Acute Care Hospitals · Voluntary non-profit - Private
St Luke's the Woodlands Hospital
- 17200 St Luke's Way, the Woodlands, TX 77384
- (936) 266-4050
- Acute Care Hospitals
- Emergency services available 24/7
At a glance
St Luke's the Woodlands Hospital 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 6 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 | 0.242 | Same as national |
| Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit | 1.467 | Same as national |
| Central Line Associated Bloodstream Infection: Number of Device Days | 8473 | Same as national |
| Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases | 7.555 | Same as national |
| Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases | 5 | Same as national |
| Central Line Associated Bloodstream Infection (ICU + select Wards) | 0.662 | Same as national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit | 0.362 | Same as national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit | 1.481 | Same as national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days | 8412 | Same as national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases | 10.260 | Same as national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases | 8 | Same as national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards) | 0.780 | Same as national |
| SSI - Colon Surgery: Lower Confidence Limit | 0.451 | Same as national |
| SSI - Colon Surgery: Upper Confidence Limit | 3.420 | Same as national |
| SSI - Colon Surgery: Number of Procedures | 106 | Same as national |
| SSI - Colon Surgery: Predicted Cases | 2.821 | Same as national |
| SSI - Colon Surgery: Observed Cases | 4 | Same as national |
| SSI - Colon Surgery | 1.418 | Same as national |
| SSI - Abdominal Hysterectomy: Lower Confidence Limit | 0.187 | Same as national |
| SSI - Abdominal Hysterectomy: Upper Confidence Limit | 3.687 | Same as national |
| SSI - Abdominal Hysterectomy: Number of Procedures | 212 | Same as national |
| SSI - Abdominal Hysterectomy: Predicted Cases | 1.792 | Same as national |
| SSI - Abdominal Hysterectomy: Observed Cases | 2 | Same as national |
| SSI - Abdominal Hysterectomy | 1.116 | Same as national |
| MRSA Bacteremia: Lower Confidence Limit | 0.346 | Same as national |
| MRSA Bacteremia: Upper Confidence Limit | 2.626 | Same as national |
| MRSA Bacteremia: Patient Days | 58940 | Same as national |
| MRSA Bacteremia: Predicted Cases | 3.674 | Same as national |
| MRSA Bacteremia: Observed Cases | 4 | Same as national |
| MRSA Bacteremia | 1.089 | Same as national |
| Clostridium Difficile (C.Diff): Lower Confidence Limit | 0.193 | Better than national |
| Clostridium Difficile (C.Diff): Upper Confidence Limit | 0.679 | Better than national |
| Clostridium Difficile (C.Diff): Patient Days | 53400 | Better than national |
| Clostridium Difficile (C.Diff): Predicted Cases | 26.267 | Better than national |
| Clostridium Difficile (C.Diff): Observed Cases | 10 | Better than national |
| Clostridium Difficile (C.Diff) | 0.381 | 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 | — | Not available | — |
| Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate | 3.7 | Same as national | 997 |
| Death rate for heart attack patients | 12.3 | Same as national | 101 |
| Death rate for CABG surgery patients | 1.9 | Same as national | 68 |
| Death rate for COPD patients | 9.1 | Same as national | 70 |
| Death rate for heart failure patients | 11.6 | Same as national | 293 |
| Death rate for pneumonia patients | 15 | Same as national | 281 |
| Death rate for stroke patients | 13.2 | Same as national | 159 |
| Pressure ulcer rate | 0.68 | Same as national | 3446 |
| Death rate among surgical inpatients with serious treatable complications | 154.33 | Same as national | 49 |
| Iatrogenic pneumothorax rate | 0.16 | Same as national | 3980 |
| In-hospital fall-associated fracture rate | 0.31 | Same as national | 4313 |
| Postoperative hemorrhage or hematoma rate | 1.81 | Same as national | 813 |
| Postoperative acute kidney injury requiring dialysis rate | 1.52 | Same as national | 296 |
| Postoperative respiratory failure rate | 7.08 | Same as national | 302 |
| Perioperative pulmonary embolism or deep vein thrombosis rate | 3.29 | Same as national | 835 |
| Postoperative sepsis rate | 6.10 | Same as national | 288 |
| Postoperative wound dehiscence rate | 1.68 | Same as national | 194 |
| Abdominopelvic accidental puncture or laceration rate | 1.11 | Same as national | 811 |
| CMS Medicare PSI 90: Patient safety and adverse events composite | 0.96 | 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 | 26.4 | Not available | 96 |
| Hospital return days for heart failure patients | -7.6 | Not available | 333 |
| Hospital return days for pneumonia patients | -7.5 | Not available | 291 |
| Hybrid Hospital-Wide All-Cause Readmission Measure (HWR) | 14.6 | Same as national | 1581 |
| Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies) | 14.1 | Same as national | 568 |
| Rate of inpatient admissions for patients receiving outpatient chemotherapy | 11.8 | Same as national | 64 |
| Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy | 5.4 | Same as national | 64 |
| Ratio of unplanned hospital visits after hospital outpatient surgery | 1.1 | Same as national | 174 |
| Acute Myocardial Infarction (AMI) 30-Day Readmission Rate | 13.9 | Same as national | 96 |
| Rate of readmission for CABG | 11.4 | Same as national | 68 |
| Rate of readmission for chronic obstructive pulmonary disease (COPD) patients | 18 | Same as national | 84 |
| Heart failure (HF) 30-Day Readmission Rate | 19.6 | Same as national | 333 |
| Rate of readmission after hip/knee replacement | — | Not available | — |
| Pneumonia (PN) 30-Day Readmission Rate | 15.8 | Same as national | 291 |
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 | 4 | 510 |
| Doctor communication - star rating | 3 | 510 |
| Communication about medicines - star rating | 2 | 510 |
| Discharge information - star rating | 3 | 510 |
| Cleanliness - star rating | 4 | 510 |
| Quietness - star rating | 4 | 510 |
| Overall hospital rating - star rating | 4 | 510 |
| Recommend hospital - star rating | 5 | 510 |
| Summary star rating | 3 | 510 |
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 | — | — |
| Hospital Harm - Severe Hypoglycemia | — | — |
| Hospital Harm - Opioid Related Adverse Events | — | — |
| Healthcare workers given influenza vaccination | 83 | 2037 |
| 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 | 168 | 407 |
| 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 | 168 | 392 |
| 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 | 1 | 61509 |
| Head CT results | — | — |
| Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients | 99 | 67 |
| Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery | — | — |
| ST-Segment Elevation Myocardial Infarction (STEMI) | — | — |
| Safe Use of Opioids - Concurrent Prescribing | 15 | 4382 |
| Appropriate care for severe sepsis and septic shock | 62 | 102 |
| Septic Shock 3-Hour Bundle | 63 | 35 |
| Septic Shock 6-Hour Bundle | 90 | 20 |
| Severe Sepsis 3-Hour Bundle | 83 | 103 |
| Severe Sepsis 6-Hour Bundle | 85 | 47 |
| Discharged on Antithrombotic Therapy | 97 | 219 |
| Anticoagulation Therapy for Atrial Fibrillation/Flutter | — | — |
| Antithrombotic Therapy by End of Hospital Day 2 | 91 | 192 |
| Venous Thromboembolism Prophylaxis | — | — |
| Intensive Care Unit Venous Thromboembolism Prophylaxis | 97 | 1639 |
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 St Luke's the Woodlands Hospital rated?
- St Luke's the Woodlands Hospital has a 3 out of 5 CMS overall star rating as of the latest CMS release.
- Does St Luke's the Woodlands Hospital have emergency services?
- Yes. St Luke's the Woodlands Hospital operates a 24/7 emergency department.
- Where is St Luke's the Woodlands Hospital located?
- St Luke's the Woodlands Hospital is located at 17200 St Luke's Way, the Woodlands, TX 77384.
- What type of hospital is St Luke's the Woodlands Hospital?
- St Luke's the Woodlands Hospital is classified by CMS as a Acute Care Hospitals facility (Voluntary non-profit - Private).
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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.