Acute Care Hospitals · Voluntary non-profit - Private
Memorial Hermann Hospital System
- 1635 North Loop West, Houston, TX 77008
- (713) 448-6796
- Acute Care Hospitals
- Emergency services available 24/7
At a glance
Memorial Hermann Hospital System 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 24 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.
| Measure | Score | Compared to national |
|---|---|---|
| Central Line Associated Bloodstream Infection (ICU + select Wards): Lower Confidence Limit | 0.400 | Better than national |
| Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit | 0.879 | Better than national |
| Central Line Associated Bloodstream Infection: Number of Device Days | 39489 | Better than national |
| Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases | 41.352 | Better than national |
| Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases | 25 | Better than national |
| Central Line Associated Bloodstream Infection (ICU + select Wards) | 0.605 | Better than national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit | 0.170 | Better than national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit | 0.472 | Better than national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days | 37428 | Better than national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases | 51.246 | Better than national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases | 15 | Better than national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards) | 0.293 | Better than national |
| SSI - Colon Surgery: Lower Confidence Limit | 0.376 | Same as national |
| SSI - Colon Surgery: Upper Confidence Limit | 1.082 | Same as national |
| SSI - Colon Surgery: Number of Procedures | 790 | Same as national |
| SSI - Colon Surgery: Predicted Cases | 21.194 | Same as national |
| SSI - Colon Surgery: Observed Cases | 14 | Same as national |
| SSI - Colon Surgery | 0.661 | Same as national |
| SSI - Abdominal Hysterectomy: Lower Confidence Limit | 0.696 | Same as national |
| SSI - Abdominal Hysterectomy: Upper Confidence Limit | 3.147 | Same as national |
| SSI - Abdominal Hysterectomy: Number of Procedures | 529 | Same as national |
| SSI - Abdominal Hysterectomy: Predicted Cases | 4.400 | Same as national |
| SSI - Abdominal Hysterectomy: Observed Cases | 7 | Same as national |
| SSI - Abdominal Hysterectomy | 1.591 | Same as national |
| MRSA Bacteremia: Lower Confidence Limit | 0.277 | Better than national |
| MRSA Bacteremia: Upper Confidence Limit | 0.796 | Better than national |
| MRSA Bacteremia: Patient Days | 393601 | Better than national |
| MRSA Bacteremia: Predicted Cases | 28.800 | Better than national |
| MRSA Bacteremia: Observed Cases | 14 | Better than national |
| MRSA Bacteremia | 0.486 | Better than national |
| Clostridium Difficile (C.Diff): Lower Confidence Limit | 0.093 | Better than national |
| Clostridium Difficile (C.Diff): Upper Confidence Limit | 0.212 | Better than national |
| Clostridium Difficile (C.Diff): Patient Days | 353957 | Better than national |
| Clostridium Difficile (C.Diff): Predicted Cases | 160.470 | Better than national |
| Clostridium Difficile (C.Diff): Observed Cases | 23 | Better than national |
| Clostridium Difficile (C.Diff) | 0.143 | Better 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.
| Measure | Score | Compared to national | Sample |
|---|---|---|---|
| Rate of complications for hip/knee replacement patients | 3.8 | Same as national | 30 |
| Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate | 3.5 | Better than national | 4458 |
| Death rate for heart attack patients | 14.9 | Worse than national | 380 |
| Death rate for CABG surgery patients | 2.4 | Same as national | 219 |
| Death rate for COPD patients | 9.9 | Same as national | 319 |
| Death rate for heart failure patients | 9.8 | Better than national | 1299 |
| Death rate for pneumonia patients | 14.7 | Same as national | 1451 |
| Death rate for stroke patients | 12 | Same as national | 635 |
| Pressure ulcer rate | 0.26 | Better than national | 17391 |
| Death rate among surgical inpatients with serious treatable complications | 137.67 | Better than national | 432 |
| Iatrogenic pneumothorax rate | 0.20 | Same as national | 19726 |
| In-hospital fall-associated fracture rate | 0.19 | Same as national | 20235 |
| Postoperative hemorrhage or hematoma rate | 1.26 | Better than national | 4969 |
| Postoperative acute kidney injury requiring dialysis rate | 1.10 | Same as national | 1329 |
| Postoperative respiratory failure rate | 9.88 | Same as national | 1369 |
| Perioperative pulmonary embolism or deep vein thrombosis rate | 4.34 | Same as national | 5295 |
| Postoperative sepsis rate | 9.19 | Worse than national | 1305 |
| Postoperative wound dehiscence rate | 2.08 | Same as national | 1174 |
| Abdominopelvic accidental puncture or laceration rate | 0.99 | Same as national | 4154 |
| CMS Medicare PSI 90: Patient safety and adverse events composite | 1.02 | Same 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.
| Measure | Score | Compared to national | Sample |
|---|---|---|---|
| Hospital return days for heart attack patients | 51.4 | Not available | 372 |
| Hospital return days for heart failure patients | 19.7 | Not available | 1508 |
| Hospital return days for pneumonia patients | 22.5 | Not available | 1483 |
| Hybrid Hospital-Wide All-Cause Readmission Measure (HWR) | 14.8 | Same as national | 7528 |
| Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies) | 12.7 | Same as national | 2275 |
| Rate of inpatient admissions for patients receiving outpatient chemotherapy | — | Not available | — |
| Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy | — | Not available | — |
| Ratio of unplanned hospital visits after hospital outpatient surgery | 1 | Same as national | 1658 |
| Acute Myocardial Infarction (AMI) 30-Day Readmission Rate | 14.3 | Same as national | 372 |
| Rate of readmission for CABG | 11.4 | Same as national | 213 |
| Rate of readmission for chronic obstructive pulmonary disease (COPD) patients | 17.8 | Same as national | 344 |
| Heart failure (HF) 30-Day Readmission Rate | 20 | Same as national | 1508 |
| Rate of readmission after hip/knee replacement | 5.6 | Same as national | 28 |
| Pneumonia (PN) 30-Day Readmission Rate | 16.7 | Same as national | 1483 |
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.
| Measure | Score | Sample |
|---|---|---|
| Nurse communication - star rating | 3 | 1863 |
| Doctor communication - star rating | 3 | 1863 |
| Communication about medicines - star rating | 2 | 1863 |
| Discharge information - star rating | 2 | 1863 |
| Cleanliness - star rating | 4 | 1863 |
| Quietness - star rating | 3 | 1863 |
| Overall hospital rating - star rating | 3 | 1863 |
| Recommend hospital - star rating | 4 | 1863 |
| Summary star rating | 3 | 1863 |
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.
| Measure | Score | Sample |
|---|---|---|
| Emergency department volume | very 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 | 8 | 139254 |
| Hospital Harm - Severe Hypoglycemia | — | — |
| Hospital Harm - Opioid Related Adverse Events | — | — |
| Healthcare workers given influenza vaccination | 95 | 17082 |
| 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 better | 238 | 447 |
| 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 better | 229 | 424 |
| Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better | 350 | 11 |
| Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better | 338 | 12 |
| Left before being seen | 1 | 296823 |
| Head CT results | 51 | 93 |
| Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients | 93 | 271 |
| Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery | — | — |
| ST-Segment Elevation Myocardial Infarction (STEMI) | 79 | 42 |
| Safe Use of Opioids - Concurrent Prescribing | 10 | 10826 |
| Appropriate care for severe sepsis and septic shock | 43 | 667 |
| Septic Shock 3-Hour Bundle | 58 | 149 |
| Septic Shock 6-Hour Bundle | 75 | 55 |
| Severe Sepsis 3-Hour Bundle | 64 | 667 |
| Severe Sepsis 6-Hour Bundle | 80 | 301 |
| Discharged on Antithrombotic Therapy | 93 | 1288 |
| Anticoagulation Therapy for Atrial Fibrillation/Flutter | — | — |
| Antithrombotic Therapy by End of Hospital Day 2 | — | — |
| Venous Thromboembolism Prophylaxis | 90 | 39533 |
| 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.
| Measure | Score | Sample |
|---|---|---|
| Cesarean Birth | — | — |
| Risk Adjusted Severe Obstetric Complications (All) | — | — |
| Risk Adjusted Severe Obstetric Complications (excluding blood-transfusion-only cases) | — | — |
| Maternal Morbidity Structural Measure | Yes | — |
Frequently asked questions
- How is Memorial Hermann Hospital System rated?
- Memorial Hermann Hospital System has a 3 out of 5 CMS overall star rating as of the latest CMS release.
- Does Memorial Hermann Hospital System have emergency services?
- Yes. Memorial Hermann Hospital System operates a 24/7 emergency department.
- Where is Memorial Hermann Hospital System located?
- Memorial Hermann Hospital System is located at 1635 North Loop West, Houston, TX 77008.
- What type of hospital is Memorial Hermann Hospital System?
- Memorial Hermann Hospital System is classified by CMS as a Acute Care Hospitals facility (Voluntary non-profit - Private).
Compare with nearby hospitals
- Compare side-by-side →Not rated overall
Houston, TX
- Compare side-by-side →Not rated overall
Houston, TX
- Compare side-by-side →
Baylor St Lukes Medical Center
Houston, TX
- Compare side-by-side →Not rated overall
Houston, TX
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.