JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Proprietary

Baylor Scott & White Heart & Vascular Hospital - Dallas

5 / 5

At a glance

Baylor Scott & White Heart & Vascular Hospital - Dallas carries a 5-star CMS overall rating — above the national norm.

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 LimitNot available
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence LimitNot available
Central Line Associated Bloodstream Infection: Number of Device DaysNot available
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted CasesNot available
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed CasesNot available
Central Line Associated Bloodstream Infection (ICU + select Wards)Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence LimitNot available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence LimitNot available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter DaysNot available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted CasesNot available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed CasesNot available
Catheter Associated Urinary Tract Infections (ICU + select Wards)Not available
SSI - Colon Surgery: Lower Confidence LimitNot available
SSI - Colon Surgery: Upper Confidence LimitNot available
SSI - Colon Surgery: Number of ProceduresNot available
SSI - Colon Surgery: Predicted CasesNot available
SSI - Colon Surgery: Observed CasesNot available
SSI - Colon SurgeryNot available
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of ProceduresNot available
SSI - Abdominal Hysterectomy: Predicted CasesNot available
SSI - Abdominal Hysterectomy: Observed CasesNot available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitNot available
MRSA Bacteremia: Upper Confidence LimitNot available
MRSA Bacteremia: Patient Days12817Not available
MRSA Bacteremia: Predicted Cases0.392Not available
MRSA Bacteremia: Observed Cases1Not available
MRSA BacteremiaNot available
Clostridium Difficile (C.Diff): Lower Confidence LimitSame as national
Clostridium Difficile (C.Diff): Upper Confidence Limit1.206Same as national
Clostridium Difficile (C.Diff): Patient Days12817Same as national
Clostridium Difficile (C.Diff): Predicted Cases2.483Same as national
Clostridium Difficile (C.Diff): Observed Cases0Same as national
Clostridium Difficile (C.Diff)0.000Same as 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 Rate3.2Same as national500
Death rate for heart attack patients11.8Same as national126
Death rate for CABG surgery patientsNot available
Death rate for COPD patientsNot available
Death rate for heart failure patients9.1Same as national148
Death rate for pneumonia patientsNot available
Death rate for stroke patientsNot available
Pressure ulcer rate0.36Same as national930
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.26Same as national1860
In-hospital fall-associated fracture rate0.25Same as national1960
Postoperative hemorrhage or hematoma rate2.17Same as national953
Postoperative acute kidney injury requiring dialysis rate1.35Same as national460
Postoperative respiratory failure rate8.46Same as national528
Perioperative pulmonary embolism or deep vein thrombosis rate2.84Same as national944
Postoperative sepsis rate4.35Same as national502
Postoperative wound dehiscence rate1.74Same as national35
Abdominopelvic accidental puncture or laceration rate1.29Same as national167
CMS Medicare PSI 90: Patient safety and adverse events composite0.83Same 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 patients19.6Not available153
Hospital return days for heart failure patients11.9Not available183
Hospital return days for pneumonia patientsNot available
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)15.2Same as national763
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)Not available
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 national326
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate15.5Same as national153
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patientsNot available
Heart failure (HF) 30-Day Readmission Rate18.6Same as national183
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission RateNot available

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 rating5602
Doctor communication - star rating4602
Communication about medicines - star rating4602
Discharge information - star rating4602
Cleanliness - star rating5602
Quietness - star rating4602
Overall hospital rating - star rating5602
Recommend hospital - star rating5602
Summary star rating4602

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 vaccination952540
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
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
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 better
Left before being seen
Head CT results
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 Prescribing151250
Appropriate care for severe sepsis and septic shock
Septic Shock 3-Hour Bundle
Septic Shock 6-Hour Bundle
Severe Sepsis 3-Hour Bundle
Severe Sepsis 6-Hour Bundle
Discharged on Antithrombotic Therapy
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 2
Venous Thromboembolism Prophylaxis853811
Intensive Care Unit Venous Thromboembolism Prophylaxis891440

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 MeasureNo

Frequently asked questions

How is Baylor Scott & White Heart & Vascular Hospital - Dallas rated?
Baylor Scott & White Heart & Vascular Hospital - Dallas has a 5 out of 5 CMS overall star rating as of the latest CMS release.
Does Baylor Scott & White Heart & Vascular Hospital - Dallas have emergency services?
Yes. Baylor Scott & White Heart & Vascular Hospital - Dallas operates a 24/7 emergency department.
Where is Baylor Scott & White Heart & Vascular Hospital - Dallas located?
Baylor Scott & White Heart & Vascular Hospital - Dallas is located at 621 North Hall Street, Dallas, TX 75226.
What type of hospital is Baylor Scott & White Heart & Vascular Hospital - Dallas?
Baylor Scott & White Heart & Vascular Hospital - Dallas is classified by CMS as a Acute Care Hospitals facility (Proprietary).

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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