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Overview

Address
16088 SAN PEDRO, SAN ANTONIO, TX 78232
Phone
(210) 402-4092
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.

Mortality 2 of 7 measures reported
2
Better No different Worse
30-day death rates for heart attack, heart failure, pneumonia, COPD, stroke, CABG, and kidney disease.
Safety of Care 1 of 8 measures reported
1
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) 0 discharges
— Not reported
Heart Failure
— Not reported
Pneumonia
0.9835 p41
COPD
0.9543 p13
Hip/Knee Replacement
— Not reported
CABG Surgery
— Not reported
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.

71.7 p99
Total Performance Score
National median: 29.5
Clinical Outcomes 25% weight
13.3 p91
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
25.0 p98
Nat'l median: 10.0
Patient safety measures including healthcare-associated infections (CLABSI, CAUTI, SSI, MRSA, C. diff) and perioperative complications.
Efficiency & Cost Reduction 25% weight
33.3 p99
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)
Not Penalized
Worst ERR: 0.9835
Value-Based Purchasing
71.7 TPS
Above national median
HAC Reduction
Payment Reduced
HAC Score: 2.0149

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
Hybrid_HWM 3.60 No Different Than the National Rate 131
MORT_30_AMI Number of Cases Too Small
MORT_30_CABG
MORT_30_COPD 8.50 No Different Than the National Rate 36
MORT_30_HF Number of Cases Too Small
MORT_30_PN 12.00 No Different Than the National Rate 84
MORT_30_STK
PSI_03 0.60 No Different Than the National Rate 234
PSI_04
PSI_06 0.21 No Different Than the National Rate 460
PSI_08 0.27 No Different Than the National Rate 470
PSI_09
PSI_10
PSI_11
PSI_12
PSI_13
PSI_14
PSI_15 Number of Cases Too Small
PSI_90

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
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well
H_COMP_1_U_P: Nurses "usually" communicated well
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
H_NURSE_RESPECT_SN_P: Nurses "sometimes" or "never" treated them with courtesy and respect
H_NURSE_RESPECT_U_P: Nurses "usually" treated them with courtesy and respect
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully
H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand
H_NURSE_EXPLAIN_SN_P: Nurses "sometimes" or "never" explained things so they could understand
H_NURSE_EXPLAIN_U_P: Nurses "usually" explained things so they could understand
H_COMP_2_A_P: Doctors "always" communicated well
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well
H_COMP_2_U_P: Doctors "usually" communicated well
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
H_DOCTOR_RESPECT_SN_P: Doctors "sometimes" or "never" treated them with courtesy and respect
H_DOCTOR_RESPECT_U_P: Doctors "usually" treated them with courtesy and respect
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully
H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand
H_DOCTOR_EXPLAIN_SN_P: Doctors "sometimes" or "never" explained things so they could understand
H_DOCTOR_EXPLAIN_U_P: Doctors "usually" explained things so they could understand
H_COMP_5_A_P: Staff "always" explained
H_COMP_5_SN_P: Staff "sometimes" or "never" explained
H_COMP_5_U_P: Staff "usually" explained
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
H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications
H_MED_FOR_U_P: Staff "usually" explained new medications
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects
H_SIDE_EFFECTS_SN_P: Staff "sometimes" or "never" explained possible side effects
H_SIDE_EFFECTS_U_P: Staff "usually" explained possible side effects
H_COMP_6_N_P: No, staff "did not" give patients this information
H_COMP_6_Y_P: Yes, staff "did" give patients this information
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
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge
H_SYMPTOMS_N_P: No, staff "did not" give patients information about possible symptoms
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms
H_CLEAN_HSP_A_P: Room was "always" clean
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean
H_CLEAN_HSP_U_P: Room was "usually" clean
H_CLEAN_LINEAR_SCORE: Cleanliness - linear mean score
H_CLEAN_STAR_RATING: Cleanliness - star rating
H_QUIET_HSP_A_P: "Always" quiet at night
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night
H_QUIET_HSP_U_P: "Usually" quiet at night
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)
H_HSP_RATING_7_8: Patients who gave a rating of "7" or "8" (medium)
H_HSP_RATING_9_10: Patients who gave a rating of "9" or "10" (high)
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)
H_RECMND_DY: "YES", patients would definitely recommend the hospital
H_RECMND_PY: "YES", patients would probably recommend the hospital
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 12.000
HAI_1_ELIGCASES 0.007
HAI_1_NUMERATOR 0.000
HAI_1_SIR
HAI_2_CILOWER
HAI_2_CIUPPER
HAI_2_DOPC 34.000
HAI_2_ELIGCASES 0.019
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 3017.000
HAI_5_ELIGCASES 0.083
HAI_5_NUMERATOR 0.000
HAI_5_SIR
HAI_6_CILOWER
HAI_6_CIUPPER
HAI_6_DOPC 3017.000
HAI_6_ELIGCASES 0.899
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 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 Electronic Clinical Quality Measure
HH_ORAE Electronic Clinical Quality Measure
IMM_3 89.0 Healthcare Personnel Vaccination
OP_18a 123.0 Emergency Department
OP_18b 117.0 Emergency Department
OP_18c Emergency Department
OP_18d 283.0 Emergency Department
OP_22 2.0 Emergency Department
OP_23 73.0 Emergency Department
OP_29 Colonoscopy care
OP_31 Cataract surgery outcome
OP_40 Electronic Clinical Quality Measure
SAFE_USE_OF_OPIOIDS Electronic Clinical Quality Measure
SEP_1 79.0 Sepsis Care
SEP_SH_3HR 71.0 Sepsis Care
SEP_SH_6HR Sepsis Care
SEV_SEP_3HR 86.0 Sepsis Care
SEV_SEP_6HR 96.0 Sepsis Care
STK_02 Electronic Clinical Quality Measure
STK_03 Electronic Clinical Quality Measure
STK_05 Electronic Clinical Quality Measure
VTE_1 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 7.00 Average Days per 100 Discharges
Hybrid_HWR 15.00 No Different Than the National Rate
OP_32
OP_35_ADM Number of Cases Too Small
OP_35_ED Number of Cases Too Small
OP_36
READM_30_AMI
READM_30_CABG
READM_30_COPD 17.30 No Different Than the National Rate
READM_30_HF Number of Cases Too Small
READM_30_HIP_KNEE
READM_30_PN 15.70 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
0.82

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 0.05 metrics.cost_to_charge_ratio
Cost Report Current Ratio 18.14 metrics.current_ratio
Cost Report Employees per Bed 6.11 metrics.employees_per_bed
Cost Report fiscal_year 2,023 fiscal_year
Cost Report Fund Balance ($) $344,924,294 metrics.fund_balance
Cost Report Net Income ($) $46,061,054 metrics.net_income
Cost Report Net Patient Revenue ($) $134,994,453 metrics.net_patient_revenue
Cost Report Operating Margin (%) 30.0% metrics.operating_margin
Cost Report Total Assets ($) $370,838,199 metrics.total_assets
Cost Report Total Costs ($) $80,918,919 metrics.total_costs
Cost Report Total Liabilities ($) $25,913,905 metrics.total_liabilities
Cost Report Total Margin (%) 32.8% metrics.total_margin
General Information Address 16088 SAN PEDRO Address
General Information City/Town SAN ANTONIO City/Town
General Information Count of Facility MORT Measures 2 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 1 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 0 Count of MORT Measures Better
General Information Count of MORT Measures No Different 2 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 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 1 Count of Safety Measures No Different
General Information Count of Safety Measures Worse 0 Count of Safety Measures Worse
General Information County/Parish BEXAR County/Parish
General Information Emergency Services Yes Emergency Services
General Information Facility ID 670078 Facility ID
General Information Facility Name BAPTIST NEIGHBORHOOD HOSPITAL THOUSAND OAKS 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 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 (210) 402-4092 Telephone Number
General Information ZIP Code 78232 ZIP Code
HAC Reduction Program fiscal_year 2,026 fiscal_year
HAC Reduction Program measures — cdi — sir 0.90 measures.cdi.sir
HAC Reduction Program payment_reduction Yes payment_reduction
HAC Reduction Program total_hac_score 2.01 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 0.82 Value
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of discharges 0 READM-30-AMI-HRRP.num_discharges
Readmissions (HRRP) COPD — Excess readmission ratio 0.95 0.9969 p13 READM-30-COPD-HRRP.excess_readmission_ratio
Readmissions (HRRP) COPD — Expected readmission rate 12.4% READM-30-COPD-HRRP.expected_readmission_rate
Readmissions (HRRP) COPD — Predicted readmission rate 11.8% READM-30-COPD-HRRP.predicted_readmission_rate
Readmissions (HRRP) Pneumonia — Excess readmission ratio 0.98 0.9955 p41 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 10.9% READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Predicted readmission rate 10.7% READM-30-PN-HRRP.predicted_readmission_rate
Value-Based Purchasing Clinical Outcomes 13.33 5.00 p91 clinical_outcomes_score
Value-Based Purchasing Efficiency & Cost Reduction 33.33 2.50 p99 efficiency_score
Value-Based Purchasing Safety 25.00 10.00 p98 safety_score
Value-Based Purchasing Total Performance Score 71.67 29.50 p99 total_performance_score
Methodology

Full methodology →