JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Christus Mother Frances Hospital

4 / 5

At a glance

Christus Mother Frances Hospital carries a 4-star CMS overall rating — above the national norm. On healthcare-associated infection measures, it performs better than the national average on 18 and worse on 0. For 30-day readmissions, it beats the national rate on 3 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 Limit0.076Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit0.811Better than national
Central Line Associated Bloodstream Infection: Number of Device Days8701Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases10.071Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases3Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.298Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.022Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit0.435Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days8856Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases15.198Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases2Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.132Better than national
SSI - Colon Surgery: Lower Confidence Limit0.409Same as national
SSI - Colon Surgery: Upper Confidence Limit1.674Same as national
SSI - Colon Surgery: Number of Procedures318Same as national
SSI - Colon Surgery: Predicted Cases9.077Same as national
SSI - Colon Surgery: Observed Cases8Same as national
SSI - Colon Surgery0.881Same as national
SSI - Abdominal Hysterectomy: Lower Confidence Limit0.185Same as national
SSI - Abdominal Hysterectomy: Upper Confidence Limit3.653Same as national
SSI - Abdominal Hysterectomy: Number of Procedures212Same as national
SSI - Abdominal Hysterectomy: Predicted Cases1.809Same as national
SSI - Abdominal Hysterectomy: Observed Cases2Same as national
SSI - Abdominal Hysterectomy1.106Same as national
MRSA Bacteremia: Lower Confidence Limit0.169Same as national
MRSA Bacteremia: Upper Confidence Limit1.022Same as national
MRSA Bacteremia: Patient Days147217Same as national
MRSA Bacteremia: Predicted Cases10.849Same as national
MRSA Bacteremia: Observed Cases5Same as national
MRSA Bacteremia0.461Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.047Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.213Better than national
Clostridium Difficile (C.Diff): Patient Days134726Better than national
Clostridium Difficile (C.Diff): Predicted Cases65.045Better than national
Clostridium Difficile (C.Diff): Observed Cases7Better than national
Clostridium Difficile (C.Diff)0.108Better 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 patients4.2Same as national33
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4.2Same as national3308
Death rate for heart attack patients12.8Same as national417
Death rate for CABG surgery patients2.9Same as national316
Death rate for COPD patients9.2Same as national242
Death rate for heart failure patients13Same as national804
Death rate for pneumonia patients16.8Same as national1084
Death rate for stroke patients15.7Worse than national642
Pressure ulcer rate0.08Better than national11282
Death rate among surgical inpatients with serious treatable complications156.58Same as national247
Iatrogenic pneumothorax rate0.19Same as national12567
In-hospital fall-associated fracture rate0.29Same as national13169
Postoperative hemorrhage or hematoma rate4.00Worse than national3304
Postoperative acute kidney injury requiring dialysis rate1.82Same as national1287
Postoperative respiratory failure rate11.11Same as national1185
Perioperative pulmonary embolism or deep vein thrombosis rate2.44Same as national3829
Postoperative sepsis rate3.80Same as national1206
Postoperative wound dehiscence rate1.89Same as national791
Abdominopelvic accidental puncture or laceration rate1.32Same as national2851
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 patients-12.6Not available452
Hospital return days for heart failure patients17Not available899
Hospital return days for pneumonia patients-5.7Not available1131
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)13.6Better than national5245
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)10.2Better than national6782
Rate of inpatient admissions for patients receiving outpatient chemotherapy9.2Same as national162
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy5.1Same as national162
Ratio of unplanned hospital visits after hospital outpatient surgery0.9Same as national1944
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate11.7Same as national452
Rate of readmission for CABG8Better than national310
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients16.9Same as national243
Heart failure (HF) 30-Day Readmission Rate19.7Same as national899
Rate of readmission after hip/knee replacement4.9Same as national26
Pneumonia (PN) 30-Day Readmission Rate15.1Same as national1131

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 rating2514
Doctor communication - star rating3514
Communication about medicines - star rating2514
Discharge information - star rating3514
Cleanliness - star rating3514
Quietness - star rating4514
Overall hospital rating - star rating3514
Recommend hospital - star rating4514
Summary star rating3514

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 Hyperglycemia343325
Hospital Harm - Severe Hypoglycemia
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination834611
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 better108812
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 better105777
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better15224
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better39115
Left before being seen0175508
Head CT results5014
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients100105
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)5645
Safe Use of Opioids - Concurrent Prescribing149478
Appropriate care for severe sepsis and septic shock81295
Septic Shock 3-Hour Bundle90108
Septic Shock 6-Hour Bundle9374
Severe Sepsis 3-Hour Bundle89295
Severe Sepsis 6-Hour Bundle99136
Discharged on Antithrombotic Therapy96765
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 291640
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 MeasureYes

Frequently asked questions

How is Christus Mother Frances Hospital rated?
Christus Mother Frances Hospital has a 4 out of 5 CMS overall star rating as of the latest CMS release.
Does Christus Mother Frances Hospital have emergency services?
Yes. Christus Mother Frances Hospital operates a 24/7 emergency department.
Where is Christus Mother Frances Hospital located?
Christus Mother Frances Hospital is located at 800 East Dawson, Tyler, TX 75701.
What type of hospital is Christus Mother Frances Hospital?
Christus Mother Frances Hospital 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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