JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Houston Methodist Willowbrook Hospital

5 / 5

At a glance

Houston Methodist Willowbrook Hospital carries a 5-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.

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 Limit0.004Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit0.433Better than national
Central Line Associated Bloodstream Infection: Number of Device Days10909Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases11.391Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases1Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.088Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.004Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit0.365Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days11023Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases13.503Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases1Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.074Better than national
SSI - Colon Surgery: Lower Confidence Limit0.244Same as national
SSI - Colon Surgery: Upper Confidence Limit1.474Same as national
SSI - Colon Surgery: Number of Procedures300Same as national
SSI - Colon Surgery: Predicted Cases7.521Same as national
SSI - Colon Surgery: Observed Cases5Same as national
SSI - Colon Surgery0.665Same as national
SSI - Abdominal Hysterectomy: Lower Confidence Limit0.035Same as national
SSI - Abdominal Hysterectomy: Upper Confidence Limit3.444Same as national
SSI - Abdominal Hysterectomy: Number of Procedures168Same as national
SSI - Abdominal Hysterectomy: Predicted Cases1.432Same as national
SSI - Abdominal Hysterectomy: Observed Cases1Same as national
SSI - Abdominal Hysterectomy0.698Same as national
MRSA Bacteremia: Lower Confidence Limit0.138Same as national
MRSA Bacteremia: Upper Confidence Limit1.480Same as national
MRSA Bacteremia: Patient Days104262Same as national
MRSA Bacteremia: Predicted Cases5.515Same as national
MRSA Bacteremia: Observed Cases3Same as national
MRSA Bacteremia0.544Same as national
Clostridium Difficile (C.Diff): Lower Confidence LimitBetter than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.071Better than national
Clostridium Difficile (C.Diff): Patient Days91074Better than national
Clostridium Difficile (C.Diff): Predicted Cases42.301Better 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 patientsNot available
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate3.3Better than national2085
Death rate for heart attack patients11.5Same as national201
Death rate for CABG surgery patients3.2Same as national50
Death rate for COPD patients7.8Same as national96
Death rate for heart failure patients7.3Better than national632
Death rate for pneumonia patients11.4Better than national587
Death rate for stroke patients10.5Better than national329
Pressure ulcer rate0.10Better than national7144
Death rate among surgical inpatients with serious treatable complications111.17Better than national101
Iatrogenic pneumothorax rate0.13Same as national8613
In-hospital fall-associated fracture rate0.20Same as national8830
Postoperative hemorrhage or hematoma rate2.60Same as national1719
Postoperative acute kidney injury requiring dialysis rate1.45Same as national498
Postoperative respiratory failure rate5.34Same as national521
Perioperative pulmonary embolism or deep vein thrombosis rate3.36Same as national1822
Postoperative sepsis rate3.09Same as national501
Postoperative wound dehiscence rate1.54Same as national486
Abdominopelvic accidental puncture or laceration rate0.71Same as national1718
CMS Medicare PSI 90: Patient safety and adverse events composite0.61Better 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 patients17.2Not available199
Hospital return days for heart failure patients-3.6Not available748
Hospital return days for pneumonia patients11.5Not available635
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.8Same as national3510
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)11.1Same as national2055
Rate of inpatient admissions for patients receiving outpatient chemotherapy13.8Same as national127
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy4.5Same as national127
Ratio of unplanned hospital visits after hospital outpatient surgery0.8Same as national676
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate14.1Same as national199
Rate of readmission for CABG10.9Same as national49
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients18.4Same as national118
Heart failure (HF) 30-Day Readmission Rate21.1Same as national748
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate17.2Same as national635

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 rating42590
Doctor communication - star rating32590
Communication about medicines - star rating32590
Discharge information - star rating42590
Cleanliness - star rating42590
Quietness - star rating42590
Overall hospital rating - star rating42590
Recommend hospital - star rating42590
Summary star rating42590

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 Hypoglycemia16926
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination595450
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 better175399
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 better176392
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 seen161165
Head CT results6319
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients7783
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing116823
Appropriate care for severe sepsis and septic shock79117
Septic Shock 3-Hour Bundle7638
Septic Shock 6-Hour Bundle10024
Severe Sepsis 3-Hour Bundle92118
Severe Sepsis 6-Hour Bundle9573
Discharged on Antithrombotic Therapy99614
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 2
Venous Thromboembolism Prophylaxis
Intensive Care Unit Venous Thromboembolism Prophylaxis972202

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 Houston Methodist Willowbrook Hospital rated?
Houston Methodist Willowbrook Hospital has a 5 out of 5 CMS overall star rating as of the latest CMS release.
Does Houston Methodist Willowbrook Hospital have emergency services?
Yes. Houston Methodist Willowbrook Hospital operates a 24/7 emergency department.
Where is Houston Methodist Willowbrook Hospital located?
Houston Methodist Willowbrook Hospital is located at 18220 State Highway 249, Houston, TX 77070.
What type of hospital is Houston Methodist Willowbrook Hospital?
Houston Methodist Willowbrook 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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