JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Physician

Baylor Scott & White Texas Spine & Joint Hospital

5 / 5

At a glance

Baylor Scott & White Texas Spine & Joint Hospital 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 Limit—Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit—Not available
Central Line Associated Bloodstream Infection: Number of Device Days307Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases0.179Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases0Not available
Central Line Associated Bloodstream Infection (ICU + select Wards)—Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit—Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit—Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days2009Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases0.985Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases0Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards)—Not available
SSI - Colon Surgery: Lower Confidence Limit—Not available
SSI - Colon Surgery: Upper Confidence Limit—Not available
SSI - Colon Surgery: Number of Procedures—Not available
SSI - Colon Surgery: Predicted Cases—Not available
SSI - Colon Surgery: Observed Cases—Not available
SSI - Colon Surgery—Not available
SSI - Abdominal Hysterectomy: Lower Confidence Limit—Not available
SSI - Abdominal Hysterectomy: Upper Confidence Limit—Not available
SSI - Abdominal Hysterectomy: Number of Procedures—Not available
SSI - Abdominal Hysterectomy: Predicted Cases—Not available
SSI - Abdominal Hysterectomy: Observed Cases—Not available
SSI - Abdominal Hysterectomy—Not available
MRSA Bacteremia: Lower Confidence Limit—Not available
MRSA Bacteremia: Upper Confidence Limit—Not available
MRSA Bacteremia: Patient Days3386Not available
MRSA Bacteremia: Predicted Cases0.073Not available
MRSA Bacteremia: Observed Cases0Not available
MRSA Bacteremia—Not available
Clostridium Difficile (C.Diff): Lower Confidence Limit—Not available
Clostridium Difficile (C.Diff): Upper Confidence Limit—Not available
Clostridium Difficile (C.Diff): Patient Days3386Not available
Clostridium Difficile (C.Diff): Predicted Cases0.822Not available
Clostridium Difficile (C.Diff): Observed Cases0Not available
Clostridium Difficile (C.Diff)—Not available

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 patients3.3Same as national923
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate3.7Same as national522
Death rate for heart attack patients—Not available—
Death rate for CABG surgery patients—Not available—
Death rate for COPD patients—Not available—
Death rate for heart failure patients—Not available—
Death rate for pneumonia patients—Not available—
Death rate for stroke patients—Not available—
Pressure ulcer rate0.51Same as national474
Death rate among surgical inpatients with serious treatable complications—Not available—
Iatrogenic pneumothorax rate0.20Same as national1504
In-hospital fall-associated fracture rate0.24Same as national1473
Postoperative hemorrhage or hematoma rate1.87Same as national1416
Postoperative acute kidney injury requiring dialysis rate1.54Same as national1439
Postoperative respiratory failure rate7.21Same as national1429
Perioperative pulmonary embolism or deep vein thrombosis rate2.81Same as national1488
Postoperative sepsis rate3.79Same as national1385
Postoperative wound dehiscence rate1.74Same as national600
Abdominopelvic accidental puncture or laceration rate1.00Same as national648
CMS Medicare PSI 90: Patient safety and adverse events composite0.80Same 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 patients—Not available—
Hospital return days for heart failure patients—Not available—
Hospital return days for pneumonia patients—Not available—
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)13.4Same as national571
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)—Not available—
Rate of inpatient admissions for patients receiving outpatient chemotherapy—Not available—
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy—Not available—
Ratio of unplanned hospital visits after hospital outpatient surgery0.9Same as national1013
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate—Not available—
Rate of readmission for CABG—Not available—
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients—Not available—
Heart failure (HF) 30-Day Readmission Rate—Not available—
Rate of readmission after hip/knee replacement3.9Same as national899
Pneumonia (PN) 30-Day Readmission Rate—Not 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 rating5407
Doctor communication - star rating4407
Communication about medicines - star rating3407
Discharge information - star rating4407
Cleanliness - star rating3407
Quietness - star rating4407
Overall hospital rating - star rating4407
Recommend hospital - star rating5407
Summary star rating4407

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 volumelow—
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 vaccination51762
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 better145423
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 better145423
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 seen13466
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 Prescribing171148
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 Prophylaxis——
Intensive Care Unit Venous Thromboembolism Prophylaxis——

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 MeasureNot Applicable (our hospital does not provide inpatient labor/delivery care)—

Frequently asked questions

How is Baylor Scott & White Texas Spine & Joint Hospital rated?
Baylor Scott & White Texas Spine & Joint Hospital has a 5 out of 5 CMS overall star rating as of the latest CMS release.
Does Baylor Scott & White Texas Spine & Joint Hospital have emergency services?
Yes. Baylor Scott & White Texas Spine & Joint Hospital operates a 24/7 emergency department.
Where is Baylor Scott & White Texas Spine & Joint Hospital located?
Baylor Scott & White Texas Spine & Joint Hospital is located at 1814 Roseland Boulevard, Tyler, TX 75701.
What type of hospital is Baylor Scott & White Texas Spine & Joint Hospital?
Baylor Scott & White Texas Spine & Joint Hospital is classified by CMS as a Acute Care Hospitals facility (Physician).

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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