Bottom quartile Middle Top quartile Percentile badges compare this hospital to all 5,426 hospitals nationally.

Overview

Address
6411 FANNIN, HOUSTON, TX 77030
Phone
(713) 704-3700
Hospital Type
Acute Care
Ownership
Non-Profit
Emergency Services
Yes
Birthing Friendly
Yes
3 /5
CMS Overall Rating
p30
Acute Care — General medical and surgical hospital participating in Medicare IPPS. Subject to CMS quality reporting and payment adjustment programs (VBP, HRRP, HAC).

CMS Star Rating — Quality Domain Breakdown

CMS computes the overall star rating from five quality domains. Each domain compares this hospital's measures against national benchmarks.

Mortality 7 of 7 measures reported
1
6
Better No different Worse
30-day death rates for heart attack, heart failure, pneumonia, COPD, stroke, CABG, and kidney disease.
Safety of Care 7 of 8 measures reported
4
3
Better No different Worse
Healthcare-associated infections and patient safety indicators (PSI-90 composite).
Readmission 10 of 11 measures reported
1
9
Better No different Worse
30-day unplanned readmission rates for heart attack, heart failure, pneumonia, COPD, hip/knee replacement, and CABG.
Patient Experience 8 of 8 measures reported
8 measures reported (comparative data not available for this domain)
HCAHPS survey scores — patient-reported experience with communication, responsiveness, cleanliness, and discharge planning.
Timely & Effective Care 12 of 12 measures reported
12 measures reported (comparative data not available for this domain)
Process-of-care measures including flu immunization, blood clot prevention, and appropriate use of imaging.

Readmissions — Hospital Readmissions Reduction Program

The Excess Readmission Ratio (ERR) compares this hospital's 30-day readmission rate to expected, adjusting for patient mix. An ERR of 1.0 means readmissions are as expected; > 1.0 triggers a Medicare payment penalty (up to 3%).

This hospital has excess readmissions in at least one condition and is subject to HRRP payment reduction.
Acute Myocardial Infarction (Heart Attack) 225 discharges
0.8871 p3
Heart Failure 481 discharges
0.9419 p16
Pneumonia 330 discharges
1.0374 p74
COPD 71 discharges
0.9815 p35
Hip/Knee Replacement
— Not reported
CABG Surgery 84 discharges
1.0230 p59
Expected (1.0) National median

Value-Based Purchasing

The Hospital VBP Program adjusts Medicare payments based on clinical quality. The Total Performance Score (TPS) is a weighted composite of four domains, each worth 25%. This hospital's TPS is below the national median, suggesting a negative payment adjustment.

26.6 p39
Total Performance Score
National median: 29.5
Clinical Outcomes 25% weight
11.5 p87
Nat'l median: 5.0
Measures mortality rates for conditions like heart attack, heart failure, pneumonia, and COPD. Based on 30-day risk-standardized mortality.
Safety 25% weight
7.1 p25
Nat'l median: 10.0
Patient safety measures including healthcare-associated infections (CLABSI, CAUTI, SSI, MRSA, C. diff) and perioperative complications.
Person & Community Engagement 25% weight
8.0 p43
Nat'l median: 8.8
Based on HCAHPS patient experience survey results — communication with nurses and doctors, hospital cleanliness, pain management, discharge information.
Efficiency & Cost Reduction 25% weight
0.0 p0
Nat'l median: 2.5
Based on Medicare Spending Per Beneficiary (MSPB). Measures episode-of-care costs from 3 days before admission through 30 days after discharge.

CMS Payment Programs

Three Medicare programs adjust hospital payments based on quality performance. Hospitals can be penalized under multiple programs simultaneously.

Readmissions (HRRP)
Penalized
Worst ERR: 1.0374
Value-Based Purchasing
26.6 TPS
Below national median
HAC Reduction
No Reduction
HAC Score: -0.1101

Complications & Deaths

30-day mortality rates, patient safety indicators, and complication rates. "Better" means statistically significantly better than the national rate.

Measure Score vs. National Denominator
COMP_HIP_KNEE Number of Cases Too Small
Hybrid_HWM 3.10 Better Than the National Rate 2,086
MORT_30_AMI 11.90 No Different Than the National Rate 170
MORT_30_CABG 2.40 No Different Than the National Rate 89
MORT_30_COPD 10.90 No Different Than the National Rate 64
MORT_30_HF 9.50 No Different Than the National Rate 386
MORT_30_PN 13.50 No Different Than the National Rate 315
MORT_30_STK 12.90 No Different Than the National Rate 413
PSI_03 0.61 No Different Than the National Rate 9,104
PSI_04 158.49 No Different Than the National Rate 360
PSI_06 0.22 No Different Than the National Rate 9,923
PSI_08 0.18 No Different Than the National Rate 9,628
PSI_09 2.88 No Different Than the National Rate 3,572
PSI_10 1.07 No Different Than the National Rate 996
PSI_11 5.90 No Different Than the National Rate 1,048
PSI_12 5.51 Worse Than the National Rate 3,925
PSI_13 8.07 No Different Than the National Rate 1,039
PSI_14 1.71 No Different Than the National Rate 612
PSI_15 1.00 No Different Than the National Rate 2,066
PSI_90 1.05 No Different Than the National Value

Patient Experience (HCAHPS)

Hospital Consumer Assessment of Healthcare Providers and Systems — standardized patient survey measuring satisfaction with care.

Measure Score Star Rating
H_COMP_1_A_P: Nurses "always" communicated well 75%
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 5%
H_COMP_1_U_P: Nurses "usually" communicated well 20%
H_COMP_1_LINEAR_SCORE: Nurse communication - linear mean score
H_COMP_1_STAR_RATING: Nurse communication - star rating 3
H_NURSE_RESPECT_A_P: Nurses "always" treated them with courtesy and respect 83%
H_NURSE_RESPECT_SN_P: Nurses "sometimes" or "never" treated them with courtesy and respect 3%
H_NURSE_RESPECT_U_P: Nurses "usually" treated them with courtesy and respect 14%
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 72%
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 5%
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 23%
H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand 71%
H_NURSE_EXPLAIN_SN_P: Nurses "sometimes" or "never" explained things so they could understand 6%
H_NURSE_EXPLAIN_U_P: Nurses "usually" explained things so they could understand 23%
H_COMP_2_A_P: Doctors "always" communicated well 76%
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 6%
H_COMP_2_U_P: Doctors "usually" communicated well 18%
H_COMP_2_LINEAR_SCORE: Doctor communication - linear mean score
H_COMP_2_STAR_RATING: Doctor communication - star rating 3
H_DOCTOR_RESPECT_A_P: Doctors "always" treated them with courtesy and respect 82%
H_DOCTOR_RESPECT_SN_P: Doctors "sometimes" or "never" treated them with courtesy and respect 4%
H_DOCTOR_RESPECT_U_P: Doctors "usually" treated them with courtesy and respect 14%
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 75%
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 6%
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 19%
H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand 71%
H_DOCTOR_EXPLAIN_SN_P: Doctors "sometimes" or "never" explained things so they could understand 7%
H_DOCTOR_EXPLAIN_U_P: Doctors "usually" explained things so they could understand 22%
H_COMP_5_A_P: Staff "always" explained 57%
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 23%
H_COMP_5_U_P: Staff "usually" explained 20%
H_COMP_5_LINEAR_SCORE: Communication about medicines - linear mean score
H_COMP_5_STAR_RATING: Communication about medicines - star rating 2
H_MED_FOR_A_P: Staff "always" explained new medications 71%
H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications 12%
H_MED_FOR_U_P: Staff "usually" explained new medications 17%
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 43%
H_SIDE_EFFECTS_SN_P: Staff "sometimes" or "never" explained possible side effects 34%
H_SIDE_EFFECTS_U_P: Staff "usually" explained possible side effects 23%
H_COMP_6_N_P: No, staff "did not" give patients this information 15%
H_COMP_6_Y_P: Yes, staff "did" give patients this information 85%
H_COMP_6_LINEAR_SCORE: Discharge information - linear mean score
H_COMP_6_STAR_RATING: Discharge information - star rating 3
H_DISCH_HELP_N_P: No, staff "did not" give patients information about help after discharge 16%
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge 84%
H_SYMPTOMS_N_P: No, staff "did not" give patients information about possible symptoms 14%
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms 86%
H_CLEAN_HSP_A_P: Room was "always" clean 71%
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 8%
H_CLEAN_HSP_U_P: Room was "usually" clean 21%
H_CLEAN_LINEAR_SCORE: Cleanliness - linear mean score
H_CLEAN_STAR_RATING: Cleanliness - star rating 3
H_QUIET_HSP_A_P: "Always" quiet at night 60%
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 10%
H_QUIET_HSP_U_P: "Usually" quiet at night 30%
H_QUIET_LINEAR_SCORE: Quietness - linear mean score
H_QUIET_STAR_RATING: Quietness - star rating 3
H_HSP_RATING_0_6: Patients who gave a rating of "6" or lower (low) 10%
H_HSP_RATING_7_8: Patients who gave a rating of "7" or "8" (medium) 18%
H_HSP_RATING_9_10: Patients who gave a rating of "9" or "10" (high) 72%
H_HSP_RATING_LINEAR_SCORE: Overall hospital rating - linear mean score
H_HSP_RATING_STAR_RATING: Overall hospital rating - star rating 3
H_RECMND_DN: "NO", patients would not recommend the hospital (they probably would not or definitely would not recommend it) 8%
H_RECMND_DY: "YES", patients would definitely recommend the hospital 71%
H_RECMND_PY: "YES", patients would probably recommend the hospital 21%
H_RECMND_LINEAR_SCORE: Recommend hospital - linear mean score
H_RECMND_STAR_RATING: Recommend hospital - star rating 4
H_STAR_RATING: Summary star rating 3

Healthcare Associated Infections

Standardized Infection Ratios (SIR). A SIR < 1.0 means fewer infections than predicted based on national baseline data.

Measure Score (SIR) vs. National
HAI_1_CILOWER 0.307 Better than the National Benchmark
HAI_1_CIUPPER 0.638 Better than the National Benchmark
HAI_1_DOPC 49706.000 Better than the National Benchmark
HAI_1_ELIGCASES 64.471 Better than the National Benchmark
HAI_1_NUMERATOR 29.000 Better than the National Benchmark
HAI_1_SIR 0.450 Better than the National Benchmark
HAI_2_CILOWER 0.235 Better than the National Benchmark
HAI_2_CIUPPER 0.569 Better than the National Benchmark
HAI_2_DOPC 26904.000 Better than the National Benchmark
HAI_2_ELIGCASES 53.336 Better than the National Benchmark
HAI_2_NUMERATOR 20.000 Better than the National Benchmark
HAI_2_SIR 0.375 Better than the National Benchmark
HAI_3_CILOWER 0.603 No Different than National Benchmark
HAI_3_CIUPPER 1.734 No Different than National Benchmark
HAI_3_DOPC 414.000 No Different than National Benchmark
HAI_3_ELIGCASES 13.223 No Different than National Benchmark
HAI_3_NUMERATOR 14.000 No Different than National Benchmark
HAI_3_SIR 1.059 No Different than National Benchmark
HAI_4_CILOWER 0.069 No Different than National Benchmark
HAI_4_CIUPPER 1.351 No Different than National Benchmark
HAI_4_DOPC 480.000 No Different than National Benchmark
HAI_4_ELIGCASES 4.892 No Different than National Benchmark
HAI_4_NUMERATOR 2.000 No Different than National Benchmark
HAI_4_SIR 0.409 No Different than National Benchmark
HAI_5_CILOWER 0.412 Better than the National Benchmark
HAI_5_CIUPPER 0.956 Better than the National Benchmark
HAI_5_DOPC 361019.000 Better than the National Benchmark
HAI_5_ELIGCASES 34.282 Better than the National Benchmark
HAI_5_NUMERATOR 22.000 Better than the National Benchmark
HAI_5_SIR 0.642 Better than the National Benchmark
HAI_6_CILOWER 0.106 Better than the National Benchmark
HAI_6_CIUPPER 0.229 Better than the National Benchmark
HAI_6_DOPC 304538.000 Better than the National Benchmark
HAI_6_ELIGCASES 163.743 Better than the National Benchmark
HAI_6_NUMERATOR 26.000 Better than the National Benchmark
HAI_6_SIR 0.159 Better than the National Benchmark

Timely & Effective Care

Process-of-care measures including ED wait times, treatment timeliness, and preventive care.

Measure Score Condition
EDV very high Emergency Department
GMCS Electronic Clinical Quality Measure
GMCS_Malnutrition_Diagnosis_Documented Electronic Clinical Quality Measure
GMCS_Malnutrition_Screening Electronic Clinical Quality Measure
GMCS_Nutrition_Assessment Electronic Clinical Quality Measure
GMCS_Nutritional_Care_Plan Electronic Clinical Quality Measure
HH_HYPER 6.0 Electronic Clinical Quality Measure
HH_HYPO Electronic Clinical Quality Measure
HH_ORAE Electronic Clinical Quality Measure
IMM_3 95.0 Healthcare Personnel Vaccination
OP_18a 264.0 Emergency Department
OP_18b 255.0 Emergency Department
OP_18c 917.0 Emergency Department
OP_18d Emergency Department
OP_22 5.0 Emergency Department
OP_23 74.0 Emergency Department
OP_29 96.0 Colonoscopy care
OP_31 Cataract surgery outcome
OP_40 Electronic Clinical Quality Measure
SAFE_USE_OF_OPIOIDS 10.0 Electronic Clinical Quality Measure
SEP_1 40.0 Sepsis Care
SEP_SH_3HR 47.0 Sepsis Care
SEP_SH_6HR 71.0 Sepsis Care
SEV_SEP_3HR 64.0 Sepsis Care
SEV_SEP_6HR 78.0 Sepsis Care
STK_02 89.0 Electronic Clinical Quality Measure
STK_03 Electronic Clinical Quality Measure
STK_05 Electronic Clinical Quality Measure
VTE_1 90.0 Electronic Clinical Quality Measure
VTE_2 Electronic Clinical Quality Measure

Unplanned Hospital Visits

Readmission and ED return rates within 30 days of discharge.

Measure Score vs. National
EDAC_30_AMI -17.50 Fewer Days Than Average per 100 Discharges
EDAC_30_HF 16.60 More Days Than Average per 100 Discharges
EDAC_30_PN 32.80 More Days Than Average per 100 Discharges
Hybrid_HWR 14.60 No Different Than the National Rate
OP_32 11.60 No Different Than the National Rate
OP_35_ADM 11.40 No Different Than the National Rate
OP_35_ED 4.30 No Different Than the National Rate
OP_36 1.10 No Different than expected
READM_30_AMI 12.10 No Different Than the National Rate
READM_30_CABG 10.80 No Different Than the National Rate
READM_30_COPD 17.80 No Different Than the National Rate
READM_30_HF 18.70 No Different Than the National Rate
READM_30_HIP_KNEE Number of Cases Too Small
READM_30_PN 16.50 No Different Than the National Rate

Medicare Spending Per Beneficiary

MSPB ratio: values > 1.0 mean this hospital's episode spending is higher than the national median hospital.

Value
1.03

Financial Health (Cost Report — FY 2024)

All Data

Every labeled metric surfaced for this hospital, with national medians and percentiles where a benchmark is available.

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Show 93 rows
Source Metric Value National Median Pctl. Raw key
Cost Report Cost-to-Charge Ratio 0.19 metrics.cost_to_charge_ratio
Cost Report Employees per Bed 6.91 metrics.employees_per_bed
Cost Report fiscal_year 2,024 fiscal_year
Cost Report Fund Balance ($) $1,802,687,061 metrics.fund_balance
Cost Report Net Income ($) $167,696,950 metrics.net_income
Cost Report Net Patient Revenue ($) $2,987,785,423 metrics.net_patient_revenue
Cost Report Occupancy Rate (%) 0.0% metrics.occupancy_rate
Cost Report Operating Margin (%) 2.8% metrics.operating_margin
Cost Report Total Assets ($) $1,550,880,400 metrics.total_assets
Cost Report Total Costs ($) $2,194,474,099 metrics.total_costs
Cost Report Total Liabilities ($) $-251,806,661 metrics.total_liabilities
Cost Report Total Margin (%) 5.5% metrics.total_margin
Cost Report Uncompensated Care (%) 6.7% metrics.uncompensated_care_pct
General Information Address 6411 FANNIN Address
General Information City/Town HOUSTON City/Town
General Information Count of Facility MORT Measures 7 Count of Facility MORT Measures
General Information Count of Facility Pt Exp Measures 8 Count of Facility Pt Exp Measures
General Information Count of Facility READM Measures 10 Count of Facility READM Measures
General Information Count of Facility Safety Measures 7 Count of Facility Safety Measures
General Information Count of Facility TE Measures 12 Count of Facility TE Measures
General Information Count of MORT Measures Better 1 Count of MORT Measures Better
General Information Count of MORT Measures No Different 6 Count of MORT Measures No Different
General Information Count of MORT Measures Worse 0 Count of MORT Measures Worse
General Information Count of READM Measures Better 1 Count of READM Measures Better
General Information Count of READM Measures No Different 9 Count of READM Measures No Different
General Information Count of READM Measures Worse 0 Count of READM Measures Worse
General Information Count of Safety Measures Better 4 Count of Safety Measures Better
General Information Count of Safety Measures No Different 3 Count of Safety Measures No Different
General Information Count of Safety Measures Worse 0 Count of Safety Measures Worse
General Information County/Parish HARRIS County/Parish
General Information Emergency Services Yes Emergency Services
General Information Facility ID 450068 Facility ID
General Information Facility Name MEMORIAL HERMANN - TEXAS MEDICAL CENTER Facility Name
General Information Hospital overall rating 3 Hospital overall rating
General Information Hospital overall rating footnote Hospital overall rating footnote
General Information Hospital Ownership Voluntary non-profit - Private Hospital Ownership
General Information Hospital Type Acute Care Hospitals Hospital Type
General Information Meets criteria for birthing friendly designation Y Meets criteria for birthing friendly designation
General Information MORT Group Footnote MORT Group Footnote
General Information MORT Group Measure Count 7 MORT Group Measure Count
General Information Pt Exp Group Footnote Pt Exp Group Footnote
General Information Pt Exp Group Measure Count 8 Pt Exp Group Measure Count
General Information READM Group Footnote READM Group Footnote
General Information READM Group Measure Count 11 READM Group Measure Count
General Information Safety Group Footnote Safety Group Footnote
General Information Safety Group Measure Count 8 Safety Group Measure Count
General Information State TX State
General Information TE Group Footnote TE Group Footnote
General Information TE Group Measure Count 12 TE Group Measure Count
General Information Telephone Number (713) 704-3700 Telephone Number
General Information ZIP Code 77030 ZIP Code
HAC Reduction Program fiscal_year 2,026 fiscal_year
HAC Reduction Program measures — cauti — sir 0.38 measures.cauti.sir
HAC Reduction Program measures — cdi — sir 0.19 measures.cdi.sir
HAC Reduction Program measures — clabsi — sir 0.76 measures.clabsi.sir
HAC Reduction Program measures — mrsa — sir 0.62 measures.mrsa.sir
HAC Reduction Program measures — ssi — sir 0.70 measures.ssi.sir
HAC Reduction Program payment_reduction No payment_reduction
HAC Reduction Program total_hac_score -0.11 total_hac_score
Medicare Spending per Beneficiary End Date 12/31/2024 End Date
Medicare Spending per Beneficiary Measure ID MSPB-1 Measure ID
Medicare Spending per Beneficiary Start Date 01/01/2024 Start Date
Medicare Spending per Beneficiary Value 1.03 Value
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Excess readmission ratio 0.89 0.9995 p3 READM-30-AMI-HRRP.excess_readmission_ratio
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Expected readmission rate 15.1% READM-30-AMI-HRRP.expected_readmission_rate
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of discharges 225 READM-30-AMI-HRRP.num_discharges
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of readmissions 24 READM-30-AMI-HRRP.num_readmissions
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Predicted readmission rate 13.4% READM-30-AMI-HRRP.predicted_readmission_rate
Readmissions (HRRP) CABG Surgery — Excess readmission ratio 1.02 1.0000 p59 READM-30-CABG-HRRP.excess_readmission_ratio
Readmissions (HRRP) CABG Surgery — Expected readmission rate 12.1% READM-30-CABG-HRRP.expected_readmission_rate
Readmissions (HRRP) CABG Surgery — Number of discharges 84 READM-30-CABG-HRRP.num_discharges
Readmissions (HRRP) CABG Surgery — Number of readmissions 11 READM-30-CABG-HRRP.num_readmissions
Readmissions (HRRP) CABG Surgery — Predicted readmission rate 12.4% READM-30-CABG-HRRP.predicted_readmission_rate
Readmissions (HRRP) COPD — Excess readmission ratio 0.98 0.9969 p35 READM-30-COPD-HRRP.excess_readmission_ratio
Readmissions (HRRP) COPD — Expected readmission rate 20.7% READM-30-COPD-HRRP.expected_readmission_rate
Readmissions (HRRP) COPD — Number of discharges 71 READM-30-COPD-HRRP.num_discharges
Readmissions (HRRP) COPD — Number of readmissions 13 READM-30-COPD-HRRP.num_readmissions
Readmissions (HRRP) COPD — Predicted readmission rate 20.3% READM-30-COPD-HRRP.predicted_readmission_rate
Readmissions (HRRP) Heart Failure — Excess readmission ratio 0.94 0.9983 p16 READM-30-HF-HRRP.excess_readmission_ratio
Readmissions (HRRP) Heart Failure — Expected readmission rate 22.2% READM-30-HF-HRRP.expected_readmission_rate
Readmissions (HRRP) Heart Failure — Number of discharges 481 READM-30-HF-HRRP.num_discharges
Readmissions (HRRP) Heart Failure — Number of readmissions 96 READM-30-HF-HRRP.num_readmissions
Readmissions (HRRP) Heart Failure — Predicted readmission rate 20.9% READM-30-HF-HRRP.predicted_readmission_rate
Readmissions (HRRP) Pneumonia — Excess readmission ratio 1.04 0.9955 p74 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 17.1% READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Number of discharges 330 READM-30-PN-HRRP.num_discharges
Readmissions (HRRP) Pneumonia — Number of readmissions 61 READM-30-PN-HRRP.num_readmissions
Readmissions (HRRP) Pneumonia — Predicted readmission rate 17.7% READM-30-PN-HRRP.predicted_readmission_rate
Value-Based Purchasing Clinical Outcomes 11.50 5.00 p87 clinical_outcomes_score
Value-Based Purchasing Efficiency & Cost Reduction 0.00 2.50 p0 efficiency_score
Value-Based Purchasing Person & Community Engagement 8.00 8.75 p43 person_community_score
Value-Based Purchasing Safety 7.08 10.00 p25 safety_score
Value-Based Purchasing Total Performance Score 26.58 29.50 p39 total_performance_score
Methodology

Full methodology →