JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Northwest Hills Surgical Hospital

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 LimitNot available
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence LimitNot available
Central Line Associated Bloodstream Infection: Number of Device DaysNot available
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted CasesNot available
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed CasesNot available
Central Line Associated Bloodstream Infection (ICU + select Wards)Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence LimitNot available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence LimitNot available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days176Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases0.059Not 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 LimitNot available
SSI - Colon Surgery: Upper Confidence LimitNot available
SSI - Colon Surgery: Number of ProceduresNot available
SSI - Colon Surgery: Predicted CasesNot available
SSI - Colon Surgery: Observed CasesNot available
SSI - Colon SurgeryNot available
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of ProceduresNot available
SSI - Abdominal Hysterectomy: Predicted CasesNot available
SSI - Abdominal Hysterectomy: Observed CasesNot available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitNot available
MRSA Bacteremia: Upper Confidence LimitNot available
MRSA Bacteremia: Patient Days634Not available
MRSA Bacteremia: Predicted Cases0.010Not available
MRSA Bacteremia: Observed Cases0Not available
MRSA BacteremiaNot available
Clostridium Difficile (C.Diff): Lower Confidence LimitNot available
Clostridium Difficile (C.Diff): Upper Confidence LimitNot available
Clostridium Difficile (C.Diff): Patient Days634Not available
Clostridium Difficile (C.Diff): Predicted Cases0.086Not 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 patientsNot available
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4.1Same as national58
Death rate for heart attack patientsNot available
Death rate for CABG surgery patientsNot available
Death rate for COPD patientsNot available
Death rate for heart failure patientsNot available
Death rate for pneumonia patientsNot available
Death rate for stroke patientsNot available
Pressure ulcer rateNot available
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.21Same as national187
In-hospital fall-associated fracture rate0.27Same as national184
Postoperative hemorrhage or hematoma rate2.23Same as national185
Postoperative acute kidney injury requiring dialysis rate1.66Same as national186
Postoperative respiratory failure rate7.87Same as national185
Perioperative pulmonary embolism or deep vein thrombosis rate3.22Same as national187
Postoperative sepsis rate4.96Same as national185
Postoperative wound dehiscence rate1.77Same as national41
Abdominopelvic accidental puncture or laceration rate1.05Same as national109
CMS Medicare PSI 90: Patient safety and adverse events composite0.93Same 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 patientsNot available
Hospital return days for pneumonia patientsNot available
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.4Same as national60
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)12.5Same as national707
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 national75
Acute Myocardial Infarction (AMI) 30-Day Readmission RateNot available
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patientsNot available
Heart failure (HF) 30-Day Readmission RateNot available
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission RateNot 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 rating82
Doctor communication - star rating82
Communication about medicines - star rating82
Discharge information - star rating82
Cleanliness - star rating82
Quietness - star rating82
Overall hospital rating - star rating82
Recommend hospital - star rating82
Summary star rating82

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 Hyperglycemia
Hospital Harm - Severe Hypoglycemia
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination26400
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 patients99128
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing16136
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 Therapy0
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 2
Venous Thromboembolism Prophylaxis96127
Intensive Care Unit Venous Thromboembolism Prophylaxis0

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 Northwest Hills Surgical Hospital rated?
CMS does not assign an overall star rating to Northwest Hills Surgical Hospital, but does publish underlying safety and quality measures shown on this page.
Does Northwest Hills Surgical Hospital have emergency services?
Yes. Northwest Hills Surgical Hospital operates a 24/7 emergency department.
Where is Northwest Hills Surgical Hospital located?
Northwest Hills Surgical Hospital is located at 6818 Austin Ctr Blvd Suite 100, Austin, TX 78731.
What type of hospital is Northwest Hills Surgical Hospital?
Northwest Hills Surgical 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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