Hospital

HOUSTON METHODIST BAYTOWN HOSPITAL

CCN: 450424 · BAYTOWN, TX 77521 · HARRIS County

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

Overview

Address
4401 GARTH ROAD, BAYTOWN, TX 77521
Phone
(281) 420-8600
Hospital Type
Acute Care
Ownership
Non-Profit
Emergency Services
Yes
Birthing Friendly
Yes
5 /5
★★★★★
CMS Overall Rating
p89
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 6 of 8 measures reported
3
3
Better No different Worse
Healthcare-associated infections and patient safety indicators (PSI-90 composite).
Readmission 10 of 11 measures reported
10
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) 109 discharges
0.9895 p42
Heart Failure 464 discharges
0.8876 p3
Pneumonia 394 discharges
0.8990 p4
COPD 96 discharges
1.0248 p72
Hip/Knee Replacement
— Not reported
CABG Surgery
0.9392 p25
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 above the national median, suggesting a positive payment adjustment.

48.7 p92
Total Performance Score
National median: 29.5
Clinical Outcomes 25% weight
19.5 p98
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
12.9 p68
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
16.3 p88
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: 1.0248
Value-Based Purchasing
48.7 TPS
Above national median
HAC Reduction
No Reduction
HAC Score: -0.4851

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 3.30 Better Than the National Rate 1,086
MORT_30_AMI 11.00 No Different Than the National Rate 115
MORT_30_CABG 2.10 No Different Than the National Rate 36
MORT_30_COPD 7.10 No Different Than the National Rate 87
MORT_30_HF 7.70 Better Than the National Rate 395
MORT_30_PN 13.30 Better Than the National Rate 375
MORT_30_STK 13.70 No Different Than the National Rate 125
PSI_03 0.13 No Different Than the National Rate 4,180
PSI_04 152.24 No Different Than the National Rate 46
PSI_06 0.16 No Different Than the National Rate 4,745
PSI_08 0.22 No Different Than the National Rate 4,982
PSI_09 2.69 No Different Than the National Rate 717
PSI_10 1.40 No Different Than the National Rate 141
PSI_11 8.41 No Different Than the National Rate 154
PSI_12 3.48 No Different Than the National Rate 816
PSI_13 4.46 No Different Than the National Rate 146
PSI_14 1.66 No Different Than the National Rate 159
PSI_15 0.90 No Different Than the National Rate 669
PSI_90 0.77 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 82% —
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 3% —
H_COMP_1_U_P: Nurses "usually" communicated well 15% —
H_COMP_1_LINEAR_SCORE: Nurse communication - linear mean score — —
H_COMP_1_STAR_RATING: Nurse communication - star rating — 4
H_NURSE_RESPECT_A_P: Nurses "always" treated them with courtesy and respect 89% —
H_NURSE_RESPECT_SN_P: Nurses "sometimes" or "never" treated them with courtesy and respect 2% —
H_NURSE_RESPECT_U_P: Nurses "usually" treated them with courtesy and respect 9% —
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 80% —
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 3% —
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 17% —
H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand 76% —
H_NURSE_EXPLAIN_SN_P: Nurses "sometimes" or "never" explained things so they could understand 4% —
H_NURSE_EXPLAIN_U_P: Nurses "usually" explained things so they could understand 20% —
H_COMP_2_A_P: Doctors "always" communicated well 77% —
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 6% —
H_COMP_2_U_P: Doctors "usually" communicated well 17% —
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 84% —
H_DOCTOR_RESPECT_SN_P: Doctors "sometimes" or "never" treated them with courtesy and respect 3% —
H_DOCTOR_RESPECT_U_P: Doctors "usually" treated them with courtesy and respect 13% —
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 76% —
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 6% —
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 18% —
H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand 72% —
H_DOCTOR_EXPLAIN_SN_P: Doctors "sometimes" or "never" explained things so they could understand 8% —
H_DOCTOR_EXPLAIN_U_P: Doctors "usually" explained things so they could understand 20% —
H_COMP_5_A_P: Staff "always" explained 64% —
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 17% —
H_COMP_5_U_P: Staff "usually" explained 19% —
H_COMP_5_LINEAR_SCORE: Communication about medicines - linear mean score — —
H_COMP_5_STAR_RATING: Communication about medicines - star rating — 3
H_MED_FOR_A_P: Staff "always" explained new medications 76% —
H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications 8% —
H_MED_FOR_U_P: Staff "usually" explained new medications 16% —
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 52% —
H_SIDE_EFFECTS_SN_P: Staff "sometimes" or "never" explained possible side effects 26% —
H_SIDE_EFFECTS_U_P: Staff "usually" explained possible side effects 22% —
H_COMP_6_N_P: No, staff "did not" give patients this information 12% —
H_COMP_6_Y_P: Yes, staff "did" give patients this information 88% —
H_COMP_6_LINEAR_SCORE: Discharge information - linear mean score — —
H_COMP_6_STAR_RATING: Discharge information - star rating — 4
H_DISCH_HELP_N_P: No, staff "did not" give patients information about help after discharge 13% —
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge 87% —
H_SYMPTOMS_N_P: No, staff "did not" give patients information about possible symptoms 10% —
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms 90% —
H_CLEAN_HSP_A_P: Room was "always" clean 83% —
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 4% —
H_CLEAN_HSP_U_P: Room was "usually" clean 13% —
H_CLEAN_LINEAR_SCORE: Cleanliness - linear mean score — —
H_CLEAN_STAR_RATING: Cleanliness - star rating — 5
H_QUIET_HSP_A_P: "Always" quiet at night 72% —
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 5% —
H_QUIET_HSP_U_P: "Usually" quiet at night 23% —
H_QUIET_LINEAR_SCORE: Quietness - linear mean score — —
H_QUIET_STAR_RATING: Quietness - star rating — 5
H_HSP_RATING_0_6: Patients who gave a rating of "6" or lower (low) 5% —
H_HSP_RATING_7_8: Patients who gave a rating of "7" or "8" (medium) 16% —
H_HSP_RATING_9_10: Patients who gave a rating of "9" or "10" (high) 79% —
H_HSP_RATING_LINEAR_SCORE: Overall hospital rating - linear mean score — —
H_HSP_RATING_STAR_RATING: Overall hospital rating - star rating — 4
H_RECMND_DN: "NO", patients would not recommend the hospital (they probably would not or definitely would not recommend it) 3% —
H_RECMND_DY: "YES", patients would definitely recommend the hospital 78% —
H_RECMND_PY: "YES", patients would probably recommend the hospital 19% —
H_RECMND_LINEAR_SCORE: Recommend hospital - linear mean score — —
H_RECMND_STAR_RATING: Recommend hospital - star rating — 5
H_STAR_RATING: Summary star rating — 4

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 0.091 Better than the National Benchmark
HAI_1_CIUPPER 0.971 Better than the National Benchmark
HAI_1_DOPC 10571.000 Better than the National Benchmark
HAI_1_ELIGCASES 8.411 Better than the National Benchmark
HAI_1_NUMERATOR 3.000 Better than the National Benchmark
HAI_1_SIR 0.357 Better than the National Benchmark
HAI_2_CILOWER N/A Better than the National Benchmark
HAI_2_CIUPPER 0.356 Better than the National Benchmark
HAI_2_DOPC 9666.000 Better than the National Benchmark
HAI_2_ELIGCASES 8.422 Better than the National Benchmark
HAI_2_NUMERATOR 0.000 Better than the National Benchmark
HAI_2_SIR 0.000 Better than the National Benchmark
HAI_3_CILOWER 0.264 No Different than National Benchmark
HAI_3_CIUPPER 2.829 No Different than National Benchmark
HAI_3_DOPC 105.000 No Different than National Benchmark
HAI_3_ELIGCASES 2.886 No Different than National Benchmark
HAI_3_NUMERATOR 3.000 No Different than National Benchmark
HAI_3_SIR 1.040 No Different than National Benchmark
HAI_4_CILOWER — —
HAI_4_CIUPPER — —
HAI_4_DOPC 22.000 —
HAI_4_ELIGCASES 0.193 —
HAI_4_NUMERATOR 0.000 —
HAI_4_SIR — —
HAI_5_CILOWER 0.168 No Different than National Benchmark
HAI_5_CIUPPER 1.794 No Different than National Benchmark
HAI_5_DOPC 77680.000 No Different than National Benchmark
HAI_5_ELIGCASES 4.550 No Different than National Benchmark
HAI_5_NUMERATOR 3.000 No Different than National Benchmark
HAI_5_SIR 0.659 No Different than National Benchmark
HAI_6_CILOWER 0.074 Better than the National Benchmark
HAI_6_CIUPPER 0.380 Better than the National Benchmark
HAI_6_DOPC 72824.000 Better than the National Benchmark
HAI_6_ELIGCASES 32.820 Better than the National Benchmark
HAI_6_NUMERATOR 6.000 Better than the National Benchmark
HAI_6_SIR 0.183 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 — Electronic Clinical Quality Measure
HH_HYPO 1.0 Electronic Clinical Quality Measure
HH_ORAE — Electronic Clinical Quality Measure
IMM_3 56.0 Healthcare Personnel Vaccination
OP_18a 230.0 Emergency Department
OP_18b 224.0 Emergency Department
OP_18c 554.0 Emergency Department
OP_18d — Emergency Department
OP_22 2.0 Emergency Department
OP_23 94.0 Emergency Department
OP_29 100.0 Colonoscopy care
OP_31 — Cataract surgery outcome
OP_40 — Electronic Clinical Quality Measure
SAFE_USE_OF_OPIOIDS 11.0 Electronic Clinical Quality Measure
SEP_1 74.0 Sepsis Care
SEP_SH_3HR 84.0 Sepsis Care
SEP_SH_6HR 100.0 Sepsis Care
SEV_SEP_3HR 86.0 Sepsis Care
SEV_SEP_6HR 91.0 Sepsis Care
STK_02 99.0 Electronic Clinical Quality Measure
STK_03 — Electronic Clinical Quality Measure
STK_05 — Electronic Clinical Quality Measure
VTE_1 — Electronic Clinical Quality Measure
VTE_2 99.0 Electronic Clinical Quality Measure

Unplanned Hospital Visits

Readmission and ED return rates within 30 days of discharge.

Measure Score vs. National
EDAC_30_AMI 7.80 Average Days per 100 Discharges
EDAC_30_HF -20.30 Fewer Days Than Average per 100 Discharges
EDAC_30_PN -7.90 Average Days per 100 Discharges
Hybrid_HWR 13.90 No Different Than the National Rate
OP_32 11.90 No Different Than the National Rate
OP_35_ADM 10.80 No Different Than the National Rate
OP_35_ED 6.00 No Different Than the National Rate
OP_36 0.80 No Different than expected
READM_30_AMI 13.80 No Different Than the National Rate
READM_30_CABG 10.00 No Different Than the National Rate
READM_30_COPD 18.60 No Different Than the National Rate
READM_30_HF 17.40 No Different Than the National Rate
READM_30_HIP_KNEE — Number of Cases Too Small
READM_30_PN 14.40 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
1.02

Financial Health (Cost Report — FY 2023)

All Data

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

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Source Metric Value National Median Pctl. Raw key
Cost Report Cost-to-Charge Ratio 0.14 — metrics.cost_to_charge_ratio
Cost Report Current Ratio 1.22 — metrics.current_ratio
Cost Report Employees per Bed 6.93 — metrics.employees_per_bed
Cost Report fiscal_year 2,023 — fiscal_year
Cost Report Fund Balance ($) $326,916,610 — metrics.fund_balance
Cost Report Net Income ($) $10,855,042 — metrics.net_income
Cost Report Net Patient Revenue ($) $430,615,413 — metrics.net_patient_revenue
Cost Report Operating Margin (%) 1.9% — metrics.operating_margin
Cost Report Total Assets ($) $376,385,407 — metrics.total_assets
Cost Report Total Costs ($) $424,155,381 — metrics.total_costs
Cost Report Total Liabilities ($) $48,742,382 — metrics.total_liabilities
Cost Report Total Margin (%) 2.5% — metrics.total_margin
Cost Report Uncompensated Care (%) 11.3% — metrics.uncompensated_care_pct
General Information Address 4401 GARTH ROAD — Address
General Information City/Town BAYTOWN — 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 6 — 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 0 — Count of READM Measures Better
General Information Count of READM Measures No Different 10 — 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 3 — 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 450424 — Facility ID
General Information Facility Name HOUSTON METHODIST BAYTOWN HOSPITAL — Facility Name
General Information Hospital overall rating 5 — 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 (281) 420-8600 — Telephone Number
General Information ZIP Code 77521 — ZIP Code
HAC Reduction Program fiscal_year 2,026 — fiscal_year
HAC Reduction Program measures — cauti — sir 0 — measures.cauti.sir
HAC Reduction Program measures — cdi — sir 0.28 — measures.cdi.sir
HAC Reduction Program measures — clabsi — sir 0.45 — measures.clabsi.sir
HAC Reduction Program measures — mrsa — sir 0.61 — measures.mrsa.sir
HAC Reduction Program measures — ssi — sir 1.32 — measures.ssi.sir
HAC Reduction Program payment_reduction No — payment_reduction
HAC Reduction Program total_hac_score -0.49 — 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 1.02 — Value
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Excess readmission ratio 0.99 0.9995 p42 READM-30-AMI-HRRP.excess_readmission_ratio
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Expected readmission rate 16.3% — READM-30-AMI-HRRP.expected_readmission_rate
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of discharges 109 — READM-30-AMI-HRRP.num_discharges
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of readmissions 17 — READM-30-AMI-HRRP.num_readmissions
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Predicted readmission rate 16.1% — READM-30-AMI-HRRP.predicted_readmission_rate
Readmissions (HRRP) CABG Surgery — Excess readmission ratio 0.94 1.0000 p25 READM-30-CABG-HRRP.excess_readmission_ratio
Readmissions (HRRP) CABG Surgery — Expected readmission rate 10.7% — READM-30-CABG-HRRP.expected_readmission_rate
Readmissions (HRRP) CABG Surgery — Predicted readmission rate 10.0% — READM-30-CABG-HRRP.predicted_readmission_rate
Readmissions (HRRP) COPD — Excess readmission ratio 1.02 0.9969 p72 READM-30-COPD-HRRP.excess_readmission_ratio
Readmissions (HRRP) COPD — Expected readmission rate 22.4% — READM-30-COPD-HRRP.expected_readmission_rate
Readmissions (HRRP) COPD — Number of discharges 96 — READM-30-COPD-HRRP.num_discharges
Readmissions (HRRP) COPD — Number of readmissions 24 — READM-30-COPD-HRRP.num_readmissions
Readmissions (HRRP) COPD — Predicted readmission rate 23.0% — READM-30-COPD-HRRP.predicted_readmission_rate
Readmissions (HRRP) Heart Failure — Excess readmission ratio 0.89 0.9983 p3 READM-30-HF-HRRP.excess_readmission_ratio
Readmissions (HRRP) Heart Failure — Expected readmission rate 22.3% — READM-30-HF-HRRP.expected_readmission_rate
Readmissions (HRRP) Heart Failure — Number of discharges 464 — READM-30-HF-HRRP.num_discharges
Readmissions (HRRP) Heart Failure — Number of readmissions 83 — READM-30-HF-HRRP.num_readmissions
Readmissions (HRRP) Heart Failure — Predicted readmission rate 19.8% — READM-30-HF-HRRP.predicted_readmission_rate
Readmissions (HRRP) Pneumonia — Excess readmission ratio 0.90 0.9955 p4 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 18.4% — READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Number of discharges 394 — READM-30-PN-HRRP.num_discharges
Readmissions (HRRP) Pneumonia — Number of readmissions 58 — READM-30-PN-HRRP.num_readmissions
Readmissions (HRRP) Pneumonia — Predicted readmission rate 16.6% — READM-30-PN-HRRP.predicted_readmission_rate
Value-Based Purchasing Clinical Outcomes 19.50 5.00 p98 clinical_outcomes_score
Value-Based Purchasing Efficiency & Cost Reduction 0.00 2.50 p0 efficiency_score
Value-Based Purchasing Person & Community Engagement 16.25 8.75 p88 person_community_score
Value-Based Purchasing Safety 12.92 10.00 p68 safety_score
Value-Based Purchasing Total Performance Score 48.67 29.50 p92 total_performance_score
Methodology

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