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North Mississippi Health Services - South Marion
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Hospital Overall Rating:4 / 5
CMS Quality Score:50.45 / 100
partial

North Mississippi Health Services - South Marion

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

North Mississippi Health Services - South Marion, located at 1530 U S Highway 43, Winfield, AL 35594. As a acute care hospitals with 24/7 emergency services. CMS Hospital Overall Rating: 4 out of 5.

Ownership:Proprietary
Hospital Type:Acute Care Hospitals
Address:1530 U S Highway 43, Winfield, AL 35594, USA
Phone:+1 205-487-7000
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Patient Experience Survey (HCAHPS)
Reporting Period: 10/01/2024 – 09/30/2025
84 completed surveys 18% response rate
Want to understand this data? What is the HCAHPS Survey? →
Nurse Communication
Nurses "always" communicated well
Hospital
71%
AL Avg
80%
US Avg
80%
Nurses "sometimes" or "never" communicated well
Hospital
6%
AL Avg
5%
US Avg
4%
Nurses "usually" communicated well
Hospital
23%
AL Avg
15%
US Avg
16%
Doctor Communication
Doctors "always" communicated well
Hospital
82%
AL Avg
82%
US Avg
80%
Doctors "sometimes" or "never" communicated well
Hospital
3%
AL Avg
5%
US Avg
5%
Doctors "usually" communicated well
Hospital
15%
AL Avg
13%
US Avg
15%
Communication About Medicines
Staff "always" explained
Hospital
54%
AL Avg
63%
US Avg
62%
Staff "sometimes" or "never" explained
Hospital
20%
AL Avg
20%
US Avg
19%
Staff "usually" explained
Hospital
26%
AL Avg
17%
US Avg
19%
Discharge Information
Yes, staff "did" give patients this information
Hospital
92%
AL Avg
86%
US Avg
87%
No, staff "did not" give patients this information
Hospital
8%
AL Avg
14%
US Avg
13%
Cleanliness of Hospital
Room was "always" clean
Hospital
73%
AL Avg
71%
US Avg
74%
Room was "sometimes" or "never" clean
Hospital
7%
AL Avg
11%
US Avg
9%
Room was "usually" clean
Hospital
20%
AL Avg
18%
US Avg
17%
Quietness of Hospital
"Always" quiet at night
Hospital
72%
AL Avg
67%
US Avg
60%
"Sometimes" or "never" quiet at night
Hospital
0%
AL Avg
6%
US Avg
10%
"Usually" quiet at night
Hospital
28%
AL Avg
27%
US Avg
30%
Overall Hospital Rating
Patients who gave a rating of "9" or "10" (high)
Hospital
67%
AL Avg
71%
US Avg
72%
Patients who gave a rating of "7" or "8" (medium)
Hospital
25%
AL Avg
21%
US Avg
20%
Patients who gave a rating of "6" or lower (low)
Hospital
8%
AL Avg
8%
US Avg
8%
Recommend the Hospital
"YES", patients would definitely recommend the hospital
Hospital
72%
AL Avg
70%
US Avg
71%
"YES", patients would probably recommend the hospital
Hospital
17%
AL Avg
24%
US Avg
23%
"NO", patients would not recommend the hospital (they probably would not or definitely would not recommend it)
Hospital
11%
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 COPD patients MORT_30_COPD9.16.2 – 13.457 Average
Death rate for pneumonia patients MORT_30_PN13.810.8 – 17.374 Average
Complications
Hover over a bar or Y-axis label to see the full definition.
MeasureScore 95% CI Cases vs. National
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality RateHybrid_HWM54 – 6.1207 Worse
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_030.530 – 1.77489 Average
Iatrogenic pneumothorax ratePSI_060.210 – 0.44575 Average
In-hospital fall-associated fracture ratePSI_080.270.05 – 0.48606 Average
Postoperative hemorrhage or hematoma ratePSI_092.320.59 – 4.0526 Average
Perioperative pulmonary embolism or deep vein thrombosis ratePSI_123.480.84 – 6.1126 Average
Abdominopelvic accidental puncture or laceration ratePSI_151.050 – 2.1431 Average
CMS Medicare PSI 90: Patient safety and adverse events composite PSI_900.960.47 – 1.46— 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_2998
Electronic Clinical Quality Measure
MeasureScore
Hospital Harm - Severe Hyperglycemia HH_HYPER12
Hospital Harm - Severe Hypoglycemia HH_HYPO2
Safe Use of Opioids - Concurrent Prescribing SAFE_USE_OF_OPIOIDS17
Venous Thromboembolism ProphylaxisVTE_195
Emergency Department
MeasureScore
Emergency department volumeEDVlow
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_18a144
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_18b130
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_18c193
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better OP_18d430
Left before being seen OP_224
Healthcare Personnel Vaccination
MeasureScore
Healthcare workers given influenza vaccination IMM_351
Sepsis Care
MeasureScore
Appropriate care for severe sepsis and septic shock SEP_165
Severe Sepsis 3-Hour BundleSEV_SEP_3HR82
Severe Sepsis 6-Hour BundleSEV_SEP_6HR97
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 pneumonia patients EDAC_30_PN8 fewer37 avg26 more-57—-74.2 – -30.269 Better
Unplanned Readmissions
Hover over a bar or Y-axis label to see the full definition.
MeasureScore US Avg 95% CI Cases vs. National
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients READM_30_COPD0 better49 avg1 worse19.218.216.5 – 22.5— Average
Heart failure (HF) 30-Day Readmission Rate READM_30_HF0 better58 avg0 worse21.119.718.6 – 23.8— Average
Pneumonia (PN) 30-Day Readmission Rate READM_30_PN0 better71 avg0 worse15.71613.4 – 18.4— 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 worse12.7139.5 – 17.1— 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
8.8%
Abdomen CT Use of Contrast Material
Outpatient CT scans of the abdomen that were "combination" (double) scans.
Above national benchmark
OP-39
3.6%
Breast Cancer Screening Recall Rates
Percentage of screening mammograms that result in a recommendation for additional imaging.
At or below national benchmark
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)
2
Better than expected
1
About average
0
Above expected
Condition
ERR
Predicted %
Expected %
Discharges
Status
COPD
READM-30-COPD-HRRP
0.9161
17.96%
19.60%
—
Better
Heart Failure
READM-30-HF-HRRP
1.0125
19.71%
19.47%
—
Average
Pneumonia
READM-30-PN-HRRP
0.9155
13.62%
14.87%
—
Better
Footnote codes: 1, 5. 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 →
1% Medicare Payment Reduction Applied
CMS assessed a 1% reduction in Medicare payments because this hospital ranked in the worst-performing quartile for hospital-acquired conditions.
Total HAC Score
0.5965
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.
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.