Acute Care Hospital

Baylor St Lukes Medical Center

6720 Bertner Ave, Ste Mc1-266, Houston, TX 77030

Part of Commonspirit Healthsee all 175 affiliated facilities

24/7 Emergency Services Nonprofit
4 out of 5 Stars Why 4 stars? Baylor St Lukes Medical Center's 4-star rating reflects above-average performance on Mortality, Safety of Care, and Readmissions and below-average performance on Timely Care.

CMS Overall Hospital Quality Star Rating · Baylor St Lukes Medical Center

How was Baylor St Lukes Medical Center's 4-star rating calculated?

The CMS Overall Hospital Quality Star Rating applies to acute care hospitals like Baylor St Lukes Medical Center. CMS standardizes every underlying measure against the national rate, computes a weighted score for each of five domains, sums them by the fixed weights below, and assigns 1–5 stars using k-means clustering across all reporting hospitals.

Domains that fed Baylor St Lukes Medical Center's rating
Domain Weight Measures reported Hospital performance vs. national
Mortality 22% 7 of 7 2 better 5 same 0 worse
Safety of Care 22% 18 of 19 4 better 14 same 0 worse
Readmissions 22% 5 of 6 2 better 3 same 0 worse
Timely & Effective Care 12% 14 of 22 1 better 10 same 3 worse
Patient Experience 22% HCAHPS See HCAHPS detail below

How star meaning varies by hospital type. This CMS Overall Star Rating only applies to acute care hospitals. Children's hospitals (Pediatric Quality), psychiatric hospitals (IPFQR), inpatient rehabilitation facilities (IRF QRP), long-term acute care hospitals (LTACH QRP), and VA medical centers each use separate quality programs designed for their patient populations. Comparing star ratings across these facility types isn't meaningful — see the methodology page for the full mapping of which program applies to which facility.

How CareRanks computes ratings → · CMS official methodology ↗

Emergency & urgent care

How this emergency department performs on the measures that matter most when you need care fast.

166 min Typical ER visit before heading home Near the national median of 148 min
2% Walked out before being seen Worse than ~75% of hospitals · national median 1%
63% Recommended sepsis care given Near the national median of 64%

From CMS Timely & Effective Care reporting.

Quality measures

Mortality

Better than National Average

Measures the rate at which patients die within 30 days of hospital admission for specific conditions. A lower mortality rate indicates better outcomes.

Underlying measures: Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate Better Than the National Rate Hospital score: 3.40 95% interval: 2.80 – 4.10 Sample size: 1,550 Reporting period: 07/01/2023 – 06/30/2024 CMS measure id: Hybrid_HWM Death rate for pneumonia patients Better Than the National Rate Hospital score: 11.30 95% interval: 8.40 – 14.90 Sample size: 145 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_PN Death rate for CABG surgery patients No Different Than the National Rate Hospital score: 2.90 95% interval: 1.70 – 4.80 Sample size: 231 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_CABG Death rate for COPD patients No Different Than the National Rate Hospital score: 9.50 95% interval: 5.60 – 14.90 Sample size: 25 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_COPD Death rate for heart attack patients No Different Than the National Rate Hospital score: 10.50 95% interval: 7.80 – 13.90 Sample size: 112 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_AMI Death rate for heart failure patients No Different Than the National Rate Hospital score: 8.80 95% interval: 6.70 – 11.60 Sample size: 383 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_HF Death rate for stroke patients No Different Than the National Rate Hospital score: 11.10 95% interval: 8.50 – 14.00 Sample size: 171 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_STK

Safety of Care

Better than National Average

Tracks hospital-acquired infections, surgical complications, and other patient safety indicators. Lower rates indicate better safety practices.

Underlying measures: Clostridium Difficile (C.Diff) Better than the National Benchmark Hospital score: 0.20 SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_6_SIR Catheter Associated Urinary Tract Infections (ICU + select Wards) Better than the National Benchmark Hospital score: 0.35 SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_2_SIR MRSA Bacteremia Better than the National Benchmark Hospital score: 0.33 SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_5_SIR SSI - Colon Surgery Better than the National Benchmark Hospital score: 0.34 SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_3_SIR Abdominopelvic accidental puncture or laceration rate No Different Than the National Rate Hospital score: 0.88 95% interval: 0.08 – 1.68 Sample size: 2,306 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_15 Central Line Associated Bloodstream Infection (ICU + select Wards) No Different than National Benchmark Hospital score: 0.96 SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_1_SIR Iatrogenic pneumothorax rate No Different Than the National Rate Hospital score: 0.17 95% interval: 0.00 – 0.36 Sample size: 6,880 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_06 In-hospital fall-associated fracture rate No Different Than the National Rate Hospital score: 0.23 95% interval: 0.04 – 0.42 Sample size: 8,122 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_08 Postoperative hemorrhage or hematoma rate No Different Than the National Rate Hospital score: 1.79 95% interval: 0.63 – 2.95 Sample size: 2,497 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_09 Perioperative pulmonary embolism or deep vein thrombosis rate No Different Than the National Rate Hospital score: 3.57 95% interval: 1.93 – 5.22 Sample size: 2,795 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_12 Postoperative acute kidney injury requiring dialysis rate No Different Than the National Rate Hospital score: 1.23 95% interval: 0.04 – 2.41 Sample size: 1,331 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_10 Postoperative respiratory failure rate No Different Than the National Rate Hospital score: 9.24 95% interval: 5.82 – 12.67 Sample size: 1,416 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_11 Postoperative sepsis rate No Different Than the National Rate Hospital score: 6.87 95% interval: 4.63 – 9.10 Sample size: 1,438 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_13 Pressure ulcer rate No Different Than the National Rate Hospital score: 0.71 95% interval: 0.27 – 1.15 Sample size: 6,740 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_03 CMS Medicare PSI 90: Patient safety and adverse events composite No Different Than the National Value Hospital score: 1.03 95% interval: 0.83 – 1.24 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_90 SSI - Abdominal Hysterectomy No Different than National Benchmark Hospital score: 0.97 SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_4_SIR Death rate among surgical inpatients with serious treatable complications No Different Than the National Rate Hospital score: 157.74 95% interval: 126.03 – 189.45 Sample size: 223 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_04 Postoperative wound dehiscence rate No Different Than the National Rate Hospital score: 1.88 95% interval: 0.54 – 3.21 Sample size: 736 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_14 Rate of complications for hip/knee replacement patients Number of Cases Too Small Hospital score: Reporting period: 04/01/2021 – 03/31/2024 CMS measure id: COMP_HIP_KNEE

Readmissions

Better than National Average

Measures how often patients return to the hospital within 30 days of discharge. Lower readmission rates suggest effective treatment and discharge planning.

Underlying measures: 30-day Readmission, Bypass Surgery Better than expected Hospital score: 0.86 Sample size: 225 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-CABG-HRRP 30-day Readmission, Heart Attack Better than expected Hospital score: 0.92 Sample size: 171 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-AMI-HRRP 30-day Readmission, COPD As expected Hospital score: 0.97 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-COPD-HRRP 30-day Readmission, Heart Failure As expected Hospital score: 0.97 Sample size: 463 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-HF-HRRP 30-day Readmission, Pneumonia As expected Hospital score: 0.97 Sample size: 159 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-PN-HRRP 30-day Readmission, Hip/Knee Replacement Hospital score: Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-HIP-KNEE-HRRP

Patient Experience

Same as National Average

Based on the HCAHPS survey — patient satisfaction with communication, cleanliness, pain management, and discharge information.

Patient survey detail — the questions feeding the Patient Experience domain above expand ↓

CMS computes the Patient Experience domain from the federal HCAHPS survey. Each bar below is one survey question; the percentage is the share of Baylor's recent patients who gave the most positive response. HCAHPS percentages aren't directly comparable across all measures — see the methodology page for how CMS weights them.

  • Communication with Nurses 73%
  • Communication with Doctors 77%
  • Hospital Cleanliness 57%
  • Hospital Quietness 57%
  • Staff Responsiveness N/A
  • Discharge Information 83%
  • Overall Hospital Rating (9 or 10) 68%
  • Would Recommend Hospital 64%

Percentages represent patients who gave the most positive response. Survey conducted by CMS through the HCAHPS program.

Timely & Effective Care

Below National Average

Measures how quickly the hospital provides important treatments such as antibiotics for pneumonia or interventions for heart attacks.

Underlying measures: Intensive Care Unit Venous Thromboembolism Prophylaxis Better than ~75% of hospitals Hospital score: 99.00 % National median: 97.00 % (higher is better) Sample size: 5,979 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: VTE_2 Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients Near the national median Hospital score: 95.00 % National median: 97.00 % (higher is better) Sample size: 86 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: OP_29 Average (median) time patients spent in the emergency department before leaving from the visit, excluding patients transferred to another facility or psychiatric care/mental health patients. A lower number of minutes is better Near the national median Hospital score: 166.00 min National median: 148.00 min (lower is better) Sample size: 390 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: OP_18b Average (median) time all patients spent in the emergency department before leaving from the visit, including psychiatric/mental health patients and patients who were transferred to another facility. A lower number of minutes is better Near the national median Hospital score: 168.00 min National median: 154.00 min (lower is better) Sample size: 400 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: OP_18a Appropriate care for severe sepsis and septic shock Near the national median Hospital score: 63.00 % National median: 64.00 % (higher is better) Sample size: 78 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: SEP_1 Septic Shock 3-Hour Bundle Near the national median Hospital score: 67.00 % National median: 72.00 % (higher is better) Sample size: 24 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: SEP_SH_3HR Septic Shock 6-Hour Bundle Near the national median Hospital score: 93.00 % National median: 89.00 % (higher is better) Sample size: 14 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: SEP_SH_6HR Severe Sepsis 3-Hour Bundle Near the national median Hospital score: 83.00 % National median: 81.00 % (higher is better) Sample size: 78 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: SEV_SEP_3HR Severe Sepsis 6-Hour Bundle Near the national median Hospital score: 91.00 % National median: 94.00 % (higher is better) Sample size: 47 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: SEV_SEP_6HR Healthcare workers given influenza vaccination Near the national median Hospital score: 83.00 % National median: 79.00 % (higher is better) Sample size: 6,559 Reporting period: 10/01/2024 – 03/31/2025 CMS measure id: IMM_3 Venous Thromboembolism Prophylaxis Near the national median Hospital score: 93.00 % National median: 90.00 % (higher is better) Sample size: 13,361 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: VTE_1 Discharged on Antithrombotic Therapy Worse than ~75% of hospitals Hospital score: 96.00 % National median: 98.00 % (higher is better) Sample size: 414 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: STK_02 Safe Use of Opioids - Concurrent Prescribing Worse than ~75% of hospitals Hospital score: 18.00 % National median: 15.00 % (lower is better) Sample size: 6,161 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: SAFE_USE_OF_OPIOIDS Left before being seen Worse than ~75% of hospitals Hospital score: 2.00 % National median: 1.00 % (lower is better) Sample size: 46,712 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: OP_22

Clinical Staff

Baylor St Lukes Medical Center has 1,178 CMS-affiliated clinicians on its roster — physicians, advanced practice providers, and other Medicare-enrolled professionals who list this hospital as an affiliated facility.

Top specialties

  • Internal Medicine 125
  • Nurse Practitioner 90
  • Certified Registered Nurse Anesthetist (Crna) 70
  • Hospitalist 65
  • Anesthesiology 63
  • Cardiovascular Disease (Cardiology) 58
  • Emergency Medicine 55
  • Diagnostic Radiology 52

Self-reported primary specialty in the CMS Doctors & Clinicians dataset. Many clinicians serve multiple facilities.

Practice characteristics

Accept Medicare assignment
1,174 (100%)

Bill Medicare directly at the approved rate — patients only owe co-insurance/deductible.

Offer telehealth
319 (27%)

Indicated by the clinician in their CMS profile as routinely providing virtual visits.

Medicare quality scoring (MIPS)

740 of these clinicians have a published Merit-based Incentive Payment System (MIPS) final score. Of those, 484 (65%) score above the national median of 85.5.

MIPS scoring is heavily compressed at the top of the 0–100 range, so individual scores are not a reliable consumer signal. We surface roster-level coverage and the share above the national median instead.

Source: CMS Doctors and Clinicians (Care Compare) national downloadable file and MIPS Performance Year final scores, as of 2026-07-18. Affiliations from the CMS Facility Affiliations dataset. About 16% of small facilities (critical access, rural emergency, freestanding psych, IRF/LTCH) do not appear in the affiliations file and therefore have no panel.

Find a Doctor

Search the 1,178 clinicians affiliated with Baylor St Lukes Medical Center. Each name links to that clinician's official Medicare Care Compare profile, where you can see their credentials, secondary specialties, group affiliations, and (when applicable) MIPS quality scores.

Showing 30 of 1,178 clinicians (alphabetical)

Roster from CMS Doctors and Clinicians (Care Compare), updated 2026-07-18. A clinician may also practice at other facilities; "affiliated" means this hospital is on their CMS profile, not that they exclusively work here. Procedure volumes are Medicare fee-for-service counts from the CMS clinician utilization file (all practice locations, not just this hospital). Industry payment totals are from CMS Open Payments, program year 2024, and include meals, travel, consulting, and speaking fees; payments are legal and common — we show them for transparency, not as a quality judgment.

Pricing & Costs

Facility Information

Licensed beds
881
Facility type
Acute Care Hospitals
Ownership
Voluntary non-profit - Church
Emergency services
Yes — 24/7

Ownership & Finances

Ownership
Nonprofit
Charity care spend (FY2023)
$28.8M
List prices vs. actual cost
≈ 5.3× actual cost

From the hospital's FY2023 Medicare cost report (HCRIS).

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How Baylor St Lukes Medical Center compares nearby

Compared with the 8 other acute-care hospitals within 25 miles — 9 facilities in all, CMS data only.

Among the 9 acute-care hospitals within 25 miles, Baylor St Lukes Medical Center's overall star rating is 4★; the median among the 7 peers reporting it is 4★.

Measure This facility Nearby median Best nearby
Overall star rating reported by 7 of 8 nearby peers 4★ 4★ 5★
Patient experience (HCAHPS) star reported by 8 of 8 nearby peers 3★ 3★ 4★
Mortality reported by 8 of 8 nearby peers Better than National Average Same as National Average Better than National Average
Safety of Care reported by 8 of 8 nearby peers Better than National Average Same as National Average Better than National Average
Readmissions reported by 7 of 8 nearby peers Better than National Average Same as National Average Better than National Average

The comparison group

Cohort: within 25 miles · CMS data period 2026-06 · method cohort-v1 · comparisons are never affected by claiming or payment. How nearby comparisons work

Compare this hospital with another →

Skilled nursing facilities nearby

For planning care after discharge — CMS five-star ratings shown; always confirm availability and coverage with the facility and your insurer.

About this data

Quality and ratings data are sourced from the U.S. Centers for Medicare & Medicaid Services (CMS) Hospital Compare program. Star ratings are CMS's own calculation; CareRanks does not modify or re-weight them. Facility-level details (address, beds, ownership, teaching status) come from CMS provider files and the CMS Provider of Services file.

Pricing data, where shown, is drawn from the hospital's own Machine-Readable File (MRF) published under the federal Hospital Price Transparency Rule. See our methodology for the full update cadence and limitations.

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