BAYLOR SCOTT & WHITE HEART & VASCULAR HOSPITAL - DALLAS
621 NORTH HALL STREET, DALLAS, TX, 75226 · (214) 820-0600
CMS facility ID 450851
How this hospital compares, by group
Counts published by CMS: how many of its measures were better, no different, or worse than the national average.
| Group | Better | No different | Worse | Measures reported |
|---|---|---|---|---|
| Mortality | 0 | 3 | 0 | 3 |
| Safety | 0 | 2 | 0 | 2 |
| Readmission | 0 | 2 | 2 | 4 |
"Compared to National" labels are published by CMS itself. This site displays them as issued and does not derive or re-rank them.
Healthcare-associated infections
Infections patients acquired while in hospital. 36 measures.
| Measure | Compared to national | Score | 95% interval | Cases | Period |
|---|---|---|---|---|---|
| Catheter Associated Urinary Tract Infections (ICU + select Wards) | — | Not reported | — | — | 2024-10-01 → 2025-09-30 |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit | — | Not reported | — | — | 2024-10-01 → 2025-09-30 |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days | — | Not reported | — | — | 2024-10-01 → 2025-09-30 |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases | — | Not reported | — | — | 2024-10-01 → 2025-09-30 |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases | — | Not reported | — | — | 2024-10-01 → 2025-09-30 |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit | — | Not reported | — | — | 2024-10-01 → 2025-09-30 |
| Central Line Associated Bloodstream Infection (ICU + select Wards) | — | Not reported | — | — | 2024-10-01 → 2025-09-30 |
| Central Line Associated Bloodstream Infection (ICU + select Wards): Lower Confidence Limit | — | Not reported | — | — | 2024-10-01 → 2025-09-30 |
| Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases | — | Not reported | — | — | 2024-10-01 → 2025-09-30 |
| Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases | — | Not reported | — | — | 2024-10-01 → 2025-09-30 |
| Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit | — | Not reported | — | — | 2024-10-01 → 2025-09-30 |
| Central Line Associated Bloodstream Infection: Number of Device Days | — | Not reported | — | — | 2024-10-01 → 2025-09-30 |
| Clostridium Difficile (C.Diff) | No different from national | 0 | — | — | 2024-10-01 → 2025-09-30 |
| Clostridium Difficile (C.Diff): Lower Confidence Limit | No different from national | Not reported | — | — | 2024-10-01 → 2025-09-30 |
| Clostridium Difficile (C.Diff): Observed Cases | No different from national | 0 | — | — | 2024-10-01 → 2025-09-30 |
| Clostridium Difficile (C.Diff): Patient Days | No different from national | 13475 | — | — | 2024-10-01 → 2025-09-30 |
| Clostridium Difficile (C.Diff): Predicted Cases | No different from national | 2.608 | — | — | 2024-10-01 → 2025-09-30 |
| Clostridium Difficile (C.Diff): Upper Confidence Limit | No different from national | 1.149 | — | — | 2024-10-01 → 2025-09-30 |
| MRSA Bacteremia | — | Not reported | — | — | 2024-10-01 → 2025-09-30 |
| MRSA Bacteremia: Lower Confidence Limit | — | Not reported | — | — | 2024-10-01 → 2025-09-30 |
| MRSA Bacteremia: Observed Cases | — | 0 | — | — | 2024-10-01 → 2025-09-30 |
| MRSA Bacteremia: Patient Days | — | 13475 | — | — | 2024-10-01 → 2025-09-30 |
| MRSA Bacteremia: Predicted Cases | — | 0.376 | — | — | 2024-10-01 → 2025-09-30 |
| MRSA Bacteremia: Upper Confidence Limit | — | Not reported | — | — | 2024-10-01 → 2025-09-30 |
| SSI - Abdominal Hysterectomy | — | Not reported | — | — | 2024-10-01 → 2025-09-30 |
| SSI - Abdominal Hysterectomy: Lower Confidence Limit | — | Not reported | — | — | 2024-10-01 → 2025-09-30 |
| SSI - Abdominal Hysterectomy: Number of Procedures | — | Not reported | — | — | 2024-10-01 → 2025-09-30 |
| SSI - Abdominal Hysterectomy: Observed Cases | — | Not reported | — | — | 2024-10-01 → 2025-09-30 |
| SSI - Abdominal Hysterectomy: Predicted Cases | — | Not reported | — | — | 2024-10-01 → 2025-09-30 |
| SSI - Abdominal Hysterectomy: Upper Confidence Limit | — | Not reported | — | — | 2024-10-01 → 2025-09-30 |
| SSI - Colon Surgery | — | Not reported | — | — | 2024-10-01 → 2025-09-30 |
| SSI - Colon Surgery: Lower Confidence Limit | — | Not reported | — | — | 2024-10-01 → 2025-09-30 |
| SSI - Colon Surgery: Number of Procedures | — | Not reported | — | — | 2024-10-01 → 2025-09-30 |
| SSI - Colon Surgery: Observed Cases | — | Not reported | — | — | 2024-10-01 → 2025-09-30 |
| SSI - Colon Surgery: Predicted Cases | — | Not reported | — | — | 2024-10-01 → 2025-09-30 |
| SSI - Colon Surgery: Upper Confidence Limit | — | Not reported | — | — | 2024-10-01 → 2025-09-30 |
Complications and deaths
Rates of death and serious complications for common conditions, compared with the national average. 20 measures.
| Measure | Compared to national | Score | 95% interval | Cases | Period |
|---|---|---|---|---|---|
| Abdominopelvic accidental puncture or laceration rate | No different from national | 1.29 | 0.22 – 2.36 | 167 | 2022-07-01 → 2024-06-30 |
| CMS Medicare PSI 90: Patient safety and adverse events composite | No different from national | 0.83 | 0.43 – 1.23 | — | 2022-07-01 → 2024-06-30 |
| Death rate among surgical inpatients with serious treatable complications | Number of Cases Too Small | Not reported | — | — | 2022-07-01 → 2024-06-30 |
| Death rate for CABG surgery patients | — | Not reported | — | — | 2022-07-01 → 2025-06-30 |
| Death rate for COPD patients | Number of Cases Too Small | Not reported | — | — | 2022-07-01 → 2025-06-30 |
| Death rate for heart attack patients | No different from national | 10.2 | 7.3 – 13.8 | 114 | 2022-07-01 → 2025-06-30 |
| Death rate for heart failure patients | No different from national | 9.3 | 6.2 – 13.8 | 153 | 2022-07-01 → 2025-06-30 |
| Death rate for pneumonia patients | Number of Cases Too Small | Not reported | — | — | 2022-07-01 → 2025-06-30 |
| Death rate for stroke patients | Number of Cases Too Small | Not reported | — | — | 2023-07-01 → 2025-06-30 |
| Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate | No different from national | 3.7 | 3.1 – 5.3 | 989 | 2024-07-01 → 2025-06-30 |
| Iatrogenic pneumothorax rate | No different from national | 0.26 | 0.05 – 0.46 | 1,860 | 2022-07-01 → 2024-06-30 |
| In-hospital fall-associated fracture rate | No different from national | 0.25 | 0.04 – 0.47 | 1,960 | 2022-07-01 → 2024-06-30 |
| Perioperative pulmonary embolism or deep vein thrombosis rate | No different from national | 2.84 | 0.46 – 5.22 | 944 | 2022-07-01 → 2024-06-30 |
| Postoperative acute kidney injury requiring dialysis rate | No different from national | 1.35 | 0 – 2.91 | 460 | 2022-07-01 → 2024-06-30 |
| Postoperative hemorrhage or hematoma rate | No different from national | 2.17 | 0.69 – 3.64 | 953 | 2022-07-01 → 2024-06-30 |
| Postoperative respiratory failure rate | No different from national | 8.46 | 1.58 – 15.34 | 528 | 2022-07-01 → 2024-06-30 |
| Postoperative sepsis rate | No different from national | 4.35 | 0.39 – 8.31 | 502 | 2022-07-01 → 2024-06-30 |
| Postoperative wound dehiscence rate | No different from national | 1.74 | 0.22 – 3.26 | 35 | 2022-07-01 → 2024-06-30 |
| Pressure ulcer rate | No different from national | 0.36 | 0 – 1.39 | 930 | 2022-07-01 → 2024-06-30 |
| Rate of complications for hip/knee replacement patients | — | Not reported | — | — | 2023-04-01 → 2025-03-31 |
Medicare spending per beneficiary
What Medicare paid per patient, relative to the national average. This is a Medicare figure — not what a patient pays. 1 measures.
| Measure | Compared to national | Score | 95% interval | Cases | Period |
|---|---|---|---|---|---|
| Medicare hospital spending per patient (Medicare Spending per Beneficiary) | — | 0.97 | — | — | 2024-01-01 → 2024-12-31 |
Timely and effective care
How quickly and reliably the hospital delivered recommended care. 30 measures.
| Measure | Compared to national | Score | 95% interval | Cases | Period |
|---|---|---|---|---|---|
| Anticoagulation Therapy for Atrial Fibrillation/FlutterElectronic Clinical Quality Measure | — | Not reported | — | — | 2024-01-01 → 2024-12-31 |
| Antithrombotic Therapy by End of Hospital Day 2Electronic Clinical Quality Measure | — | Not reported | — | — | 2024-01-01 → 2024-12-31 |
| Appropriate care for severe sepsis and septic shockSepsis Care | — | Not reported | — | — | 2024-10-01 → 2025-09-30 |
| 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 betterEmergency Department | — | Not reported | — | — | 2024-10-01 → 2025-09-30 |
| Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is betterEmergency Department | — | Not reported | — | — | 2024-10-01 → 2025-09-30 |
| 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 betterEmergency Department | — | Not reported | — | — | 2024-10-01 → 2025-09-30 |
| Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is betterEmergency Department | — | Not reported | — | — | 2024-10-01 → 2025-09-30 |
| Discharged on Antithrombotic TherapyElectronic Clinical Quality Measure | — | Not reported | — | — | 2024-01-01 → 2024-12-31 |
| Emergency department volumeEmergency Department | — | Not reported | — | — | 2024-01-01 → 2024-12-31 |
| Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patientsColonoscopy care | — | Not reported | — | — | 2024-01-01 → 2024-12-31 |
| Global Malnutrition Composite ScoreElectronic Clinical Quality Measure | — | Not reported | — | — | 2024-01-01 → 2024-12-31 |
| Global Malnutrition Composite Score: Malnutrition Diagnosis DocumentedElectronic Clinical Quality Measure | — | Not reported | — | — | 2024-01-01 → 2024-12-31 |
| Global Malnutrition Composite Score: Malnutrition Risk ScreeningElectronic Clinical Quality Measure | — | Not reported | — | — | 2024-01-01 → 2024-12-31 |
| Global Malnutrition Composite Score: Nutrition AssessmentElectronic Clinical Quality Measure | — | Not reported | — | — | 2024-01-01 → 2024-12-31 |
| Global Malnutrition Composite Score: Nutritional Care PlanElectronic Clinical Quality Measure | — | Not reported | — | — | 2024-01-01 → 2024-12-31 |
| Head CT resultsEmergency Department | — | Not reported | — | — | 2024-10-01 → 2025-09-30 |
| Healthcare workers given influenza vaccinationHealthcare Personnel Vaccination | — | 95 | — | 2,540 | 2024-10-01 → 2025-03-31 |
| Hospital Harm - Opioid Related Adverse EventsElectronic Clinical Quality Measure | — | Not reported | — | — | 2024-01-01 → 2024-12-31 |
| Hospital Harm - Severe HyperglycemiaElectronic Clinical Quality Measure | — | Not reported | — | — | 2024-01-01 → 2024-12-31 |
| Hospital Harm - Severe HypoglycemiaElectronic Clinical Quality Measure | — | Not reported | — | — | 2024-01-01 → 2024-12-31 |
| Improvement in Patient's Visual Function within 90 Days Following Cataract SurgeryCataract surgery outcome | — | Not reported | — | — | 2024-01-01 → 2024-12-31 |
| Intensive Care Unit Venous Thromboembolism ProphylaxisElectronic Clinical Quality Measure | — | 89 | — | 1,440 | 2024-01-01 → 2024-12-31 |
| Left before being seenEmergency Department | — | Not reported | — | — | 2024-01-01 → 2024-12-31 |
| ST-Segment Elevation Myocardial Infarction (STEMI)Electronic Clinical Quality Measure | — | Not reported | — | — | 2024-01-01 → 2024-12-31 |
| Safe Use of Opioids - Concurrent PrescribingElectronic Clinical Quality Measure | — | 15 | — | 1,250 | 2024-01-01 → 2024-12-31 |
| Septic Shock 3-Hour BundleSepsis Care | — | Not reported | — | — | 2024-10-01 → 2025-09-30 |
| Septic Shock 6-Hour BundleSepsis Care | — | Not reported | — | — | 2024-10-01 → 2025-09-30 |
| Severe Sepsis 3-Hour BundleSepsis Care | — | Not reported | — | — | 2024-10-01 → 2025-09-30 |
| Severe Sepsis 6-Hour BundleSepsis Care | — | Not reported | — | — | 2024-10-01 → 2025-09-30 |
| Venous Thromboembolism ProphylaxisElectronic Clinical Quality Measure | — | 85 | — | 3,811 | 2024-01-01 → 2024-12-31 |
Unplanned hospital visits
How often patients came back to hospital unexpectedly after discharge. 14 measures.
| Measure | Compared to national | Score | 95% interval | Cases | Period |
|---|---|---|---|---|---|
| Acute Myocardial Infarction (AMI) 30-Day Readmission Rate | No different from national | 15.4 | 12.8 – 18.3 | 191 | 2023-07-01 → 2025-06-30 |
| Heart failure (HF) 30-Day Readmission Rate | No different from national | 21.7 | 18.7 – 25.1 | 240 | 2023-07-01 → 2025-06-30 |
| Hospital return days for heart attack patients | Average Days per 100 Discharges | 35.5 | -9.8 – 102.5 | 138 | 2022-07-01 → 2025-06-30 |
| Hospital return days for heart failure patients | Average Days per 100 Discharges | 7.9 | -30 – 60 | 191 | 2022-07-01 → 2025-06-30 |
| Hospital return days for pneumonia patients | Number of Cases Too Small | Not reported | — | — | 2022-07-01 → 2025-06-30 |
| Hybrid Hospital-Wide All-Cause Readmission Measure (HWR) | — | Not reported | — | — | 2024-07-01 → 2025-06-30 |
| Pneumonia (PN) 30-Day Readmission Rate | Number of Cases Too Small | Not reported | — | — | 2023-07-01 → 2025-06-30 |
| Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy | Number of Cases Too Small | Not reported | — | — | 2024-01-01 → 2024-12-31 |
| Rate of inpatient admissions for patients receiving outpatient chemotherapy | Number of Cases Too Small | Not reported | — | — | 2024-01-01 → 2024-12-31 |
| Rate of readmission after hip/knee replacement | — | Not reported | — | — | 2023-07-01 → 2025-06-30 |
| Rate of readmission for CABG | — | Not reported | — | — | 2023-07-01 → 2025-06-30 |
| Rate of readmission for chronic obstructive pulmonary disease (COPD) patients | — | Not reported | — | — | 2023-07-01 → 2025-06-30 |
| Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies) | Number of Cases Too Small | Not reported | — | — | 2022-01-01 → 2024-12-31 |
| Ratio of unplanned hospital visits after hospital outpatient surgery | No different from national | 1 | 0.7 – 1.3 | 326 | 2024-01-01 → 2024-12-31 |
Score units differ between measures (rates, ratios, and Medicare dollars per beneficiary). Each measure is shown with its own name and reporting period; do not compare scores across measures.
Patient experience (HCAHPS)
Survey responses from patients, as published by CMS. Star ratings are 1–5; a blank means CMS withheld it.
Patients who reported that their room and bathroom were "Always" clean
Not rated| Room was "always" clean | 83% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that their room and bathroom were "Sometimes" or "Never" clean
Not rated| Room was "sometimes" or "never" clean | 4% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that their room and bathroom were "Usually" clean
Not rated| Room was "usually" clean | 13% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Cleanliness - linear mean score
Not ratedNo answer breakdown reported.
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Cleanliness - star rating
5 / 5 — HighestNo answer breakdown reported.
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that their nurses "Always" communicated well
Not rated| Nurses "always" communicated well | 87% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Nurse communication - linear mean score
Not ratedNo answer breakdown reported.
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that their nurses "Sometimes" or "Never" communicated well
Not rated| Nurses "sometimes" or "never" communicated well | 2% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Nurse communication - star rating
5 / 5 — HighestNo answer breakdown reported.
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that their nurses "Usually" communicated well
Not rated| Nurses "usually" communicated well | 11% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that their doctors "Always" communicated well
Not rated| Doctors "always" communicated well | 84% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Doctor communication - linear mean score
Not ratedNo answer breakdown reported.
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that their doctors "Sometimes" or "Never" communicated well
Not rated| Doctors "sometimes" or "never" communicated well | 4% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Doctor communication - star rating
4 / 5 — Rating 4 of 5No answer breakdown reported.
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that their doctors "Usually" communicated well
Not rated| Doctors "usually" communicated well | 12% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that staff "Always" explained about medicines before giving it to them
Not rated| Staff "always" explained | 71% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Communication about medicines - linear mean score
Not ratedNo answer breakdown reported.
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that staff "Sometimes" or "Never" explained about medicines before giving it to them
Not rated| Staff "sometimes" or "never" explained | 15% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Communication about medicines - star rating
4 / 5 — Rating 4 of 5No answer breakdown reported.
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that staff "Usually" explained about medicines before giving it to them
Not rated| Staff "usually" explained | 14% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Discharge information - linear mean score
Not ratedNo answer breakdown reported.
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that NO, they were not given information about what to do during their recovery at home
Not rated| No, staff "did not" give patients this information | 11% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Discharge information - star rating
4 / 5 — Rating 4 of 5No answer breakdown reported.
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that YES, they were given information about what to do during their recovery at home
Not rated| Yes, staff "did" give patients this information | 89% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that NO, they did not discuss whether they would need help after discharge
Not rated| No, staff "did not" give patients information about help after discharge | 13% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that YES, they did discuss whether they would need help after discharge
Not rated| Yes, staff "did" give patients information about help after discharge | 87% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that their doctors "Always" explained things in a way they could understand
Not rated| Doctors "always" explained things so they could understand | 79% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that their doctors "Sometimes" or "Never" explained things in a way they could understand
Not rated| Doctors "sometimes" or "never" explained things so they could understand | 6% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that their doctors "Usually" explained things in a way they could understand
Not rated| Doctors "usually" explained things so they could understand | 15% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that their doctors "Always" listened carefully to them
Not rated| Doctors "always" listened carefully | 84% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that their doctors "Sometimes" or "Never" listened carefully to them
Not rated| Doctors "sometimes" or "never" listened carefully | 4% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that their doctors "Usually" listened carefully to them
Not rated| Doctors "usually" listened carefully | 12% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that their doctors "Always" treated them with courtesy and respect
Not rated| Doctors "always" treated them with courtesy and respect | 90% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that their doctors "Sometimes" or "Never" treated them with courtesy and respect
Not rated| Doctors "sometimes" or "never" treated them with courtesy and respect | 2% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that their doctors "Usually" treated them with courtesy and respect
Not rated| Doctors "usually" treated them with courtesy and respect | 8% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who gave their hospital a rating of 6 or lower on a scale from 0 (lowest) to 10 (highest)
Not rated| Patients who gave a rating of "6" or lower (low) | 4% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who gave their hospital a rating of 7 or 8 on a scale from 0 (lowest) to 10 (highest)
Not rated| Patients who gave a rating of "7" or "8" (medium) | 12% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who gave their hospital a rating of 9 or 10 on a scale from 0 (lowest) to 10 (highest)
Not rated| Patients who gave a rating of "9" or "10" (high) | 84% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Overall hospital rating - linear mean score
Not ratedNo answer breakdown reported.
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Overall hospital rating - star rating
5 / 5 — HighestNo answer breakdown reported.
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that when receiving new medication the staff "Always" communicated what the medication was for
Not rated| Staff "always" explained new medications | 84% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that when receiving new medication the staff "Sometimes" or "Never" communicated what the medication was for
Not rated| Staff "sometimes" or "never" explained new medications | 7% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that when receiving new medication the staff "Usually" communicated what the medication was for.
Not rated| Staff "usually" explained new medications | 9% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that their nurses "Always" explained things in a way they could understand
Not rated| Nurses "always" explained things so they could understand | 81% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that their nurses "Sometimes" or "Never" explained things in a way they could understand
Not rated| Nurses "sometimes" or "never" explained things so they could understand | 4% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that their nurses "Usually" explained things in a way they could understand
Not rated| Nurses "usually" explained things so they could understand | 15% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that their nurses "Always" listened carefully to them
Not rated| Nurses "always" listened carefully | 87% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that their nurses "Sometimes" or "Never" listened carefully to them
Not rated| Nurses "sometimes" or "never" listened carefully | 2% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that their nurses "Usually" listened carefully to them
Not rated| Nurses "usually" listened carefully | 11% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that their nurses "Always" treated them with courtesy and respect
Not rated| Nurses "always" treated them with courtesy and respect | 92% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that their nurses "Sometimes" or "Never" treated them with courtesy and respect
Not rated| Nurses "sometimes" or "never" treated them with courtesy and respect | 1% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that their nurses "Usually" treated them with courtesy and respect
Not rated| Nurses "usually" treated them with courtesy and respect | 7% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that the area around their room was "Always" quiet at night
Not rated| "Always" quiet at night | 66% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that the area around their room was "Sometimes" or "Never" quiet at night
Not rated| "Sometimes" or "never" quiet at night | 6% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that the area around their room was "Usually" quiet at night
Not rated| "Usually" quiet at night | 28% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Quietness - linear mean score
Not ratedNo answer breakdown reported.
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Quietness - star rating
4 / 5 — Rating 4 of 5No answer breakdown reported.
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported NO, they would probably not or definitely not recommend the hospital
Not rated| "NO", patients would not recommend the hospital (they probably would not or definitely would not recommend it) | 2% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported YES, they would definitely recommend the hospital
Not rated| "YES", patients would definitely recommend the hospital | 87% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Recommend hospital - linear mean score
Not ratedNo answer breakdown reported.
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported YES, they would probably recommend the hospital
Not rated| "YES", patients would probably recommend the hospital | 11% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Recommend hospital - star rating
5 / 5 — HighestNo answer breakdown reported.
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that when receiving new medication the staff "Always" discussed possible side effects
Not rated| Staff "always" explained possible side effects | 58% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that when receiving new medication the staff "Sometimes" or "Never" discussed possible side effects
Not rated| Staff "sometimes" or "never" explained possible side effects | 23% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that when receiving new medication the staff "Usually" discussed possible side effects
Not rated| Staff "usually" explained possible side effects | 19% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Summary star rating
4 / 5 — Rating 4 of 5No answer breakdown reported.
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that NO, they did not receive written information about possible symptoms to look out for after discharge
Not rated| No, staff "did not" give patients information about possible symptoms | 9% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Patients who reported that YES, they did receive written information about possible symptoms to look out for after discharge
Not rated| Yes, staff "did" give patients information about possible symptoms | 91% |
|---|
647 completed surveys · response rate 24% · 2024-10-01 → 2025-09-30
Missing measures are not poor results
CMS suppresses a measure when too few cases were reported for the result to be reliable — common for smaller hospitals. A blank means not reported, which is different from a poor result. Hospitals with more blanks are not necessarily worse.
This is not medical advice
These are historical, aggregate measures about an institution. They do not describe the care any individual will receive, and they cannot account for your condition.
Talk to a clinician about your own care. In an emergency, call your local emergency number.
Other Acute Care Hospitals in TX
- AD HOSPITAL EAST, LLCNot rated
- ADVANCED DALLAS HOSPITALS AND CLINICSNot rated
- ADVENTHEALTH CENTRAL TEXAS3/5
- ALTUS HOUSTON HOSPITAL, LPNot rated
- ALTUS LUMBERTON HOSPITALNot rated
- ASCENSION SETON HAYS3/5
- ASCENSION PROVIDENCE2/5
- ASCENSION SETON SOUTHWESTNot rated
- ASCENSION SETON CEDAR PARK3/5
- ASCENSION SETON MEDICAL CENTER AUSTIN3/5
- ASCENSION SETON NORTHWEST4/5
- ASCENSION SETON WILLIAMSON4/5
Source: Centers for Medicare & Medicaid Services (CMS), Provider Data Catalog (data updated 2026-07-22) — https://data.cms.gov/provider-data/ · Data last updated 2026-09-27