Acute Care Hospitals · Voluntary non-profit - Church
Baylor St Lukes Medical Center
- 6720 Bertner Ave, Ste Mc1-266, Houston, TX 77030
- (832) 355-1000
- Acute Care Hospitals
- Emergency services available 24/7
At a glance
Baylor St Lukes Medical Center carries a 4-star CMS overall rating — above the national norm. On healthcare-associated infection measures, it performs better than the national average on 24 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.
| Measure | Score | Compared to national |
|---|---|---|
| Central Line Associated Bloodstream Infection (ICU + select Wards): Lower Confidence Limit | 0.716 | Same as national |
| Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit | 1.263 | Same as national |
| Central Line Associated Bloodstream Infection: Number of Device Days | 46571 | Same as national |
| Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases | 49.971 | Same as national |
| Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases | 48 | Same as national |
| Central Line Associated Bloodstream Infection (ICU + select Wards) | 0.961 | Same as national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit | 0.194 | Better than national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit | 0.582 | Better than national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days | 24803 | Better than national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases | 37.253 | Better than national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases | 13 | Better than national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards) | 0.349 | Better than national |
| SSI - Colon Surgery: Lower Confidence Limit | 0.108 | Better than national |
| SSI - Colon Surgery: Upper Confidence Limit | 0.819 | Better than national |
| SSI - Colon Surgery: Number of Procedures | 434 | Better than national |
| SSI - Colon Surgery: Predicted Cases | 11.776 | Better than national |
| SSI - Colon Surgery: Observed Cases | 4 | Better than national |
| SSI - Colon Surgery | 0.340 | Better than national |
| SSI - Abdominal Hysterectomy: Lower Confidence Limit | 0.048 | Same as national |
| SSI - Abdominal Hysterectomy: Upper Confidence Limit | 4.774 | Same as national |
| SSI - Abdominal Hysterectomy: Number of Procedures | 119 | Same as national |
| SSI - Abdominal Hysterectomy: Predicted Cases | 1.033 | Same as national |
| SSI - Abdominal Hysterectomy: Observed Cases | 1 | Same as national |
| SSI - Abdominal Hysterectomy | 0.968 | Same as national |
| MRSA Bacteremia: Lower Confidence Limit | 0.144 | Better than national |
| MRSA Bacteremia: Upper Confidence Limit | 0.651 | Better than national |
| MRSA Bacteremia: Patient Days | 195307 | Better than national |
| MRSA Bacteremia: Predicted Cases | 21.258 | Better than national |
| MRSA Bacteremia: Observed Cases | 7 | Better than national |
| MRSA Bacteremia | 0.329 | Better than national |
| Clostridium Difficile (C.Diff): Lower Confidence Limit | 0.125 | Better than national |
| Clostridium Difficile (C.Diff): Upper Confidence Limit | 0.290 | Better than national |
| Clostridium Difficile (C.Diff): Patient Days | 195307 | Better than national |
| Clostridium Difficile (C.Diff): Predicted Cases | 113.014 | Better than national |
| Clostridium Difficile (C.Diff): Observed Cases | 22 | Better than national |
| Clostridium Difficile (C.Diff) | 0.195 | Better 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.
| Measure | Score | Compared to national | Sample |
|---|---|---|---|
| Rate of complications for hip/knee replacement patients | — | Not available | — |
| Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate | 3.4 | Better than national | 1550 |
| Death rate for heart attack patients | 10.5 | Same as national | 112 |
| Death rate for CABG surgery patients | 2.9 | Same as national | 231 |
| Death rate for COPD patients | 9.5 | Same as national | 25 |
| Death rate for heart failure patients | 8.8 | Same as national | 383 |
| Death rate for pneumonia patients | 11.3 | Better than national | 145 |
| Death rate for stroke patients | 11.1 | Same as national | 171 |
| Pressure ulcer rate | 0.71 | Same as national | 6740 |
| Death rate among surgical inpatients with serious treatable complications | 157.74 | Same as national | 223 |
| Iatrogenic pneumothorax rate | 0.17 | Same as national | 6880 |
| In-hospital fall-associated fracture rate | 0.23 | Same as national | 8122 |
| Postoperative hemorrhage or hematoma rate | 1.79 | Same as national | 2497 |
| Postoperative acute kidney injury requiring dialysis rate | 1.23 | Same as national | 1331 |
| Postoperative respiratory failure rate | 9.24 | Same as national | 1416 |
| Perioperative pulmonary embolism or deep vein thrombosis rate | 3.57 | Same as national | 2795 |
| Postoperative sepsis rate | 6.87 | Same as national | 1438 |
| Postoperative wound dehiscence rate | 1.88 | Same as national | 736 |
| Abdominopelvic accidental puncture or laceration rate | 0.88 | Same as national | 2306 |
| CMS Medicare PSI 90: Patient safety and adverse events composite | 1.03 | Same 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.
| Measure | Score | Compared to national | Sample |
|---|---|---|---|
| Hospital return days for heart attack patients | 3.4 | Not available | 171 |
| Hospital return days for heart failure patients | 6.1 | Not available | 462 |
| Hospital return days for pneumonia patients | 31.6 | Not available | 159 |
| Hybrid Hospital-Wide All-Cause Readmission Measure (HWR) | 14.5 | Same as national | 2622 |
| Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies) | 11.6 | Same as national | 1280 |
| Rate of inpatient admissions for patients receiving outpatient chemotherapy | 12.3 | Same as national | 208 |
| Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy | 5.3 | Same as national | 208 |
| Ratio of unplanned hospital visits after hospital outpatient surgery | 0.9 | Same as national | 774 |
| Acute Myocardial Infarction (AMI) 30-Day Readmission Rate | 12.8 | Same as national | 171 |
| Rate of readmission for CABG | 9.1 | Same as national | 225 |
| Rate of readmission for chronic obstructive pulmonary disease (COPD) patients | 17.6 | Same as national | 26 |
| Heart failure (HF) 30-Day Readmission Rate | 19.1 | Same as national | 462 |
| Rate of readmission after hip/knee replacement | — | Not available | — |
| Pneumonia (PN) 30-Day Readmission Rate | 15.4 | Same as national | 159 |
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.
| Measure | Score | Sample |
|---|---|---|
| Nurse communication - star rating | 2 | 529 |
| Doctor communication - star rating | 3 | 529 |
| Communication about medicines - star rating | 2 | 529 |
| Discharge information - star rating | 3 | 529 |
| Cleanliness - star rating | 2 | 529 |
| Quietness - star rating | 3 | 529 |
| Overall hospital rating - star rating | 3 | 529 |
| Recommend hospital - star rating | 3 | 529 |
| Summary star rating | 3 | 529 |
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.
| Measure | Score | Sample |
|---|---|---|
| Emergency department volume | high | — |
| 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 vaccination | 83 | 6559 |
| 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 | 168 | 400 |
| 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 | 166 | 390 |
| 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 | 2 | 46712 |
| Head CT results | — | — |
| Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients | 95 | 86 |
| Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery | — | — |
| ST-Segment Elevation Myocardial Infarction (STEMI) | — | — |
| Safe Use of Opioids - Concurrent Prescribing | 18 | 6161 |
| Appropriate care for severe sepsis and septic shock | 63 | 78 |
| Septic Shock 3-Hour Bundle | 67 | 24 |
| Septic Shock 6-Hour Bundle | 93 | 14 |
| Severe Sepsis 3-Hour Bundle | 83 | 78 |
| Severe Sepsis 6-Hour Bundle | 91 | 47 |
| Discharged on Antithrombotic Therapy | 96 | 414 |
| Anticoagulation Therapy for Atrial Fibrillation/Flutter | — | — |
| Antithrombotic Therapy by End of Hospital Day 2 | — | — |
| Venous Thromboembolism Prophylaxis | 93 | 13361 |
| Intensive Care Unit Venous Thromboembolism Prophylaxis | 99 | 5979 |
Maternal Health
lower is better · 4 measures reported
Measures of maternal outcomes and safe delivery practices, including severe complications during childbirth.
| Measure | Score | Sample |
|---|---|---|
| Cesarean Birth | — | — |
| Risk Adjusted Severe Obstetric Complications (All) | — | — |
| Risk Adjusted Severe Obstetric Complications (excluding blood-transfusion-only cases) | — | — |
| Maternal Morbidity Structural Measure | Not Applicable (our hospital does not provide inpatient labor/delivery care) | — |
Frequently asked questions
- How is Baylor St Lukes Medical Center rated?
- Baylor St Lukes Medical Center has a 4 out of 5 CMS overall star rating as of the latest CMS release.
- Does Baylor St Lukes Medical Center have emergency services?
- Yes. Baylor St Lukes Medical Center operates a 24/7 emergency department.
- Where is Baylor St Lukes Medical Center located?
- Baylor St Lukes Medical Center is located at 6720 Bertner Ave, Ste Mc1-266, Houston, TX 77030.
- What type of hospital is Baylor St Lukes Medical Center?
- Baylor St Lukes Medical Center is classified by CMS as a Acute Care Hospitals facility (Voluntary non-profit - Church).
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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.