Hospital

CHI ST LUKES LAKESIDE HOSPITAL

CCN: 670059 · THE WOODLANDS, TX 77384 · MONTGOMERY County

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

Overview

Address
17400 ST LUKES WAY, THE WOODLANDS, TX 77384
Phone
(936) 266-4055
Hospital Type
Acute Care
Ownership
Non-Profit (Other)
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 3 of 11 measures reported
3
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 7 of 12 measures reported
7 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
— Not reported
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
Value-Based Purchasing
—
HAC Reduction
No Reduction
HAC Score: -0.6604

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 4.20 No Different Than the National Rate 113
MORT_30_AMI — — —
MORT_30_CABG — — —
MORT_30_COPD — — —
MORT_30_HF — Number of Cases Too Small —
MORT_30_PN — — —
MORT_30_STK — — —
PSI_03 0.55 No Different Than the National Rate 290
PSI_04 — — —
PSI_06 0.21 No Different Than the National Rate 394
PSI_08 0.31 No Different Than the National Rate 377
PSI_09 2.12 No Different Than the National Rate 360
PSI_10 1.65 No Different Than the National Rate 277
PSI_11 7.45 No Different Than the National Rate 275
PSI_12 3.06 No Different Than the National Rate 349
PSI_13 4.89 No Different Than the National Rate 232
PSI_14 1.76 No Different Than the National Rate 117
PSI_15 1.05 No Different Than the National Rate 125
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 79% —
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 4% —
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 — 3
H_NURSE_RESPECT_A_P: Nurses "always" treated them with courtesy and respect 86% —
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 11% —
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 72% —
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 23% —
H_COMP_2_A_P: Doctors "always" communicated well 80% —
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 4% —
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 — 4
H_DOCTOR_RESPECT_A_P: Doctors "always" treated them with courtesy and respect 83% —
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 15% —
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 80% —
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 3% —
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 17% —
H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand 77% —
H_DOCTOR_EXPLAIN_SN_P: Doctors "sometimes" or "never" explained things so they could understand 5% —
H_DOCTOR_EXPLAIN_U_P: Doctors "usually" explained things so they could understand 18% —
H_COMP_5_A_P: Staff "always" explained 59% —
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 20% —
H_COMP_5_U_P: Staff "usually" explained 21% —
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 70% —
H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications 7% —
H_MED_FOR_U_P: Staff "usually" explained new medications 23% —
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 48% —
H_SIDE_EFFECTS_SN_P: Staff "sometimes" or "never" explained possible side effects 32% —
H_SIDE_EFFECTS_U_P: Staff "usually" explained possible side effects 20% —
H_COMP_6_N_P: No, staff "did not" give patients this information 14% —
H_COMP_6_Y_P: Yes, staff "did" give patients this information 86% —
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 9% —
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge 91% —
H_SYMPTOMS_N_P: No, staff "did not" give patients information about possible symptoms 19% —
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms 81% —
H_CLEAN_HSP_A_P: Room was "always" clean 78% —
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 6% —
H_CLEAN_HSP_U_P: Room was "usually" clean 16% —
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 72% —
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 4% —
H_QUIET_HSP_U_P: "Usually" quiet at night 24% —
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) 6% —
H_HSP_RATING_7_8: Patients who gave a rating of "7" or "8" (medium) 15% —
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) 2% —
H_RECMND_DY: "YES", patients would definitely recommend the hospital 79% —
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 — —
HAI_1_CIUPPER — —
HAI_1_DOPC 53.000 —
HAI_1_ELIGCASES 0.031 —
HAI_1_NUMERATOR 0.000 —
HAI_1_SIR — —
HAI_2_CILOWER — —
HAI_2_CIUPPER — —
HAI_2_DOPC 425.000 —
HAI_2_ELIGCASES 0.140 —
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 — —
HAI_4_ELIGCASES — —
HAI_4_NUMERATOR — —
HAI_4_SIR — —
HAI_5_CILOWER — —
HAI_5_CIUPPER — —
HAI_5_DOPC 1901.000 —
HAI_5_ELIGCASES 0.022 —
HAI_5_NUMERATOR 0.000 —
HAI_5_SIR — —
HAI_6_CILOWER — —
HAI_6_CIUPPER — —
HAI_6_DOPC 1901.000 —
HAI_6_ELIGCASES 0.296 —
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 low 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 13.0 Electronic Clinical Quality Measure
HH_HYPO 0.0 Electronic Clinical Quality Measure
HH_ORAE — Electronic Clinical Quality Measure
IMM_3 90.0 Healthcare Personnel Vaccination
OP_18a 137.0 Emergency Department
OP_18b 126.0 Emergency Department
OP_18c — Emergency Department
OP_18d 255.0 Emergency Department
OP_22 0.0 Emergency Department
OP_23 — Emergency Department
OP_29 — Colonoscopy care
OP_31 — Cataract surgery outcome
OP_40 — Electronic Clinical Quality Measure
SAFE_USE_OF_OPIOIDS 18.0 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_1 100.0 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 — Number of Cases Too Small
EDAC_30_PN — —
Hybrid_HWR 14.40 No Different Than the National Rate
OP_32 — —
OP_35_ADM — —
OP_35_ED — —
OP_36 1.20 No Different than expected
READM_30_AMI — —
READM_30_CABG — —
READM_30_COPD — —
READM_30_HF — Number of Cases Too Small
READM_30_HIP_KNEE — Number of Cases Too Small
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
1.18

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 0.13 — metrics.cost_to_charge_ratio
Cost Report Current Ratio 1.65 — metrics.current_ratio
Cost Report Employees per Bed 3.90 — metrics.employees_per_bed
Cost Report fiscal_year 2,024 — fiscal_year
Cost Report Fund Balance ($) $-5,370,254 — metrics.fund_balance
Cost Report Net Income ($) $8,625,053 — metrics.net_income
Cost Report Net Patient Revenue ($) $49,065,407 — metrics.net_patient_revenue
Cost Report Operating Margin (%) 17.0% — metrics.operating_margin
Cost Report Total Assets ($) $32,488,167 — metrics.total_assets
Cost Report Total Costs ($) $40,425,339 — metrics.total_costs
Cost Report Total Liabilities ($) $37,858,421 — metrics.total_liabilities
Cost Report Total Margin (%) 17.5% — metrics.total_margin
Cost Report Uncompensated Care (%) 3.4% — metrics.uncompensated_care_pct
General Information Address 17400 ST LUKES WAY — Address
General Information City/Town THE WOODLANDS — 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 3 — 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 7 — 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 0 — 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 MONTGOMERY — County/Parish
General Information Emergency Services Yes — Emergency Services
General Information Facility ID 670059 — Facility ID
General Information Facility Name CHI ST LUKES LAKESIDE HOSPITAL — 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 Voluntary non-profit - Other — 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 (936) 266-4055 — Telephone Number
General Information ZIP Code 77384 — ZIP Code
HAC Reduction Program fiscal_year 2,026 — fiscal_year
HAC Reduction Program payment_reduction No — payment_reduction
HAC Reduction Program total_hac_score -0.66 — 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 1.18 — Value
Methodology

Full methodology →