospital Overall Rating:3 / 5
CMS Quality Score:48.13 / 100
partial

Baptist Health Brookwood Hospital

Last updated on July 2026
Acute Care Hospitals
AlabamaBirmingham
Birthing Friendly:
Emergency Service:

Baptist Health Brookwood Hospital, located at 2010 Brookwood Medical Center Drive, Birmingham, AL 35209. As a acute care hospitals with 24/7 emergency services. This facility meets CMS criteria for birthing-friendly designation. CMS Hospital Overall Rating: 3 out of 5.

NPI Number:1003422320
Ownership:Proprietary
Hospital Type:Acute Care Hospitals
Address:2010 Brookwood Medical Center Drive, Birmingham, AL 35209, USA
Phone:+1 205-877-1000
CMS Birthing Friendly Haritalar Get Directions
Baptist Health Brookwood Hospital Doctors
DIAGNOSTIC RADIOLOGY Doctors (22)
JOHNRICK BISHOP
JOHNRICK BISHOP
NPI: 1063040046
EDWARD VIA COL OF OSTEO MEDICINE-CAROLINAS CAMPUS
Graduation Year: 2020
CHRISTOPHER BITTLES
CHRISTOPHER BITTLES
NPI: 1104389436
UNIVERSITY OF TEXAS MEDICAL SCHOOL AT SAN ANTONIO
Graduation Year: 2019
JEFFREY BLACK
JEFFREY BLACK (MD)
NPI: 1336646629
UNIVERSITY OF ALABAMA SCHOOL OF MEDICINE
Graduation Year: 2018
BARRETT CARY
BARRETT CARY (MD)
NPI: 1497958581
UNIVERSITY OF ALABAMA SCHOOL OF MEDICINE
Graduation Year: 2007
CERTIFIED REGISTERED NURSE ANESTHETIST (CRNA) Doctors (20)
ELIZABETH BRANDT
ELIZABETH BRANDT (CNA)
NPI: 1073886669
Graduation Year: 2011
ELLE BRISCOE
ELLE BRISCOE
NPI: 1629512967
Graduation Year: 2016
MONICKA BROWN
MONICKA BROWN (CNA)
NPI: 1619551991
Graduation Year: 2021
KAREN BRYANT
KAREN BRYANT (CNA)
NPI: 1053394049
Graduation Year: 1985
NURSE PRACTITIONER Doctors (19)
LAUREN AULT
LAUREN AULT (NP)
NPI: 1518542695
Graduation Year: 2020
BRITTANY BERKOPEC
BRITTANY BERKOPEC
NPI: 1285192187
Graduation Year: 2020
JESSICA CALLAGHAN
JESSICA CALLAGHAN
NPI: 1275399909
Graduation Year: 2023
CALEB GRAY
CALEB GRAY
NPI: 1114402500
Graduation Year: 2018
INTERNAL MEDICINE Doctors (14)
KHALID AL-DUAIS
KHALID AL-DUAIS (MD)
NPI: 1396231866
Graduation Year: 2012
GREGORY AYERS
GREGORY AYERS (MD)
NPI: 1003870353
MERCER UNIVERSITY SCHOOL OF MEDICINE
Graduation Year: 2000
MARCUS BELL
MARCUS BELL (MD)
NPI: 1083934095
UNIVERSITY OF SOUTH ALABAMA COLLEGE OF MEDICINE
Graduation Year: 2010
ALISON DAGGETT
ALISON DAGGETT (MD)
NPI: 1548284193
UNIVERSITY OF SOUTH ALABAMA COLLEGE OF MEDICINE
Graduation Year: 1993
PHYSICIAN ASSISTANT Doctors (13)
RACHAEL ABROMS
RACHAEL ABROMS
NPI: 1093326613
Graduation Year: 2021
JOSHUA BAKER
JOSHUA BAKER
NPI: 1366076473
UNIVERSITY OF ALABAMA SCHOOL OF MEDICINE
Graduation Year: 2019
JESSICA BLACKWELL
JESSICA BLACKWELL
NPI: 1447716766
Graduation Year: 2018
NINA BROWN
NINA BROWN (PA)
NPI: 1417589730
Graduation Year: 2019
Baptist Health Brookwood Hospital Departments
ANESTHESIOLOGY
CARDIAC ELECTROPHYSIOLOGY
CARDIOVASCULAR DISEASE (CARDIOLOGY)
CERTIFIED REGISTERED NURSE ANESTHETIST (CRNA)
CRITICAL CARE (INTENSIVISTS)
DIAGNOSTIC RADIOLOGY
EMERGENCY MEDICINE
FAMILY PRACTICE
GASTROENTEROLOGY
GENERAL SURGERY
GYNECOLOGICAL ONCOLOGY
HEMATOLOGY/ONCOLOGY
INFECTIOUS DISEASE
INTERNAL MEDICINE
INTERVENTIONAL CARDIOLOGY
INTERVENTIONAL RADIOLOGY
MEDICAL ONCOLOGY
NEPHROLOGY
Healthcare-Associated Infections (HAI)
Reporting Period: 10/01/2024 – 09/30/2025
Want to understand this data? What is HAI & the SIR Score? →
SIR Overview — values below 1.0 indicate fewer infections than expected (green = better, red = worse). (ⓘ = See glossary)
CLABSI
Central Line Associated Bloodstream Infection (CLABSI)
No Different than National Benchmark
SIR 0.745 (0.237 – 1.798)
Observed 4
Eligible Cases 5
Days / Procedures 5,698
CAUTI
Catheter-Associated Urinary Tract Infections (CAUTI)
No Different than National Benchmark
SIR 1.076 (0.500 – 2.043)
Observed 8
Eligible Cases 7
Days / Procedures 7,802
SSI-Colon
Surgical Site Infection from Colon Surgery (SSI-Colon)
No Different than National Benchmark
SIR 0.629 (0.160 – 1.713)
Observed 3
Eligible Cases 4
Days / Procedures 179
SSI-Hyster.
Surgical Site Infection from Abdominal Hysterectomy (SSI-Hysterectomy)
No Different than National Benchmark
SIR 0.390 (0.099 – 1.060)
Observed 3
Eligible Cases 7
Days / Procedures 886
MRSA
MRSA Bacteremia
No Different than National Benchmark
SIR 0.417 (0.070 – 1.378)
Observed 2
Eligible Cases 4
Days / Procedures 60,845
C.diff
Clostridium Difficile (C.diff) Infections (CDI)
Better than the National Benchmark
SIR 0.511 (0.307 – 0.801)
Observed 17
Eligible Cases 33
Days / Procedures 58,636
Patient Experience Survey (HCAHPS)
Reporting Period: 10/01/2024 – 09/30/2025
988 completed surveys 14% response rate
Overall Rating
2/5
Want to understand this data? What is the HCAHPS Survey? →
Category Ratings Overview
Nurse Communication
2/5
Nurses "always" communicated well
Hospital
71%
AL Avg
80%
US Avg
80%
Nurses "sometimes" or "never" communicated well
Hospital
9%
AL Avg
5%
US Avg
4%
Nurses "usually" communicated well
Hospital
20%
AL Avg
15%
US Avg
16%
Doctor Communication
3/5
Doctors "always" communicated well
Hospital
78%
AL Avg
82%
US Avg
80%
Doctors "sometimes" or "never" communicated well
Hospital
6%
AL Avg
5%
US Avg
5%
Doctors "usually" communicated well
Hospital
16%
AL Avg
13%
US Avg
15%
Communication About Medicines
1/5
Staff "always" explained
Hospital
54%
AL Avg
63%
US Avg
62%
Staff "sometimes" or "never" explained
Hospital
28%
AL Avg
20%
US Avg
19%
Staff "usually" explained
Hospital
18%
AL Avg
17%
US Avg
19%
Discharge Information
2/5
Yes, staff "did" give patients this information
Hospital
82%
AL Avg
86%
US Avg
87%
No, staff "did not" give patients this information
Hospital
18%
AL Avg
14%
US Avg
13%
Cleanliness of Hospital
2/5
Room was "always" clean
Hospital
62%
AL Avg
71%
US Avg
74%
Room was "sometimes" or "never" clean
Hospital
15%
AL Avg
11%
US Avg
9%
Room was "usually" clean
Hospital
23%
AL Avg
18%
US Avg
17%
Quietness of Hospital
3/5
"Always" quiet at night
Hospital
54%
AL Avg
67%
US Avg
60%
"Sometimes" or "never" quiet at night
Hospital
12%
AL Avg
6%
US Avg
10%
"Usually" quiet at night
Hospital
34%
AL Avg
27%
US Avg
30%
Overall Hospital Rating
2/5
Patients who gave a rating of "9" or "10" (high)
Hospital
59%
AL Avg
71%
US Avg
72%
Patients who gave a rating of "7" or "8" (medium)
Hospital
23%
AL Avg
21%
US Avg
20%
Patients who gave a rating of "6" or lower (low)
Hospital
18%
AL Avg
8%
US Avg
8%
Recommend the Hospital
2/5
"YES", patients would definitely recommend the hospital
Hospital
57%
AL Avg
70%
US Avg
71%
"YES", patients would probably recommend the hospital
Hospital
29%
AL Avg
24%
US Avg
23%
"NO", patients would not recommend the hospital (they probably would not or definitely would not recommend it)
Hospital
14%
AL Avg
6%
US Avg
6%
Complications & Deaths
Reporting Period: 04/01/2023 – 03/31/2025
Want to understand this data? Complications & Deaths Guide →
30-Day Mortality Rates
Hover over a bar or Y-axis label to see the full definition.
MeasureScore 95% CI Cases vs. National
Death rate for heart attack patients MORT_30_AMI12.59.5 – 16.181 Average
Death rate for CABG surgery patients MORT_30_CABG31.4 – 5.932 Average
Death rate for COPD patients MORT_30_COPD7.35 – 10.729 Average
Death rate for heart failure patients MORT_30_HF11.89 – 15.1133 Average
Death rate for pneumonia patients MORT_30_PN17.613.9 – 21.4183 Average
Death rate for stroke patients MORT_30_STK12.810.2 – 15.9376 Average
Complications
Hover over a bar or Y-axis label to see the full definition.
MeasureScore 95% CI Cases vs. National
Rate of complications for hip/knee replacement patients COMP_HIP_KNEE3.32 – 5.348 Average
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality RateHybrid_HWM4.13.5 – 4.72195 Average
Patient Safety Indicators (PSI)
Hover over a bar or Y-axis label to see the full definition.
MeasureScore 95% CI Cases vs. National
Pressure ulcer ratePSI_030.470 – 1.252439 Average
Death rate among surgical inpatients with serious treatable complicationsPSI_04162.11111.69 – 212.5450 Average
Iatrogenic pneumothorax ratePSI_060.170 – 0.382947 Average
In-hospital fall-associated fracture ratePSI_080.240.03 – 0.443016 Average
Postoperative hemorrhage or hematoma ratePSI_092.150.59 – 3.7781 Average
Perioperative pulmonary embolism or deep vein thrombosis ratePSI_123.691.43 – 5.94771 Average
Postoperative wound dehiscence ratePSI_142.330.84 – 3.82215 Average
Abdominopelvic accidental puncture or laceration ratePSI_150.880 – 1.87611 Average
CMS Medicare PSI 90: Patient safety and adverse events composite PSI_900.950.54 – 1.35— Average
Timely & Effective Care
Reporting Period: 01/01/2024 – 12/31/2024
Want to understand this data? Timely & Effective Care Guide →
Colonoscopy care
MeasureScore
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients OP_2994
Electronic Clinical Quality Measure
MeasureScore
Hospital Harm - Severe Hyperglycemia HH_HYPER8
Hospital Harm - Severe Hypoglycemia HH_HYPO3
Safe Use of Opioids - Concurrent Prescribing SAFE_USE_OF_OPIOIDS10
Venous Thromboembolism ProphylaxisVTE_167
Emergency Department
MeasureScore
Emergency department volumeEDVmedium
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 OP_18a161
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 OP_18b158
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better OP_18c212
Left before being seen OP_222
Healthcare Personnel Vaccination
MeasureScore
Healthcare workers given influenza vaccination IMM_369
Sepsis Care
MeasureScore
Appropriate care for severe sepsis and septic shock SEP_148
Septic Shock 3-Hour BundleSEP_SH_3HR89
Septic Shock 6-Hour BundleSEP_SH_6HR100
Severe Sepsis 3-Hour BundleSEV_SEP_3HR59
Severe Sepsis 6-Hour BundleSEV_SEP_6HR82
Unplanned Hospital Visits
Reporting Period: 07/01/2022 – 06/30/2025
Want to understand this data? Hospital Readmissions (HRRP) Guide →
Excess Days in Acute Care (EDAC)
Hover over a bar or Y-axis label to see the full definition.
MeasureScore US Avg 95% CI Cases vs. National
Hospital return days for heart attack patients EDAC_30_AMI6 fewer9 avg11 more-25.4—-59.5 – 36.590 Average
Hospital return days for heart failure patients EDAC_30_HF12 fewer22 avg24 more18.2—-33.6 – 93.5137 Average
Hospital return days for pneumonia patients EDAC_30_PN8 fewer37 avg26 more-2.9—-38.2 – 48.2171 Average
Unplanned Readmissions
Hover over a bar or Y-axis label to see the full definition.
MeasureScore US Avg 95% CI Cases vs. National
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate READM_30_AMI0 better31 avg0 worse14.213.612.1 – 16.8— Average
Rate of readmission for CABG READM_30_CABG0 better18 avg1 worse10.810.68.2 – 14.4— Average
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients READM_30_COPD0 better49 avg1 worse19.718.216.8 – 22.9— Average
Heart failure (HF) 30-Day Readmission Rate READM_30_HF0 better58 avg0 worse22.419.719.8 – 25.4— Average
Rate of readmission after hip/knee replacement READM_30_HIP_KNEE0 better32 avg0 worse5.24.83.6 – 7.3— Average
Pneumonia (PN) 30-Day Readmission Rate READM_30_PN0 better71 avg0 worse17.71615.4 – 20.3— Average
Outpatient Unplanned Returns
Hover over a bar or Y-axis label to see the full definition.
MeasureScore US Avg 95% CI Cases vs. National
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)OP_320 better65 avg0 worse13.2139.8 – 17.7— Average
Ratio of unplanned hospital visits after hospital outpatient surgeryOP_361 better43 avg0 worse0.9—0.7 – 1.2— Average
Outpatient Imaging Efficiency
07/01/2024 — 06/30/2025
Lower percentages indicate fewer unnecessary or redundant imaging tests — this generally means better, more efficient care.
Want to understand this data? Medical Imaging Efficiency Guide →
Score Overview (% of patients)
OP-10
4.6%
Abdomen CT Use of Contrast Material
Outpatient CT scans of the abdomen that were "combination" (double) scans.
At or below national benchmark
Footnote codes: 7. Refer to CMS methodology for details.
Hospital Readmissions Reduction Program (HRRP)
07/01/2021 — 06/30/2024
The Excess Readmission Ratio (ERR) compares a hospital's actual 30-day readmission rate to its expected rate for similar patients. ERR < 1.0 = fewer readmissions than expected (better). ERR > 1.0 = more than expected (CMS penalty may apply).
Want to understand this data? Hospital Readmissions (HRRP) Guide →
Excess Readmission Ratio by Condition — reference line at 1.0 (national expectation)
4
Better than expected
1
About average
0
Above expected
Condition
ERR
Predicted %
Expected %
Discharges
Status
Heart Attack (AMI)
READM-30-AMI-HRRP
0.9717
13.24%
13.62%
—
Better
Bypass Surgery (CABG)
READM-30-CABG-HRRP
0.9206
11.20%
12.17%
—
Better
COPD
READM-30-COPD-HRRP
0.9683
15.64%
16.15%
—
Better
Heart Failure
READM-30-HF-HRRP
1.0023
19.45%
19.40%
138
Average
Pneumonia
READM-30-PN-HRRP
0.9254
14.00%
15.13%
172
Better
Footnote codes: 1. Refer to CMS HRRP methodology for details.
Hospital-Acquired Condition Reduction Program (HAC)
Fiscal Year 2026
Want to understand this data? Hospital-Acquired Conditions (HAC) Guide →
No Medicare Payment Reduction
This hospital did not receive a CMS payment penalty for hospital-acquired conditions in this fiscal year.
Total HAC Score
-0.2243
Negative = fewer HACs than expected (better)
−20+2
PSI-90 Composite
N/A
Patient Safety Indicator — < 1.0 = fewer complications than expected
Infection Type
SIR
W Z-Score
Status
The HAC Reduction Program penalizes hospitals in the worst-performing quartile with a 1% reduction in all Medicare payments for the fiscal year. The Total HAC Score combines PSI-90 (patient safety) and HAI (infection) data. Lower scores = better performance.
Hospital Value-Based Purchasing Program (VBP)
Fiscal Year 2026
Want to understand this data? Value-Based Purchasing (VBP) Guide →
Total Performance Score
16.17 / 100
Below Average
0255075100
Higher score = better value-based performance
Weighted Domain Scores — each domain contributes up to 25 points
Domain
Unweighted Score
Weighted Score
Contribution
The Hospital Value-Based Purchasing (VBP) Program adjusts Medicare payments based on a hospital's performance across four domains: Clinical Outcomes, Patient & Community Engagement, Safety, and Efficiency & Cost Reduction. Hospitals with higher scores receive payment increases; lower scores result in reductions.
Data Provenance & Trust

This hospital profile and associated quality metrics are compiled directly from the official U.S. Centers for Medicare & Medicaid Services (CMS) Provider Data infrastructure. The information is automatically synchronized to reflect the most current public datasets available.

Primary DataSource: CMS.gov Provider Data Catalog
Medical Disclaimer: Hospital Data Center is a health data aggregator, not a healthcare provider. All scores, including the composite Quality Score, are algorithmic transformations of CMS datasets intended for research and comparison. They do not constitute medical advice.