JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Proprietary

St Luke's Patients Medical Center

3 / 5

At a glance

St Luke's Patients Medical Center carries a 3-star CMS overall rating — in line with the national norm.

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 LimitSame as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit1.892Same as national
Central Line Associated Bloodstream Infection: Number of Device Days2549Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases1.583Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases0Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.000Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence LimitSame as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit2.021Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days2899Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases1.482Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases0Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.000Same as national
SSI - Colon Surgery: Lower Confidence LimitNot available
SSI - Colon Surgery: Upper Confidence LimitNot available
SSI - Colon Surgery: Number of Procedures26Not available
SSI - Colon Surgery: Predicted Cases0.735Not available
SSI - Colon Surgery: Observed Cases1Not available
SSI - Colon SurgeryNot available
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures4Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.034Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitNot available
MRSA Bacteremia: Upper Confidence LimitNot available
MRSA Bacteremia: Patient Days13212Not available
MRSA Bacteremia: Predicted Cases0.549Not available
MRSA Bacteremia: Observed Cases1Not available
MRSA BacteremiaNot available
Clostridium Difficile (C.Diff): Lower Confidence Limit0.012Same as national
Clostridium Difficile (C.Diff): Upper Confidence Limit1.151Same as national
Clostridium Difficile (C.Diff): Patient Days13212Same as national
Clostridium Difficile (C.Diff): Predicted Cases4.285Same as national
Clostridium Difficile (C.Diff): Observed Cases1Same as national
Clostridium Difficile (C.Diff)0.233Same as 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 Rate4.6Same as national257
Death rate for heart attack patientsNot available
Death rate for CABG surgery patientsNot available
Death rate for COPD patients7.9Same as national29
Death rate for heart failure patients11.3Same as national87
Death rate for pneumonia patients14.3Same as national77
Death rate for stroke patientsNot available
Pressure ulcer rate0.41Same as national915
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.20Same as national1038
In-hospital fall-associated fracture rate0.26Same as national1074
Postoperative hemorrhage or hematoma rate2.23Same as national179
Postoperative acute kidney injury requiring dialysis rate1.65Same as national51
Postoperative respiratory failure rate8.46Same as national75
Perioperative pulmonary embolism or deep vein thrombosis rate3.76Same as national190
Postoperative sepsis rate5.09Same as national44
Postoperative wound dehiscence rate1.73Same as national58
Abdominopelvic accidental puncture or laceration rate1.01Same as national267
CMS Medicare PSI 90: Patient safety and adverse events composite0.91Same 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 patients30.4Not available100
Hospital return days for pneumonia patients60.4Not available81
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.6Same as national389
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)12.7Same as national401
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 national132
Acute Myocardial Infarction (AMI) 30-Day Readmission RateNot available
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients18.3Same as national33
Heart failure (HF) 30-Day Readmission Rate19.6Same as national100
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate16.4Same as national81

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 rating2389
Doctor communication - star rating2389
Communication about medicines - star rating2389
Discharge information - star rating2389
Cleanliness - star rating2389
Quietness - star rating3389
Overall hospital rating - star rating2389
Recommend hospital - star rating3389
Summary star rating2389

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 volumelow
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 Hypoglycemia0918
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination60859
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 better148404
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 better147397
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 seen017274
Head CT results
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients9973
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing10210
Appropriate care for severe sepsis and septic shock6277
Septic Shock 3-Hour Bundle6221
Septic Shock 6-Hour Bundle9111
Severe Sepsis 3-Hour Bundle8377
Severe Sepsis 6-Hour Bundle9153
Discharged on Antithrombotic Therapy
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 2
Venous Thromboembolism Prophylaxis222045
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 St Luke's Patients Medical Center rated?
St Luke's Patients Medical Center has a 3 out of 5 CMS overall star rating as of the latest CMS release.
Does St Luke's Patients Medical Center have emergency services?
Yes. St Luke's Patients Medical Center operates a 24/7 emergency department.
Where is St Luke's Patients Medical Center located?
St Luke's Patients Medical Center is located at 4600 East Sam Houston Parkway South, Pasadena, TX 77505.
What type of hospital is St Luke's Patients Medical Center?
St Luke's Patients Medical Center 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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