JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Proprietary

Hca Houston Healthcare Southeast

3 / 5

At a glance

Hca Houston Healthcare Southeast carries a 3-star CMS overall rating — in line with the national norm. On healthcare-associated infection measures, it performs better than the national average on 6 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.

MeasureScoreCompared to national
Central Line Associated Bloodstream Infection (ICU + select Wards): Lower Confidence Limit0.223Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit2.390Same as national
Central Line Associated Bloodstream Infection: Number of Device Days4260Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases3.416Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases3Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.878Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.014Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit1.368Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days4160Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases3.605Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases1Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.277Same as national
SSI - Colon Surgery: Lower Confidence Limit0.285Same as national
SSI - Colon Surgery: Upper Confidence Limit3.044Same as national
SSI - Colon Surgery: Number of Procedures101Same as national
SSI - Colon Surgery: Predicted Cases2.682Same as national
SSI - Colon Surgery: Observed Cases3Same as national
SSI - Colon Surgery1.119Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitSame as national
SSI - Abdominal Hysterectomy: Upper Confidence Limit1.821Same as national
SSI - Abdominal Hysterectomy: Number of Procedures188Same as national
SSI - Abdominal Hysterectomy: Predicted Cases1.645Same as national
SSI - Abdominal Hysterectomy: Observed Cases0Same as national
SSI - Abdominal Hysterectomy0.000Same as national
MRSA Bacteremia: Lower Confidence Limit0.410Same as national
MRSA Bacteremia: Upper Confidence Limit3.111Same as national
MRSA Bacteremia: Patient Days72700Same as national
MRSA Bacteremia: Predicted Cases3.101Same as national
MRSA Bacteremia: Observed Cases4Same as national
MRSA Bacteremia1.290Same as national
Clostridium Difficile (C.Diff): Lower Confidence LimitBetter than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.103Better than national
Clostridium Difficile (C.Diff): Patient Days66391Better than national
Clostridium Difficile (C.Diff): Predicted Cases28.997Better than national
Clostridium Difficile (C.Diff): Observed Cases0Better than national
Clostridium Difficile (C.Diff)0.000Better 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 patients3.1Same as national34
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4.3Same as national457
Death rate for heart attack patients12.7Same as national46
Death rate for CABG surgery patientsNot available
Death rate for COPD patients10.8Same as national31
Death rate for heart failure patients14Same as national101
Death rate for pneumonia patients17Same as national149
Death rate for stroke patients12.3Same as national47
Pressure ulcer rate0.27Same as national1972
Death rate among surgical inpatients with serious treatable complications149.69Same as national34
Iatrogenic pneumothorax rate0.18Same as national2206
In-hospital fall-associated fracture rate0.25Same as national2317
Postoperative hemorrhage or hematoma rate2.37Same as national496
Postoperative acute kidney injury requiring dialysis rate1.61Same as national141
Postoperative respiratory failure rate9.39Same as national148
Perioperative pulmonary embolism or deep vein thrombosis rate3.66Same as national520
Postoperative sepsis rate4.86Same as national129
Postoperative wound dehiscence rate1.72Same as national106
Abdominopelvic accidental puncture or laceration rate0.95Same as national474
CMS Medicare PSI 90: Patient safety and adverse events composite0.87Same 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 patients42Not available117
Hospital return days for pneumonia patients-3Not available144
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)15.6Same as national775
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)13Same as national47
Rate of inpatient admissions for patients receiving outpatient chemotherapyNot available
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapyNot available
Ratio of unplanned hospital visits after hospital outpatient surgery1.2Same as national63
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate14Same as national45
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients18.1Same as national32
Heart failure (HF) 30-Day Readmission Rate20.2Same as national117
Rate of readmission after hip/knee replacement4.8Same as national39
Pneumonia (PN) 30-Day Readmission Rate15.6Same as national144

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 rating2676
Doctor communication - star rating2676
Communication about medicines - star rating2676
Discharge information - star rating2676
Cleanliness - star rating3676
Quietness - star rating3676
Overall hospital rating - star rating2676
Recommend hospital - star rating2676
Summary star rating2676

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 vaccination522101
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 better133378
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 better123343
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better39226
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better33413
Left before being seen198760
Head CT results5721
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients9648
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)3628
Safe Use of Opioids - Concurrent Prescribing104249
Appropriate care for severe sepsis and septic shock84159
Septic Shock 3-Hour Bundle8842
Septic Shock 6-Hour Bundle8833
Severe Sepsis 3-Hour Bundle92159
Severe Sepsis 6-Hour Bundle97103
Discharged on Antithrombotic Therapy
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 286168
Venous Thromboembolism Prophylaxis718042
Intensive Care Unit Venous Thromboembolism Prophylaxis872290

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 Hca Houston Healthcare Southeast rated?
Hca Houston Healthcare Southeast has a 3 out of 5 CMS overall star rating as of the latest CMS release.
Does Hca Houston Healthcare Southeast have emergency services?
Yes. Hca Houston Healthcare Southeast operates a 24/7 emergency department.
Where is Hca Houston Healthcare Southeast located?
Hca Houston Healthcare Southeast is located at 4000 Spencer Hwy, Pasadena, TX 77504.
What type of hospital is Hca Houston Healthcare Southeast?
Hca Houston Healthcare Southeast is classified by CMS as a Acute Care Hospitals facility (Proprietary).

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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