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

Overview

Address
18220 STATE HIGHWAY 249, HOUSTON, TX 77070
Phone
(281) 477-1000
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
3
4
Better No different Worse
30-day death rates for heart attack, heart failure, pneumonia, COPD, stroke, CABG, and kidney disease.
Safety of Care 8 of 8 measures reported
3
5
Better No different Worse
Healthcare-associated infections and patient safety indicators (PSI-90 composite).
Readmission 11 of 11 measures reported
11
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) 199 discharges
1.0373 p72
Heart Failure 748 discharges
1.0795 p88
Pneumonia 635 discharges
1.0824 p88
COPD 118 discharges
1.0128 p63
Hip/Knee Replacement
— Not reported
CABG Surgery
1.0304 p62
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.

41.3 p81
Total Performance Score
National median: 29.5
Clinical Outcomes 25% weight
13.5 p92
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
12.5 p63
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
15.3 p85
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: 1.0824
Value-Based Purchasing
41.3 TPS
Above national median
HAC Reduction
No Reduction
HAC Score: -0.5323

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 2,085
MORT_30_AMI 11.50 No Different Than the National Rate 201
MORT_30_CABG 3.20 No Different Than the National Rate 50
MORT_30_COPD 7.80 No Different Than the National Rate 96
MORT_30_HF 7.30 Better Than the National Rate 632
MORT_30_PN 11.40 Better Than the National Rate 587
MORT_30_STK 10.50 Better Than the National Rate 329
PSI_03 0.10 Better Than the National Rate 7,144
PSI_04 111.17 Better Than the National Rate 101
PSI_06 0.13 No Different Than the National Rate 8,613
PSI_08 0.20 No Different Than the National Rate 8,830
PSI_09 2.60 No Different Than the National Rate 1,719
PSI_10 1.45 No Different Than the National Rate 498
PSI_11 5.34 No Different Than the National Rate 521
PSI_12 3.36 No Different Than the National Rate 1,822
PSI_13 3.09 No Different Than the National Rate 501
PSI_14 1.54 No Different Than the National Rate 486
PSI_15 0.71 No Different Than the National Rate 1,718
PSI_90 0.61 Better 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 81%
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 4%
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 87%
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 10%
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 79%
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 4%
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 17%
H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand 78%
H_NURSE_EXPLAIN_SN_P: Nurses "sometimes" or "never" explained things so they could understand 5%
H_NURSE_EXPLAIN_U_P: Nurses "usually" explained things so they could understand 17%
H_COMP_2_A_P: Doctors "always" communicated well 78%
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 6%
H_COMP_2_U_P: Doctors "usually" communicated well 16%
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 4%
H_DOCTOR_RESPECT_U_P: Doctors "usually" treated them with courtesy and respect 11%
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 73%
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 20%
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 9%
H_MED_FOR_U_P: Staff "usually" explained new medications 15%
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 27%
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 11%
H_COMP_6_Y_P: Yes, staff "did" give patients this information 89%
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 12%
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge 88%
H_SYMPTOMS_N_P: No, staff "did not" give patients information about possible symptoms 9%
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms 91%
H_CLEAN_HSP_A_P: Room was "always" clean 80%
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 6%
H_CLEAN_HSP_U_P: Room was "usually" clean 14%
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 66%
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 7%
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) 4%
H_RECMND_DY: "YES", patients would definitely recommend the hospital 78%
H_RECMND_PY: "YES", patients would probably recommend the hospital 18%
H_RECMND_LINEAR_SCORE: Recommend hospital - linear mean score
H_RECMND_STAR_RATING: Recommend hospital - star rating 4
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 0.062 Better than the National Benchmark
HAI_1_CIUPPER 0.667 Better than the National Benchmark
HAI_1_DOPC 11758.000 Better than the National Benchmark
HAI_1_ELIGCASES 12.237 Better than the National Benchmark
HAI_1_NUMERATOR 3.000 Better than the National Benchmark
HAI_1_SIR 0.245 Better than the National Benchmark
HAI_2_CILOWER 0.004 Better than the National Benchmark
HAI_2_CIUPPER 0.357 Better than the National Benchmark
HAI_2_DOPC 11293.000 Better than the National Benchmark
HAI_2_ELIGCASES 13.824 Better than the National Benchmark
HAI_2_NUMERATOR 1.000 Better than the National Benchmark
HAI_2_SIR 0.072 Better than the National Benchmark
HAI_3_CILOWER 0.312 No Different than National Benchmark
HAI_3_CIUPPER 1.603 No Different than National Benchmark
HAI_3_DOPC 309.000 No Different than National Benchmark
HAI_3_ELIGCASES 7.783 No Different than National Benchmark
HAI_3_NUMERATOR 6.000 No Different than National Benchmark
HAI_3_SIR 0.771 No Different than National Benchmark
HAI_4_CILOWER 0.239 No Different than National Benchmark
HAI_4_CIUPPER 4.713 No Different than National Benchmark
HAI_4_DOPC 164.000 No Different than National Benchmark
HAI_4_ELIGCASES 1.402 No Different than National Benchmark
HAI_4_NUMERATOR 2.000 No Different than National Benchmark
HAI_4_SIR 1.427 No Different than National Benchmark
HAI_5_CILOWER 0.326 No Different than National Benchmark
HAI_5_CIUPPER 1.970 No Different than National Benchmark
HAI_5_DOPC 106519.000 No Different than National Benchmark
HAI_5_ELIGCASES 5.627 No Different than National Benchmark
HAI_5_NUMERATOR 5.000 No Different than National Benchmark
HAI_5_SIR 0.889 No Different than National Benchmark
HAI_6_CILOWER 0.001 Better than the National Benchmark
HAI_6_CIUPPER 0.114 Better than the National Benchmark
HAI_6_DOPC 93064.000 Better than the National Benchmark
HAI_6_ELIGCASES 43.085 Better than the National Benchmark
HAI_6_NUMERATOR 1.000 Better than the National Benchmark
HAI_6_SIR 0.023 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 59.0 Healthcare Personnel Vaccination
OP_18a 176.0 Emergency Department
OP_18b 176.0 Emergency Department
OP_18c Emergency Department
OP_18d Emergency Department
OP_22 1.0 Emergency Department
OP_23 56.0 Emergency Department
OP_29 77.0 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 77.0 Sepsis Care
SEP_SH_3HR 78.0 Sepsis Care
SEP_SH_6HR 100.0 Sepsis Care
SEV_SEP_3HR 90.0 Sepsis Care
SEV_SEP_6HR 95.0 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 97.0 Electronic Clinical Quality Measure

Unplanned Hospital Visits

Readmission and ED return rates within 30 days of discharge.

Measure Score vs. National
EDAC_30_AMI 17.20 More Days Than Average per 100 Discharges
EDAC_30_HF -3.60 Average Days per 100 Discharges
EDAC_30_PN 11.50 More Days Than Average per 100 Discharges
Hybrid_HWR 14.80 No Different Than the National Rate
OP_32 11.10 No Different Than the National Rate
OP_35_ADM 13.80 No Different Than the National Rate
OP_35_ED 4.50 No Different Than the National Rate
OP_36 0.80 No Different than expected
READM_30_AMI 14.10 No Different Than the National Rate
READM_30_CABG 10.90 No Different Than the National Rate
READM_30_COPD 18.40 No Different Than the National Rate
READM_30_HF 21.10 No Different Than the National Rate
READM_30_HIP_KNEE Number of Cases Too Small
READM_30_PN 17.20 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
1.10

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.

Download CSV

Show 90 rows
Source Metric Value National Median Pctl. Raw key
Cost Report Cost-to-Charge Ratio 0.14 metrics.cost_to_charge_ratio
Cost Report Employees per Bed 7.30 metrics.employees_per_bed
Cost Report fiscal_year 2,023 fiscal_year
Cost Report Fund Balance ($) $739,841,538 metrics.fund_balance
Cost Report Net Income ($) $72,634,832 metrics.net_income
Cost Report Net Patient Revenue ($) $730,194,376 metrics.net_patient_revenue
Cost Report Operating Margin (%) 9.1% metrics.operating_margin
Cost Report Total Assets ($) $448,201,314 metrics.total_assets
Cost Report Total Costs ($) $630,040,881 metrics.total_costs
Cost Report Total Liabilities ($) $-291,640,224 metrics.total_liabilities
Cost Report Total Margin (%) 9.9% metrics.total_margin
Cost Report Uncompensated Care (%) 7.2% metrics.uncompensated_care_pct
General Information Address 18220 STATE HIGHWAY 249 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 11 Count of Facility READM Measures
General Information Count of Facility Safety Measures 8 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 3 Count of MORT Measures Better
General Information Count of MORT Measures No Different 4 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 11 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 5 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 450844 Facility ID
General Information Facility Name HOUSTON METHODIST WILLOWBROOK 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) 477-1000 Telephone Number
General Information ZIP Code 77070 ZIP Code
HAC Reduction Program fiscal_year 2,026 fiscal_year
HAC Reduction Program measures — cauti — sir 0.24 measures.cauti.sir
HAC Reduction Program measures — cdi — sir 0.14 measures.cdi.sir
HAC Reduction Program measures — clabsi — sir 0.33 measures.clabsi.sir
HAC Reduction Program measures — mrsa — sir 0.96 measures.mrsa.sir
HAC Reduction Program measures — ssi — sir 0.89 measures.ssi.sir
HAC Reduction Program payment_reduction No payment_reduction
HAC Reduction Program total_hac_score -0.53 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 1.10 Value
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Excess readmission ratio 1.04 0.9995 p72 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 199 READM-30-AMI-HRRP.num_discharges
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of readmissions 33 READM-30-AMI-HRRP.num_readmissions
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Predicted readmission rate 15.6% READM-30-AMI-HRRP.predicted_readmission_rate
Readmissions (HRRP) CABG Surgery — Excess readmission ratio 1.03 1.0000 p62 READM-30-CABG-HRRP.excess_readmission_ratio
Readmissions (HRRP) CABG Surgery — Expected readmission rate 12.3% READM-30-CABG-HRRP.expected_readmission_rate
Readmissions (HRRP) CABG Surgery — Predicted readmission rate 12.7% READM-30-CABG-HRRP.predicted_readmission_rate
Readmissions (HRRP) COPD — Excess readmission ratio 1.01 0.9969 p63 READM-30-COPD-HRRP.excess_readmission_ratio
Readmissions (HRRP) COPD — Expected readmission rate 20.1% READM-30-COPD-HRRP.expected_readmission_rate
Readmissions (HRRP) COPD — Number of discharges 118 READM-30-COPD-HRRP.num_discharges
Readmissions (HRRP) COPD — Number of readmissions 25 READM-30-COPD-HRRP.num_readmissions
Readmissions (HRRP) COPD — Predicted readmission rate 20.4% READM-30-COPD-HRRP.predicted_readmission_rate
Readmissions (HRRP) Heart Failure — Excess readmission ratio 1.08 0.9983 p88 READM-30-HF-HRRP.excess_readmission_ratio
Readmissions (HRRP) Heart Failure — Expected readmission rate 21.1% READM-30-HF-HRRP.expected_readmission_rate
Readmissions (HRRP) Heart Failure — Number of discharges 748 READM-30-HF-HRRP.num_discharges
Readmissions (HRRP) Heart Failure — Number of readmissions 176 READM-30-HF-HRRP.num_readmissions
Readmissions (HRRP) Heart Failure — Predicted readmission rate 22.8% READM-30-HF-HRRP.predicted_readmission_rate
Readmissions (HRRP) Pneumonia — Excess readmission ratio 1.08 0.9955 p88 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 17.7% READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Number of discharges 635 READM-30-PN-HRRP.num_discharges
Readmissions (HRRP) Pneumonia — Number of readmissions 127 READM-30-PN-HRRP.num_readmissions
Readmissions (HRRP) Pneumonia — Predicted readmission rate 19.1% READM-30-PN-HRRP.predicted_readmission_rate
Value-Based Purchasing Clinical Outcomes 13.50 5.00 p92 clinical_outcomes_score
Value-Based Purchasing Efficiency & Cost Reduction 0.00 2.50 p0 efficiency_score
Value-Based Purchasing Person & Community Engagement 15.25 8.75 p85 person_community_score
Value-Based Purchasing Safety 12.50 10.00 p63 safety_score
Value-Based Purchasing Total Performance Score 41.25 29.50 p81 total_performance_score
Methodology

Full methodology →