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Acute Care Hospitals · Voluntary non-profit - Private

Ascension Seton Hays

3 / 5

At a glance

Ascension Seton Hays carries a 3-star CMS overall rating — in line with the national norm. On healthcare-associated infection measures, it performs better than the national average on 6 and worse on 0.

Healthcare-Associated Infections

lower is better · 36 measures reported

Rates of infections patients can acquire while receiving care, such as central-line and catheter-associated infections, MRSA, and C. difficile.

MeasureScoreCompared to national
Central Line Associated Bloodstream Infection (ICU + select Wards): Lower Confidence Limit0.196Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit2.093Same as national
Central Line Associated Bloodstream Infection: Number of Device Days5626Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases3.901Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases3Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.769Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.083Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit1.627Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days5645Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases4.061Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases2Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.492Same as national
SSI - Colon Surgery: Lower Confidence Limit0.304Same as national
SSI - Colon Surgery: Upper Confidence Limit3.257Same as national
SSI - Colon Surgery: Number of Procedures84Same as national
SSI - Colon Surgery: Predicted Cases2.507Same as national
SSI - Colon Surgery: Observed Cases3Same as national
SSI - Colon Surgery1.197Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures19Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.207Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitSame as national
MRSA Bacteremia: Upper Confidence Limit1.800Same as national
MRSA Bacteremia: Patient Days39539Same as national
MRSA Bacteremia: Predicted Cases1.664Same as national
MRSA Bacteremia: Observed Cases0Same as national
MRSA Bacteremia0.000Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.023Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.444Better than national
Clostridium Difficile (C.Diff): Patient Days35916Better than national
Clostridium Difficile (C.Diff): Predicted Cases14.888Better than national
Clostridium Difficile (C.Diff): Observed Cases2Better than national
Clostridium Difficile (C.Diff)0.134Better than national

Complications & Deaths

lower is better · 20 measures reported

Rates of serious complications (like hip/knee replacement problems or accidental cuts during surgery) and 30-day mortality rates for common conditions.

MeasureScoreCompared to nationalSample
Rate of complications for hip/knee replacement patientsNot available
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4.3Same as national463
Death rate for heart attack patients12.2Same as national83
Death rate for CABG surgery patients2.6Same as national32
Death rate for COPD patients12Same as national59
Death rate for heart failure patients11Same as national184
Death rate for pneumonia patients17.2Same as national288
Death rate for stroke patients10.9Same as national112
Pressure ulcer rate0.27Same as national2175
Death rate among surgical inpatients with serious treatable complications144.15Same as national28
Iatrogenic pneumothorax rate0.19Same as national2753
In-hospital fall-associated fracture rate0.24Same as national2723
Postoperative hemorrhage or hematoma rate2.29Same as national605
Postoperative acute kidney injury requiring dialysis rate1.61Same as national110
Postoperative respiratory failure rate7.05Same as national116
Perioperative pulmonary embolism or deep vein thrombosis rate3.18Same as national610
Postoperative sepsis rate4.80Same as national118
Postoperative wound dehiscence rate1.70Same as national102
Abdominopelvic accidental puncture or laceration rate0.99Same as national397
CMS Medicare PSI 90: Patient safety and adverse events composite0.79Same as national

Unplanned Hospital Visits & Readmissions

lower is better · 14 measures reported

How often patients return to the hospital unexpectedly within 30 days of discharge — a marker of care quality and discharge planning.

MeasureScoreCompared to nationalSample
Hospital return days for heart attack patients33.9Not available96
Hospital return days for heart failure patients-22.5Not available199
Hospital return days for pneumonia patients-0.2Not available311
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.4Same as national761
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)12.7Same as national94
Rate of inpatient admissions for patients receiving outpatient chemotherapyNot available
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapyNot available
Ratio of unplanned hospital visits after hospital outpatient surgery1Same as national44
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate14.7Same as national96
Rate of readmission for CABG9.8Same as national31
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients18.4Same as national67
Heart failure (HF) 30-Day Readmission Rate18.1Same as national199
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate15.7Same as national311

Patient Experience (HCAHPS)

higher is better · 9 measures reported

What patients say about their hospital stay — communication with nurses and doctors, responsiveness, cleanliness, pain management, and whether they would recommend the hospital.

MeasureScoreSample
Nurse communication - star rating2322
Doctor communication - star rating3322
Communication about medicines - star rating2322
Discharge information - star rating3322
Cleanliness - star rating3322
Quietness - star rating3322
Overall hospital rating - star rating2322
Recommend hospital - star rating3322
Summary star rating3322

Timely & Effective Care

higher is better (unless a wait time) · 30 measures reported

How consistently hospitals follow recommended care processes — for example, giving heart-attack patients aspirin on arrival, or the average time spent in the emergency department.

MeasureScoreSample
Emergency department volume
Global Malnutrition Composite Score
Global Malnutrition Composite Score: Malnutrition Diagnosis Documented
Global Malnutrition Composite Score: Malnutrition Risk Screening
Global Malnutrition Composite Score: Nutrition Assessment
Global Malnutrition Composite Score: Nutritional Care Plan
Hospital Harm - Severe Hyperglycemia
Hospital Harm - Severe Hypoglycemia
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination851531
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 better172300
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 better165282
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better37012
Left before being seen
Head CT results4511
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing10650
Appropriate care for severe sepsis and septic shock4394
Septic Shock 3-Hour Bundle2438
Septic Shock 6-Hour Bundle
Severe Sepsis 3-Hour Bundle7894
Severe Sepsis 6-Hour Bundle9357
Discharged on Antithrombotic Therapy10028
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 210025
Venous Thromboembolism Prophylaxis811092
Intensive Care Unit Venous Thromboembolism Prophylaxis94446

Maternal Health

lower is better · 4 measures reported

Measures of maternal outcomes and safe delivery practices, including severe complications during childbirth.

MeasureScoreSample
Cesarean Birth
Risk Adjusted Severe Obstetric Complications (All)
Risk Adjusted Severe Obstetric Complications (excluding blood-transfusion-only cases)
Maternal Morbidity Structural MeasureYes

Frequently asked questions

How is Ascension Seton Hays rated?
Ascension Seton Hays has a 3 out of 5 CMS overall star rating as of the latest CMS release.
Does Ascension Seton Hays have emergency services?
Yes. Ascension Seton Hays operates a 24/7 emergency department.
Where is Ascension Seton Hays located?
Ascension Seton Hays is located at 6001 Kyle Pkwy, Kyle, TX 78640.
What type of hospital is Ascension Seton Hays?
Ascension Seton Hays is classified by CMS as a Acute Care Hospitals facility (Voluntary non-profit - Private).

Data as of 2026-06-14. Source: CMS Provider Data Catalog. This is public data provided for informational purposes only and is not medical advice. See our methodology and editorial policy.

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