JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Proprietary

Memorial Hermann Surgical Hospital Kingwood

Not rated overall

CMS reports safety and quality measures for this hospital but does not assign an overall star rating. See scores below.

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 Limit—Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit—Not available
Central Line Associated Bloodstream Infection: Number of Device Days—Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases—Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases—Not available
Central Line Associated Bloodstream Infection (ICU + select Wards)—Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit—Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit—Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days108Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases0.055Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases0Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards)—Not available
SSI - Colon Surgery: Lower Confidence Limit—Not available
SSI - Colon Surgery: Upper Confidence Limit—Not available
SSI - Colon Surgery: Number of Procedures—Not available
SSI - Colon Surgery: Predicted Cases—Not available
SSI - Colon Surgery: Observed Cases—Not available
SSI - Colon Surgery—Not available
SSI - Abdominal Hysterectomy: Lower Confidence Limit—Not available
SSI - Abdominal Hysterectomy: Upper Confidence Limit—Not available
SSI - Abdominal Hysterectomy: Number of Procedures97Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.751Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal Hysterectomy—Not available
MRSA Bacteremia: Lower Confidence Limit—Not available
MRSA Bacteremia: Upper Confidence Limit—Not available
MRSA Bacteremia: Patient Days1013Not available
MRSA Bacteremia: Predicted Cases0.020Not available
MRSA Bacteremia: Observed Cases0Not available
MRSA Bacteremia—Not available
Clostridium Difficile (C.Diff): Lower Confidence Limit—Not available
Clostridium Difficile (C.Diff): Upper Confidence Limit—Not available
Clostridium Difficile (C.Diff): Patient Days1013Not available
Clostridium Difficile (C.Diff): Predicted Cases0.205Not available
Clostridium Difficile (C.Diff): Observed Cases0Not available
Clostridium Difficile (C.Diff)—Not available

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 patients4Same as national156
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4.1Same as national50
Death rate for heart attack patients—Not available—
Death rate for CABG surgery patients—Not available—
Death rate for COPD patients—Not available—
Death rate for heart failure patients—Not available—
Death rate for pneumonia patients—Not available—
Death rate for stroke patients—Not available—
Pressure ulcer rate—Not available—
Death rate among surgical inpatients with serious treatable complications—Not available—
Iatrogenic pneumothorax rate0.21Same as national161
In-hospital fall-associated fracture rate0.27Same as national159
Postoperative hemorrhage or hematoma rate2.31Same as national160
Postoperative acute kidney injury requiring dialysis rate1.67Same as national160
Postoperative respiratory failure rate8.86Same as national160
Perioperative pulmonary embolism or deep vein thrombosis rate3.38Same as national160
Postoperative sepsis rate5.16Same as national156
Postoperative wound dehiscence rate—Not available—
Abdominopelvic accidental puncture or laceration rate1.06Same as national27
CMS Medicare PSI 90: Patient safety and adverse events composite0.97Same 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—Not available—
Hospital return days for heart failure patients—Not available—
Hospital return days for pneumonia patients—Not available—
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.8Same as national54
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)13Same as national36
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 surgery0.9Same as national260
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate—Not available—
Rate of readmission for CABG—Not available—
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients—Not available—
Heart failure (HF) 30-Day Readmission Rate—Not available—
Rate of readmission after hip/knee replacement4.2Same as national151
Pneumonia (PN) 30-Day Readmission Rate—Not available—

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 rating—37
Doctor communication - star rating—37
Communication about medicines - star rating—37
Discharge information - star rating—37
Cleanliness - star rating—37
Quietness - star rating—37
Overall hospital rating - star rating—37
Recommend hospital - star rating—37
Summary star rating—37

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 volume——
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 Hyperglycemia036
Hospital Harm - Severe Hypoglycemia——
Hospital Harm - Opioid Related Adverse Events——
Healthcare workers given influenza vaccination90194
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——
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——
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 seen——
Head CT results——
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients9840
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery——
ST-Segment Elevation Myocardial Infarction (STEMI)——
Safe Use of Opioids - Concurrent Prescribing——
Appropriate care for severe sepsis and septic shock——
Septic Shock 3-Hour Bundle——
Septic Shock 6-Hour Bundle——
Severe Sepsis 3-Hour Bundle——
Severe Sepsis 6-Hour Bundle——
Discharged on Antithrombotic Therapy——
Anticoagulation Therapy for Atrial Fibrillation/Flutter——
Antithrombotic Therapy by End of Hospital Day 2——
Venous Thromboembolism Prophylaxis9769
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 MeasureNot Applicable (our hospital does not provide inpatient labor/delivery care)—

Frequently asked questions

How is Memorial Hermann Surgical Hospital Kingwood rated?
CMS does not assign an overall star rating to Memorial Hermann Surgical Hospital Kingwood, but does publish underlying safety and quality measures shown on this page.
Does Memorial Hermann Surgical Hospital Kingwood have emergency services?
Yes. Memorial Hermann Surgical Hospital Kingwood operates a 24/7 emergency department.
Where is Memorial Hermann Surgical Hospital Kingwood located?
Memorial Hermann Surgical Hospital Kingwood is located at 300 Kingwood Medical Drive, Kingwood, TX 77339.
What type of hospital is Memorial Hermann Surgical Hospital Kingwood?
Memorial Hermann Surgical Hospital Kingwood 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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