Hospital

MEMORIAL HERMANN SURGICAL HOSPITAL KINGWOOD

CCN: 670005 · KINGWOOD, TX 77339 · HARRIS County

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

Overview

Address
300 KINGWOOD MEDICAL DRIVE, KINGWOOD, TX 77339
Phone
(281) 312-4000
Hospital Type
Acute Care
Ownership
For-Profit
Emergency Services
Yes
—
Star rating not available
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.

Safety of Care 2 of 8 measures reported
2
Better No different Worse
Healthcare-associated infections and patient safety indicators (PSI-90 composite).
Readmission 4 of 11 measures reported
3
1
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 3 of 12 measures reported
3 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 does not have excess readmissions triggering HRRP penalties.
Acute Myocardial Infarction (Heart Attack)
— Not reported
Heart Failure
— Not reported
Pneumonia
— Not reported
COPD
— Not reported
Hip/Knee Replacement
0.8680 p17
CABG Surgery
— Not reported
Expected (1.0) National median

CMS Payment Programs

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

Readmissions (HRRP)
Not Penalized
Worst ERR: 0.8680
Value-Based Purchasing
—
HAC Reduction
No Reduction
HAC Score: -0.7848

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 4.00 No Different Than the National Rate 156
Hybrid_HWM 4.10 No Different Than the National Rate 50
MORT_30_AMI — — —
MORT_30_CABG — — —
MORT_30_COPD — — —
MORT_30_HF — — —
MORT_30_PN — — —
MORT_30_STK — — —
PSI_03 — Number of Cases Too Small —
PSI_04 — — —
PSI_06 0.21 No Different Than the National Rate 161
PSI_08 0.27 No Different Than the National Rate 159
PSI_09 2.31 No Different Than the National Rate 160
PSI_10 1.67 No Different Than the National Rate 160
PSI_11 8.86 No Different Than the National Rate 160
PSI_12 3.38 No Different Than the National Rate 160
PSI_13 5.16 No Different Than the National Rate 156
PSI_14 — Number of Cases Too Small —
PSI_15 1.06 No Different Than the National Rate 27
PSI_90 0.97 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 83% —
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 6% —
H_COMP_1_U_P: Nurses "usually" communicated well 11% —
H_COMP_1_LINEAR_SCORE: Nurse communication - linear mean score — —
H_COMP_1_STAR_RATING: Nurse communication - star rating — —
H_NURSE_RESPECT_A_P: Nurses "always" treated them with courtesy and respect 91% —
H_NURSE_RESPECT_SN_P: Nurses "sometimes" or "never" treated them with courtesy and respect 4% —
H_NURSE_RESPECT_U_P: Nurses "usually" treated them with courtesy and respect 5% —
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 80% —
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 5% —
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 15% —
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 9% —
H_NURSE_EXPLAIN_U_P: Nurses "usually" explained things so they could understand 13% —
H_COMP_2_A_P: Doctors "always" communicated well 81% —
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 4% —
H_COMP_2_U_P: Doctors "usually" communicated well 15% —
H_COMP_2_LINEAR_SCORE: Doctor communication - linear mean score — —
H_COMP_2_STAR_RATING: Doctor communication - star rating — —
H_DOCTOR_RESPECT_A_P: Doctors "always" treated them with courtesy and respect 87% —
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 10% —
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 76% —
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 4% —
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 20% —
H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand 79% —
H_DOCTOR_EXPLAIN_SN_P: Doctors "sometimes" or "never" explained things so they could understand 4% —
H_DOCTOR_EXPLAIN_U_P: Doctors "usually" explained things so they could understand 17% —
H_COMP_5_A_P: Staff "always" explained 54% —
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 21% —
H_COMP_5_U_P: Staff "usually" explained 25% —
H_COMP_5_LINEAR_SCORE: Communication about medicines - linear mean score — —
H_COMP_5_STAR_RATING: Communication about medicines - star rating — —
H_MED_FOR_A_P: Staff "always" explained new medications 71% —
H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications 18% —
H_MED_FOR_U_P: Staff "usually" explained new medications 11% —
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 37% —
H_SIDE_EFFECTS_SN_P: Staff "sometimes" or "never" explained possible side effects 24% —
H_SIDE_EFFECTS_U_P: Staff "usually" explained possible side effects 39% —
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 — —
H_DISCH_HELP_N_P: No, staff "did not" give patients information about help after discharge 15% —
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge 85% —
H_SYMPTOMS_N_P: No, staff "did not" give patients information about possible symptoms 15% —
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms 85% —
H_CLEAN_HSP_A_P: Room was "always" clean 63% —
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 16% —
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 — —
H_QUIET_HSP_A_P: "Always" quiet at night 72% —
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 1% —
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 — —
H_HSP_RATING_0_6: Patients who gave a rating of "6" or lower (low) 4% —
H_HSP_RATING_7_8: Patients who gave a rating of "7" or "8" (medium) 20% —
H_HSP_RATING_9_10: Patients who gave a rating of "9" or "10" (high) 76% —
H_HSP_RATING_LINEAR_SCORE: Overall hospital rating - linear mean score — —
H_HSP_RATING_STAR_RATING: Overall hospital rating - star rating — —
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 — —
H_STAR_RATING: Summary star rating — —

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 — —
HAI_1_CIUPPER — —
HAI_1_DOPC — —
HAI_1_ELIGCASES — —
HAI_1_NUMERATOR — —
HAI_1_SIR — —
HAI_2_CILOWER — —
HAI_2_CIUPPER — —
HAI_2_DOPC 109.000 —
HAI_2_ELIGCASES 0.056 —
HAI_2_NUMERATOR 0.000 —
HAI_2_SIR — —
HAI_3_CILOWER — —
HAI_3_CIUPPER — —
HAI_3_DOPC — —
HAI_3_ELIGCASES — —
HAI_3_NUMERATOR — —
HAI_3_SIR — —
HAI_4_CILOWER — —
HAI_4_CIUPPER — —
HAI_4_DOPC 97.000 —
HAI_4_ELIGCASES 0.755 —
HAI_4_NUMERATOR 0.000 —
HAI_4_SIR — —
HAI_5_CILOWER — —
HAI_5_CIUPPER — —
HAI_5_DOPC 974.000 —
HAI_5_ELIGCASES 0.019 —
HAI_5_NUMERATOR 0.000 —
HAI_5_SIR — —
HAI_6_CILOWER — —
HAI_6_CIUPPER — —
HAI_6_DOPC 974.000 —
HAI_6_ELIGCASES 0.212 —
HAI_6_NUMERATOR 0.000 —
HAI_6_SIR — —

Timely & Effective Care

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

Measure Score Condition
EDV — 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 0.0 Electronic Clinical Quality Measure
HH_HYPO — Electronic Clinical Quality Measure
HH_ORAE — Electronic Clinical Quality Measure
IMM_3 90.0 Healthcare Personnel Vaccination
OP_18a — Emergency Department
OP_18b — Emergency Department
OP_18c — Emergency Department
OP_18d — Emergency Department
OP_22 — Emergency Department
OP_23 — Emergency Department
OP_29 98.0 Colonoscopy care
OP_31 — Cataract surgery outcome
OP_40 — Electronic Clinical Quality Measure
SAFE_USE_OF_OPIOIDS — Electronic Clinical Quality Measure
SEP_1 — Sepsis Care
SEP_SH_3HR — Sepsis Care
SEP_SH_6HR — Sepsis Care
SEV_SEP_3HR — Sepsis Care
SEV_SEP_6HR — Sepsis Care
STK_02 — Electronic Clinical Quality Measure
STK_03 — Electronic Clinical Quality Measure
STK_05 — Electronic Clinical Quality Measure
VTE_1 97.0 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 — —
EDAC_30_HF — —
EDAC_30_PN — —
Hybrid_HWR 14.80 No Different Than the National Rate
OP_32 13.00 No Different Than the National Rate
OP_35_ADM — —
OP_35_ED — —
OP_36 0.90 No Different than expected
READM_30_AMI — —
READM_30_CABG — —
READM_30_COPD — —
READM_30_HF — —
READM_30_HIP_KNEE 4.20 No Different Than the National Rate
READM_30_PN — —

Medicare Spending Per Beneficiary

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

Value
1.00

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 0.17 — metrics.cost_to_charge_ratio
Cost Report Current Ratio 1.82 — metrics.current_ratio
Cost Report Employees per Bed 7.95 — metrics.employees_per_bed
Cost Report fiscal_year 2,023 — fiscal_year
Cost Report Fund Balance ($) $2,693,071 — metrics.fund_balance
Cost Report Net Income ($) $6,615,267 — metrics.net_income
Cost Report Net Patient Revenue ($) $35,597,454 — metrics.net_patient_revenue
Cost Report Operating Margin (%) 19.9% — metrics.operating_margin
Cost Report Total Assets ($) $12,883,401 — metrics.total_assets
Cost Report Total Costs ($) $25,723,305 — metrics.total_costs
Cost Report Total Liabilities ($) $10,190,330 — metrics.total_liabilities
Cost Report Total Margin (%) 18.6% — metrics.total_margin
Cost Report Uncompensated Care (%) 0.3% — metrics.uncompensated_care_pct
General Information Address 300 KINGWOOD MEDICAL DRIVE — Address
General Information City/Town KINGWOOD — City/Town
General Information Count of Facility MORT Measures Not Available — 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 4 — Count of Facility READM Measures
General Information Count of Facility Safety Measures 2 — Count of Facility Safety Measures
General Information Count of Facility TE Measures 3 — Count of Facility TE Measures
General Information Count of MORT Measures Better Not Available — Count of MORT Measures Better
General Information Count of MORT Measures No Different Not Available — Count of MORT Measures No Different
General Information Count of MORT Measures Worse Not Available — 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 3 — Count of READM Measures No Different
General Information Count of READM Measures Worse 1 — Count of READM Measures Worse
General Information Count of Safety Measures Better 0 — Count of Safety Measures Better
General Information Count of Safety Measures No Different 2 — 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 670005 — Facility ID
General Information Facility Name MEMORIAL HERMANN SURGICAL HOSPITAL KINGWOOD — Facility Name
General Information Hospital overall rating Not Available — Hospital overall rating
General Information Hospital overall rating footnote 16 — Hospital overall rating footnote
General Information Hospital Ownership Proprietary — Hospital Ownership
General Information Hospital Type Acute Care Hospitals — Hospital Type
General Information Meets criteria for birthing friendly designation — — Meets criteria for birthing friendly designation
General Information MORT Group Footnote 5 — 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) 312-4000 — Telephone Number
General Information ZIP Code 77339 — ZIP Code
HAC Reduction Program fiscal_year 2,026 — fiscal_year
HAC Reduction Program measures — ssi — sir 0 — measures.ssi.sir
HAC Reduction Program payment_reduction No — payment_reduction
HAC Reduction Program total_hac_score -0.78 — 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 1.00 — Value
Readmissions (HRRP) Hip/Knee Replacement — Excess readmission ratio 0.87 0.9916 p17 READM-30-HIP-KNEE-HRRP.excess_readmission_ratio
Readmissions (HRRP) Hip/Knee Replacement — Expected readmission rate 4.3% — READM-30-HIP-KNEE-HRRP.expected_readmission_rate
Readmissions (HRRP) Hip/Knee Replacement — Predicted readmission rate 3.7% — READM-30-HIP-KNEE-HRRP.predicted_readmission_rate
Methodology

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