We analyze the performance of 330 hospitals using a directional distance approach. We use mortality as bad output treating its weak vs. strong disposability as a 'quality of care issue'. We identify congested hospitals, derive their inefficiency scores and show them to be negatively related to patient satisfaction. We separate congested hospitals into two: (i) efficient ones requiring uniform sacrifice of good outputs and/or extra inputs to reduce mortality, and (ii) inefficient hospitals that do not. The latter free up some inputs but require extra amounts of others and/or produce more of some outputs but less of others to reduce mortality. The first group operates at 'capacity', the second displays 'negative marginal productivity'. Patient dissatisfaction is higher in the latter group, whereas mortality reduction relates positively to patient satisfaction in 'capacity constrained' hospitals. The efficient group is more likely to be located in emigrating, the inefficient one in immigrating regions.