Hospital

TEXAS HEALTH PRESBYTERIAN HOSPITAL DENTON

CCN: 450743 · DENTON, TX 76201 · DENTON County

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

Overview

Address
3000 N I-35, DENTON, TX 76201
Phone
(940) 898-7000
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
7
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
1
5
Better No different Worse
Healthcare-associated infections and patient safety indicators (PSI-90 composite).
Readmission 8 of 11 measures reported
1
7
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 11 of 12 measures reported
11 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) 169 discharges
0.9158 p8
Heart Failure 353 discharges
0.8921 p4
Pneumonia 517 discharges
1.0335 p71
COPD 102 discharges
0.9793 p33
Hip/Knee Replacement
— Not reported
CABG Surgery
1.0043 p52
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.

44.9 p88
Total Performance Score
National median: 29.5
Clinical Outcomes 25% weight
8.0 p71
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
20.4 p94
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
14.0 p80
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
2.5 p43
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: 1.0335
Value-Based Purchasing
44.9 TPS
Above national median
HAC Reduction
No Reduction
HAC Score: -0.8759

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 3.80 No Different Than the National Rate 1,233
MORT_30_AMI 12.40 No Different Than the National Rate 140
MORT_30_CABG 1.80 No Different Than the National Rate 59
MORT_30_COPD 10.00 No Different Than the National Rate 93
MORT_30_HF 10.00 No Different Than the National Rate 315
MORT_30_PN 14.40 No Different Than the National Rate 472
MORT_30_STK 12.70 No Different Than the National Rate 141
PSI_03 0.46 No Different Than the National Rate 3,539
PSI_04 155.49 No Different Than the National Rate 56
PSI_06 0.16 No Different Than the National Rate 4,649
PSI_08 0.23 No Different Than the National Rate 4,970
PSI_09 1.85 No Different Than the National Rate 918
PSI_10 1.82 No Different Than the National Rate 305
PSI_11 8.92 No Different Than the National Rate 274
PSI_12 2.43 No Different Than the National Rate 1,011
PSI_13 5.56 No Different Than the National Rate 297
PSI_14 2.01 No Different Than the National Rate 226
PSI_15 1.13 No Different Than the National Rate 797
PSI_90 0.89 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 80% —
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 3% —
H_COMP_1_U_P: Nurses "usually" communicated well 17% —
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 88% —
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 10% —
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 76% —
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 3% —
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 21% —
H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand 75% —
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 21% —
H_COMP_2_A_P: Doctors "always" communicated well 78% —
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 4% —
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 85% —
H_DOCTOR_RESPECT_SN_P: Doctors "sometimes" or "never" treated them with courtesy and respect 2% —
H_DOCTOR_RESPECT_U_P: Doctors "usually" treated them with courtesy and respect 13% —
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 78% —
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 5% —
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 17% —
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 6% —
H_DOCTOR_EXPLAIN_U_P: Doctors "usually" explained things so they could understand 23% —
H_COMP_5_A_P: Staff "always" explained 63% —
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 18% —
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 50% —
H_SIDE_EFFECTS_SN_P: Staff "sometimes" or "never" explained possible side effects 28% —
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 14% —
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge 86% —
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 77% —
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 5% —
H_CLEAN_HSP_U_P: Room was "usually" clean 18% —
H_CLEAN_LINEAR_SCORE: Cleanliness - linear mean score — —
H_CLEAN_STAR_RATING: Cleanliness - star rating — 4
H_QUIET_HSP_A_P: "Always" quiet at night 67% —
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 6% —
H_QUIET_HSP_U_P: "Usually" quiet at night 27% —
H_QUIET_LINEAR_SCORE: Quietness - linear mean score — —
H_QUIET_STAR_RATING: Quietness - star rating — 4
H_HSP_RATING_0_6: Patients who gave a rating of "6" or lower (low) 6% —
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) 78% —
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 80% —
H_RECMND_PY: "YES", patients would probably recommend the hospital 17% —
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 0.013 No Different than National Benchmark
HAI_1_CIUPPER 1.239 No Different than National Benchmark
HAI_1_DOPC 4289.000 No Different than National Benchmark
HAI_1_ELIGCASES 3.979 No Different than National Benchmark
HAI_1_NUMERATOR 1.000 No Different than National Benchmark
HAI_1_SIR 0.251 No Different than National Benchmark
HAI_2_CILOWER 0.114 No Different than National Benchmark
HAI_2_CIUPPER 2.245 No Different than National Benchmark
HAI_2_DOPC 2980.000 No Different than National Benchmark
HAI_2_ELIGCASES 2.943 No Different than National Benchmark
HAI_2_NUMERATOR 2.000 No Different than National Benchmark
HAI_2_SIR 0.680 No Different than National Benchmark
HAI_3_CILOWER 0.021 No Different than National Benchmark
HAI_3_CIUPPER 2.044 No Different than National Benchmark
HAI_3_DOPC 85.000 No Different than National Benchmark
HAI_3_ELIGCASES 2.413 No Different than National Benchmark
HAI_3_NUMERATOR 1.000 No Different than National Benchmark
HAI_3_SIR 0.414 No Different than National Benchmark
HAI_4_CILOWER — —
HAI_4_CIUPPER — —
HAI_4_DOPC 70.000 —
HAI_4_ELIGCASES 0.638 —
HAI_4_NUMERATOR 0.000 —
HAI_4_SIR — —
HAI_5_CILOWER N/A Better than the National Benchmark
HAI_5_CIUPPER 0.983 Better than the National Benchmark
HAI_5_DOPC 60094.000 Better than the National Benchmark
HAI_5_ELIGCASES 3.049 Better than the National Benchmark
HAI_5_NUMERATOR 0.000 Better than the National Benchmark
HAI_5_SIR 0.000 Better than the National Benchmark
HAI_6_CILOWER 0.001 Better than the National Benchmark
HAI_6_CIUPPER 0.144 Better than the National Benchmark
HAI_6_DOPC 53251.000 Better than the National Benchmark
HAI_6_ELIGCASES 34.314 Better than the National Benchmark
HAI_6_NUMERATOR 1.000 Better than the National Benchmark
HAI_6_SIR 0.029 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 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 — Electronic Clinical Quality Measure
HH_ORAE — Electronic Clinical Quality Measure
IMM_3 96.0 Healthcare Personnel Vaccination
OP_18a 158.0 Emergency Department
OP_18b 155.0 Emergency Department
OP_18c 217.0 Emergency Department
OP_18d 322.0 Emergency Department
OP_22 2.0 Emergency Department
OP_23 92.0 Emergency Department
OP_29 89.0 Colonoscopy care
OP_31 — Cataract surgery outcome
OP_40 — Electronic Clinical Quality Measure
SAFE_USE_OF_OPIOIDS 14.0 Electronic Clinical Quality Measure
SEP_1 88.0 Sepsis Care
SEP_SH_3HR 83.0 Sepsis Care
SEP_SH_6HR 94.0 Sepsis Care
SEV_SEP_3HR 93.0 Sepsis Care
SEV_SEP_6HR 96.0 Sepsis Care
STK_02 100.0 Electronic Clinical Quality Measure
STK_03 — Electronic Clinical Quality Measure
STK_05 — Electronic Clinical Quality Measure
VTE_1 100.0 Electronic Clinical Quality Measure
VTE_2 100.0 Electronic Clinical Quality Measure

Unplanned Hospital Visits

Readmission and ED return rates within 30 days of discharge.

Measure Score vs. National
EDAC_30_AMI -21.70 Fewer Days Than Average per 100 Discharges
EDAC_30_HF -23.00 Fewer Days Than Average per 100 Discharges
EDAC_30_PN -5.30 Average Days per 100 Discharges
Hybrid_HWR 14.50 No Different Than the National Rate
OP_32 13.30 No Different Than the National Rate
OP_35_ADM — Number of Cases Too Small
OP_35_ED — Number of Cases Too Small
OP_36 1.00 No Different than expected
READM_30_AMI 12.50 No Different Than the National Rate
READM_30_CABG 10.60 No Different Than the National Rate
READM_30_COPD 17.80 No Different Than the National Rate
READM_30_HF 17.50 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
1.05

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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Source Metric Value National Median Pctl. Raw key
Cost Report Cost-to-Charge Ratio 0.23 — metrics.cost_to_charge_ratio
Cost Report Current Ratio 1.30 — metrics.current_ratio
Cost Report Employees per Bed 4.24 — metrics.employees_per_bed
Cost Report fiscal_year 2,024 — fiscal_year
Cost Report Fund Balance ($) $223,344,605 — metrics.fund_balance
Cost Report Net Income ($) $24,096,464 — metrics.net_income
Cost Report Net Patient Revenue ($) $291,398,217 — metrics.net_patient_revenue
Cost Report Operating Margin (%) 7.6% — metrics.operating_margin
Cost Report Total Assets ($) $339,885,096 — metrics.total_assets
Cost Report Total Costs ($) $256,266,113 — metrics.total_costs
Cost Report Total Liabilities ($) $116,540,491 — metrics.total_liabilities
Cost Report Total Margin (%) 8.2% — metrics.total_margin
Cost Report Uncompensated Care (%) 10.2% — metrics.uncompensated_care_pct
General Information Address 3000 N I-35 — Address
General Information City/Town DENTON — 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 8 — 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 11 — Count of Facility TE Measures
General Information Count of MORT Measures Better 0 — Count of MORT Measures Better
General Information Count of MORT Measures No Different 7 — 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 7 — 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 1 — Count of Safety Measures Better
General Information Count of Safety Measures No Different 5 — Count of Safety Measures No Different
General Information Count of Safety Measures Worse 0 — Count of Safety Measures Worse
General Information County/Parish DENTON — County/Parish
General Information Emergency Services Yes — Emergency Services
General Information Facility ID 450743 — Facility ID
General Information Facility Name TEXAS HEALTH PRESBYTERIAN HOSPITAL DENTON — 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 (940) 898-7000 — Telephone Number
General Information ZIP Code 76201 — ZIP Code
HAC Reduction Program fiscal_year 2,026 — fiscal_year
HAC Reduction Program measures — cauti — sir 0.15 — measures.cauti.sir
HAC Reduction Program measures — cdi — sir 0.08 — measures.cdi.sir
HAC Reduction Program measures — clabsi — sir 0.37 — measures.clabsi.sir
HAC Reduction Program measures — mrsa — sir 0.17 — measures.mrsa.sir
HAC Reduction Program measures — ssi — sir 0.35 — measures.ssi.sir
HAC Reduction Program payment_reduction No — payment_reduction
HAC Reduction Program total_hac_score -0.88 — 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 1.05 — Value
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Excess readmission ratio 0.92 0.9995 p8 READM-30-AMI-HRRP.excess_readmission_ratio
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Expected readmission rate 12.5% — READM-30-AMI-HRRP.expected_readmission_rate
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of discharges 169 — READM-30-AMI-HRRP.num_discharges
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of readmissions 15 — READM-30-AMI-HRRP.num_readmissions
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Predicted readmission rate 11.5% — READM-30-AMI-HRRP.predicted_readmission_rate
Readmissions (HRRP) CABG Surgery — Excess readmission ratio 1.00 1.0000 p52 READM-30-CABG-HRRP.excess_readmission_ratio
Readmissions (HRRP) CABG Surgery — Expected readmission rate 11.6% — READM-30-CABG-HRRP.expected_readmission_rate
Readmissions (HRRP) CABG Surgery — Predicted readmission rate 11.7% — READM-30-CABG-HRRP.predicted_readmission_rate
Readmissions (HRRP) COPD — Excess readmission ratio 0.98 0.9969 p33 READM-30-COPD-HRRP.excess_readmission_ratio
Readmissions (HRRP) COPD — Expected readmission rate 17.5% — READM-30-COPD-HRRP.expected_readmission_rate
Readmissions (HRRP) COPD — Number of discharges 102 — READM-30-COPD-HRRP.num_discharges
Readmissions (HRRP) COPD — Number of readmissions 16 — READM-30-COPD-HRRP.num_readmissions
Readmissions (HRRP) COPD — Predicted readmission rate 17.2% — READM-30-COPD-HRRP.predicted_readmission_rate
Readmissions (HRRP) Heart Failure — Excess readmission ratio 0.89 0.9983 p4 READM-30-HF-HRRP.excess_readmission_ratio
Readmissions (HRRP) Heart Failure — Expected readmission rate 19.7% — READM-30-HF-HRRP.expected_readmission_rate
Readmissions (HRRP) Heart Failure — Number of discharges 353 — READM-30-HF-HRRP.num_discharges
Readmissions (HRRP) Heart Failure — Number of readmissions 54 — READM-30-HF-HRRP.num_readmissions
Readmissions (HRRP) Heart Failure — Predicted readmission rate 17.6% — READM-30-HF-HRRP.predicted_readmission_rate
Readmissions (HRRP) Pneumonia — Excess readmission ratio 1.03 0.9955 p71 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 15.3% — READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Number of discharges 517 — READM-30-PN-HRRP.num_discharges
Readmissions (HRRP) Pneumonia — Number of readmissions 84 — READM-30-PN-HRRP.num_readmissions
Readmissions (HRRP) Pneumonia — Predicted readmission rate 15.8% — READM-30-PN-HRRP.predicted_readmission_rate
Value-Based Purchasing Clinical Outcomes 8.00 5.00 p71 clinical_outcomes_score
Value-Based Purchasing Efficiency & Cost Reduction 2.50 2.50 p43 efficiency_score
Value-Based Purchasing Person & Community Engagement 14.00 8.75 p80 person_community_score
Value-Based Purchasing Safety 20.42 10.00 p94 safety_score
Value-Based Purchasing Total Performance Score 44.92 29.50 p88 total_performance_score
Methodology

Full methodology →