JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Chi St Luke's Health Brazosport

4 / 5

At a glance

Chi St Luke's Health Brazosport carries a 4-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 LimitSame as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit2.598Same as national
Central Line Associated Bloodstream Infection: Number of Device Days1884Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases1.153Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases0Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.000Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence LimitSame as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit2.157Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days2029Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases1.389Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases0Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.000Same as national
SSI - Colon Surgery: Lower Confidence LimitNot available
SSI - Colon Surgery: Upper Confidence LimitNot available
SSI - Colon Surgery: Number of Procedures12Not available
SSI - Colon Surgery: Predicted Cases0.248Not available
SSI - Colon Surgery: Observed Cases0Not available
SSI - Colon SurgeryNot available
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures5Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.036Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitNot available
MRSA Bacteremia: Upper Confidence LimitNot available
MRSA Bacteremia: Patient Days16232Not available
MRSA Bacteremia: Predicted Cases0.722Not available
MRSA Bacteremia: Observed Cases0Not available
MRSA BacteremiaNot available
Clostridium Difficile (C.Diff): Lower Confidence Limit0.147Same as national
Clostridium Difficile (C.Diff): Upper Confidence Limit1.573Same as national
Clostridium Difficile (C.Diff): Patient Days15867Same as national
Clostridium Difficile (C.Diff): Predicted Cases5.189Same as national
Clostridium Difficile (C.Diff): Observed Cases3Same as national
Clostridium Difficile (C.Diff)0.578Same 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 Rate4.2Same as national353
Death rate for heart attack patients10.5Same as national51
Death rate for CABG surgery patientsNot available
Death rate for COPD patients7.7Same as national64
Death rate for heart failure patients12.4Same as national150
Death rate for pneumonia patients14.7Same as national117
Death rate for stroke patients12.7Same as national29
Pressure ulcer rate0.38Same as national1090
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.20Same as national1573
In-hospital fall-associated fracture rate0.30Same as national1538
Postoperative hemorrhage or hematoma rate2.24Same as national180
Postoperative acute kidney injury requiring dialysis rateNot available
Postoperative respiratory failure rateNot available
Perioperative pulmonary embolism or deep vein thrombosis rate3.24Same as national189
Postoperative sepsis rateNot available
Postoperative wound dehiscence rate1.73Same as national35
Abdominopelvic accidental puncture or laceration rate1.02Same as national131
CMS Medicare PSI 90: Patient safety and adverse events composite0.91Same 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 patientsNot available
Hospital return days for heart failure patients12.6Not available169
Hospital return days for pneumonia patients29.9Not available131
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)15.1Same as national532
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)14.1Same as national106
Rate of inpatient admissions for patients receiving outpatient chemotherapy10.1Same as national47
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy5.7Same as national47
Ratio of unplanned hospital visits after hospital outpatient surgery1Same as national80
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate12.7Same as national47
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients19.1Same as national74
Heart failure (HF) 30-Day Readmission Rate21.5Same as national169
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate16.5Same as national131

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 rating4450
Doctor communication - star rating4450
Communication about medicines - star rating3450
Discharge information - star rating3450
Cleanliness - star rating4450
Quietness - star rating3450
Overall hospital rating - star rating3450
Recommend hospital - star rating3450
Summary star rating3450

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 volumemedium
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 Hypoglycemia01115
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination72761
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 better162400
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 better155364
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better23716
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better27421
Left before being seen132036
Head CT results8137
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients8715
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing5337
Appropriate care for severe sepsis and septic shock6880
Septic Shock 3-Hour Bundle6025
Septic Shock 6-Hour Bundle7713
Severe Sepsis 3-Hour Bundle9280
Severe Sepsis 6-Hour Bundle8444
Discharged on Antithrombotic Therapy
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 27958
Venous Thromboembolism Prophylaxis
Intensive Care Unit Venous Thromboembolism Prophylaxis70418

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 Chi St Luke's Health Brazosport rated?
Chi St Luke's Health Brazosport has a 4 out of 5 CMS overall star rating as of the latest CMS release.
Does Chi St Luke's Health Brazosport have emergency services?
Yes. Chi St Luke's Health Brazosport operates a 24/7 emergency department.
Where is Chi St Luke's Health Brazosport located?
Chi St Luke's Health Brazosport is located at 100 Medical Drive, Lake Jackson, TX 77566.
What type of hospital is Chi St Luke's Health Brazosport?
Chi St Luke's Health Brazosport 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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