JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Baylor University Medical Center

4 / 5

At a glance

Baylor University 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 30 and worse on 0. For 30-day readmissions, it beats the national rate on 2 measures and trails 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 Limit0.303Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit0.715Better than national
Central Line Associated Bloodstream Infection: Number of Device Days37422Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases44.100Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases21Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.476Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.285Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit0.673Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days24544Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases46.887Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases21Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.448Better than national
SSI - Colon Surgery: Lower Confidence Limit0.638Same as national
SSI - Colon Surgery: Upper Confidence Limit1.578Same as national
SSI - Colon Surgery: Number of Procedures654Same as national
SSI - Colon Surgery: Predicted Cases18.452Same as national
SSI - Colon Surgery: Observed Cases19Same as national
SSI - Colon Surgery1.030Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitBetter than national
SSI - Abdominal Hysterectomy: Upper Confidence Limit0.793Better than national
SSI - Abdominal Hysterectomy: Number of Procedures414Better than national
SSI - Abdominal Hysterectomy: Predicted Cases3.778Better than national
SSI - Abdominal Hysterectomy: Observed Cases0Better than national
SSI - Abdominal Hysterectomy0.000Better than national
MRSA Bacteremia: Lower Confidence Limit0.303Better than national
MRSA Bacteremia: Upper Confidence Limit0.813Better than national
MRSA Bacteremia: Patient Days287439Better than national
MRSA Bacteremia: Predicted Cases31.286Better than national
MRSA Bacteremia: Observed Cases16Better than national
MRSA Bacteremia0.511Better than national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.302Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.510Better than national
Clostridium Difficile (C.Diff): Patient Days258552Better than national
Clostridium Difficile (C.Diff): Predicted Cases141.545Better than national
Clostridium Difficile (C.Diff): Observed Cases56Better than national
Clostridium Difficile (C.Diff)0.396Better 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 patients4.5Same as national80
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate3Better than national2590
Death rate for heart attack patients12.6Same as national28
Death rate for CABG surgery patients1.9Same as national225
Death rate for COPD patients7.7Same as national143
Death rate for heart failure patients12.2Same as national465
Death rate for pneumonia patients11.9Better than national480
Death rate for stroke patients12.2Same as national379
Pressure ulcer rate1.96Worse than national12005
Death rate among surgical inpatients with serious treatable complications179.16Same as national285
Iatrogenic pneumothorax rate0.16Same as national12485
In-hospital fall-associated fracture rate0.19Same as national13415
Postoperative hemorrhage or hematoma rate2.37Same as national3857
Postoperative acute kidney injury requiring dialysis rate1.82Same as national2261
Postoperative respiratory failure rate8.44Same as national2072
Perioperative pulmonary embolism or deep vein thrombosis rate3.97Same as national4364
Postoperative sepsis rate5.50Same as national2101
Postoperative wound dehiscence rate1.99Same as national1287
Abdominopelvic accidental puncture or laceration rate1.03Same as national3795
CMS Medicare PSI 90: Patient safety and adverse events composite1.37Worse than 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-45Not available52
Hospital return days for heart failure patients-38.7Not available560
Hospital return days for pneumonia patients3.7Not available530
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)13.9Better than national4591
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)14.5Same as national1313
Rate of inpatient admissions for patients receiving outpatient chemotherapy10.2Same as national81
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy5.6Same as national81
Ratio of unplanned hospital visits after hospital outpatient surgery0.9Same as national743
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate13.2Same as national52
Rate of readmission for CABG11Same as national222
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients17.2Same as national158
Heart failure (HF) 30-Day Readmission Rate17.2Better than national560
Rate of readmission after hip/knee replacement5.6Same as national89
Pneumonia (PN) 30-Day Readmission Rate15.1Same as national530

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 rating32284
Doctor communication - star rating32284
Communication about medicines - star rating22284
Discharge information - star rating32284
Cleanliness - star rating32284
Quietness - star rating32284
Overall hospital rating - star rating32284
Recommend hospital - star rating42284
Summary star rating32284

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 volumevery 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 vaccination958097
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 better274365
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 better274340
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better21720
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 seen3103412
Head CT results
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients9575
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing1411502
Appropriate care for severe sepsis and septic shock71125
Septic Shock 3-Hour Bundle8928
Septic Shock 6-Hour Bundle9520
Severe Sepsis 3-Hour Bundle82125
Severe Sepsis 6-Hour Bundle8651
Discharged on Antithrombotic Therapy98717
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 2
Venous Thromboembolism Prophylaxis8325303
Intensive Care Unit Venous Thromboembolism Prophylaxis937571

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 Baylor University Medical Center rated?
Baylor University Medical Center has a 4 out of 5 CMS overall star rating as of the latest CMS release.
Does Baylor University Medical Center have emergency services?
Yes. Baylor University Medical Center operates a 24/7 emergency department.
Where is Baylor University Medical Center located?
Baylor University Medical Center is located at 3500 Gaston Ave, Dallas, TX 75246.
What type of hospital is Baylor University Medical Center?
Baylor University Medical Center 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.

Report an issue with this page