JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Mission Regional Medical Center

4 / 5

At a glance

Mission Regional Medical Center carries a 4-star CMS overall rating — above the national norm. On healthcare-associated infection measures, it performs better than the national average on 12 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 Limit0.014Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit1.406Same as national
Central Line Associated Bloodstream Infection: Number of Device Days4000Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases3.508Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases1Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.285Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence LimitBetter than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit0.957Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days3796Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases3.130Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases0Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.000Better than national
SSI - Colon Surgery: Lower Confidence LimitSame as national
SSI - Colon Surgery: Upper Confidence Limit2.259Same as national
SSI - Colon Surgery: Number of Procedures45Same as national
SSI - Colon Surgery: Predicted Cases1.326Same as national
SSI - Colon Surgery: Observed Cases0Same as national
SSI - Colon Surgery0.000Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures70Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.547Not available
SSI - Abdominal Hysterectomy: Observed Cases1Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence Limit0.178Same as national
MRSA Bacteremia: Upper Confidence Limit3.502Same as national
MRSA Bacteremia: Patient Days42436Same as national
MRSA Bacteremia: Predicted Cases1.887Same as national
MRSA Bacteremia: Observed Cases2Same as national
MRSA Bacteremia1.060Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.087Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.525Better than national
Clostridium Difficile (C.Diff): Patient Days36153Better than national
Clostridium Difficile (C.Diff): Predicted Cases21.118Better than national
Clostridium Difficile (C.Diff): Observed Cases5Better than national
Clostridium Difficile (C.Diff)0.237Better 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 Rate3.1Better than national396
Death rate for heart attack patients12.1Same as national54
Death rate for CABG surgery patientsNot available
Death rate for COPD patients7.4Same as national41
Death rate for heart failure patients8.8Same as national72
Death rate for pneumonia patients12.1Better than national250
Death rate for stroke patients13.3Same as national28
Pressure ulcer rate0.70Same as national1487
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.19Same as national2011
In-hospital fall-associated fracture rate0.29Same as national2138
Postoperative hemorrhage or hematoma rate2.23Same as national239
Postoperative acute kidney injury requiring dialysis rate1.63Same as national41
Postoperative respiratory failure rate7.64Same as national56
Perioperative pulmonary embolism or deep vein thrombosis rate3.14Same as national260
Postoperative sepsis rate5.17Same as national28
Postoperative wound dehiscence rate1.74Same as national48
Abdominopelvic accidental puncture or laceration rate1.02Same as national236
CMS Medicare PSI 90: Patient safety and adverse events composite0.95Same 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 patients69.6Not available84
Hospital return days for pneumonia patients2Not available262
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)15.2Same as national627
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)12.8Same as national203
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 surgery0.9Same as national48
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate13.8Same as national42
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients18.7Same as national46
Heart failure (HF) 30-Day Readmission Rate21Same as national84
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate16.9Same as national262

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 rating3519
Doctor communication - star rating3519
Communication about medicines - star rating2519
Discharge information - star rating3519
Cleanliness - star rating4519
Quietness - star rating3519
Overall hospital rating - star rating3519
Recommend hospital - star rating4519
Summary star rating3519

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 volumemedium
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 Hyperglycemia415000
Hospital Harm - Severe Hypoglycemia02902
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination822222
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 better156432
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 better151406
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better15416
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 seen033760
Head CT results3315
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients100149
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing7708
Appropriate care for severe sepsis and septic shock56135
Septic Shock 3-Hour Bundle5030
Septic Shock 6-Hour Bundle8513
Severe Sepsis 3-Hour Bundle73135
Severe Sepsis 6-Hour Bundle9260
Discharged on Antithrombotic Therapy
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 25783
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 Mission Regional Medical Center rated?
Mission Regional Medical Center has a 4 out of 5 CMS overall star rating as of the latest CMS release.
Does Mission Regional Medical Center have emergency services?
Yes. Mission Regional Medical Center operates a 24/7 emergency department.
Where is Mission Regional Medical Center located?
Mission Regional Medical Center is located at 900 South Bryan Road, Mission, TX 78572.
What type of hospital is Mission Regional Medical Center?
Mission Regional Medical Center 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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