HCA Houston Healthcare Southeast

Hospital in Pasadena, TX, Medicare certification number 450097. CMS publishes 65 quality measures for it.

Medicare certification

Provider of Services

CCN: 450097The number CMS certifies the facility under, not a provider identifier
Status: Active
Provider type: Hospital – Short-term
Listed by Care Compare as: Acute Care Hospitals
Ownership: Proprietary
Control type: Private (for profit)
Participating since: Nov 25, 1968
Last certification: Jul 19, 2024
Beds: 481
Overall star rating: 3 of 5Care Compare
Most recent change of ownership: Jan 1, 2000 (2 total)
Address: 4000 Spencer Hwy
Pasadena, TX 77504
(713) 359-1000

NPI records for this facility 1

Chca Bayshore LP
- General Acute Care Hospital
- Pasadena, TX
- NPI 1174576698
Medicare enrollment

Patient survey (HCAHPS) 9

Medicare Care Compare

Cleanliness - star rating Worse3 of 5
- State average 3.71 (computed here)
- National average 3.44 (computed here)
- Period from 10/01/2024
Communication about medicines - star rating Worse2 of 5
- State average 2.67 (computed here)
- National average 2.71 (computed here)
- Period from 10/01/2024
Discharge information - star rating Worse2 of 5
- State average 3.07 (computed here)
- National average 3.31 (computed here)
- Period from 10/01/2024
Doctor communication - star rating Worse2 of 5
- State average 2.96 (computed here)
- National average 3.12 (computed here)
- Period from 10/01/2024
Nurse communication - star rating Worse2 of 5
- State average 3.28 (computed here)
- National average 3.43 (computed here)
- Period from 10/01/2024
Overall hospital rating - star rating Worse2 of 5
- State average 3.32 (computed here)
- National average 3.29 (computed here)
- Period from 10/01/2024
Quietness - star rating Worse3 of 5
- State average 3.82 (computed here)
- National average 3.27 (computed here)
- Period from 10/01/2024
Recommend hospital - star rating Worse3 of 5
- State average 3.69 (computed here)
- National average 3.64 (computed here)
- Period from 10/01/2024
Summary star rating Worse2 of 5
- State average 3.27 (computed here)
- National average 3.27 (computed here)
- Period from 10/01/2024

Complications and deaths 19

Medicare Care Compare

Abdominopelvic accidental puncture or laceration rate As expected0.95
- State average 1.03 (computed here)
- National average 1.06
- No different than the national rate
- 474 patients
- Period from 07/01/2022
CMS Medicare PSI 90: Patient safety and adverse events composite As expected0.87
- State average 0.97 (computed here)
- National average 1
- No different than the national value
- Period from 07/01/2022
Death rate among surgical inpatients with serious treatable complications As expected149.69
- State average 166 (computed here)
- National average 173.3
- No different than the national rate
- 34 patients
- Period from 07/01/2022
Death rate for COPD patients As expected8
- State average 8.7 (computed here)
- National average 8.6
- No different than the national rate
- 39 patients
- Period from 07/01/2022
Death rate for heart attack patients As expected13.4
- State average 11.91 (computed here)
- National average 11.9
- No different than the national rate
- 39 patients
- Period from 07/01/2022
Death rate for heart failure patients As expected12
- State average 10.52 (computed here)
- National average 11.1
- No different than the national rate
- 109 patients
- Period from 07/01/2022
Death rate for pneumonia patients As expected15.3
- State average 14.69 (computed here)
- National average 15.2
- No different than the national rate
- 155 patients
- Period from 07/01/2022
Death rate for stroke patients Better7.8
- State average 12.01 (computed here)
- National average 11.9
- Better than the national rate
- 128 patients
- Period from 07/01/2023
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate As expected3.6
- State average 3.89 (computed here)
- National average 3.9
- No different than the national rate
- 2,221 patients
- Period from 07/01/2024
Iatrogenic pneumothorax rate As expected0.18
- State average 0.21 (computed here)
- National average 0.21
- No different than the national rate
- 2,206 patients
- Period from 07/01/2022
In-hospital fall-associated fracture rate As expected0.25
- State average 0.26 (computed here)
- National average 0.27
- No different than the national rate
- 2,317 patients
- Period from 07/01/2022
Perioperative pulmonary embolism or deep vein thrombosis rate As expected3.66
- State average 3.34 (computed here)
- National average 3.52
- No different than the national rate
- 520 patients
- Period from 07/01/2022
Postoperative acute kidney injury requiring dialysis rate As expected1.61
- State average 1.62 (computed here)
- National average 1.67
- No different than the national rate
- 141 patients
- Period from 07/01/2022
Postoperative hemorrhage or hematoma rate As expected2.37
- State average 2.31 (computed here)
- National average 2.34
- No different than the national rate
- 496 patients
- Period from 07/01/2022
Postoperative respiratory failure rate As expected9.39
- State average 10.06 (computed here)
- National average 9.42
- No different than the national rate
- 148 patients
- Period from 07/01/2022
Postoperative sepsis rate As expected4.86
- State average 5.23 (computed here)
- National average 5.27
- No different than the national rate
- 129 patients
- Period from 07/01/2022
Postoperative wound dehiscence rate As expected1.72
- State average 1.77 (computed here)
- National average 1.77
- No different than the national rate
- 106 patients
- Period from 07/01/2022
Pressure ulcer rate As expected0.27
- State average 0.52 (computed here)
- National average 0.63
- No different than the national rate
- 1,972 patients
- Period from 07/01/2022
Rate of complications for hip/knee replacement patients As expected3.9
- State average 4.14 (computed here)
- National average 4.1
- No different than the national rate
- 125 patients
- Period from 04/01/2023

Measures CMS does not publish for this facility (1)

Death rate for CABG surgery patients — 1

Infections 6

Medicare Care Compare

Catheter Associated Urinary Tract Infections (ICU + select Wards) Better0
- State average 0.35
- National average 1
- Better than the national benchmark
- Period from 10/01/2024
Central Line Associated Bloodstream Infection (ICU + select Wards) As expected0.63
- State average 0.48
- National average 1
- No different than national benchmark
- Period from 10/01/2024
Clostridium Difficile (C.Diff) Better0
- State average 0.24
- National average 1
- Better than the national benchmark
- Period from 10/01/2024
MRSA Bacteremia As expected0.66
- State average 0.6
- National average 1
- No different than national benchmark
- Period from 10/01/2024
SSI - Abdominal Hysterectomy As expected0
- State average 0.92
- National average 1
- No different than national benchmark
- Period from 10/01/2024
SSI - Colon Surgery As expected0.76
- State average 0.73
- National average 1
- No different than national benchmark
- Period from 10/01/2024

Outpatient imaging 2

Medicare Care Compare

Abdomen CT Use of Contrast Material 4.7
- State average 7.72 (computed here)
- National average 5.83 (computed here)
- Period from 07/01/2024
Breast Cancer Screening Recall Rates 2.6
- State average 6.86 (computed here)
- National average 8.08 (computed here)
- Period from 07/01/2024

Spending per patient 1

Medicare Care Compare

Medicare hospital spending per patient (Medicare Spending per Beneficiary) 1.11
- State average 1.03
- National average 0.99 (computed here)
- Period from 01/01/2024

Timely and effective care 18

Medicare Care Compare

Antithrombotic Therapy by End of Hospital Day 2 86
- State average 92.48 (computed here)
- National average 92.79 (computed here)
- 168 patients
- Period from 01/01/2024
Appropriate care for severe sepsis and septic shock 82
- State average 68
- National average 65
- 148 patients
- Period from 10/01/2024
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 132
- State average 150
- National average 168
- 378 patients
- Period from 10/01/2024
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better 348
- State average 260
- National average 287
- 14 patients
- Period from 10/01/2024
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 122
- State average 145
- National average 162
- 345 patients
- Period from 10/01/2024
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better 506
- State average 233
- National average 257
- 24 patients
- Period from 10/01/2024
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients 96
- State average 92
- National average 93
- 48 patients
- Period from 01/01/2024
Head CT results 50
- State average 67
- National average 69
- 20 patients
- Period from 10/01/2024
Healthcare workers given influenza vaccination 52
- State average 74
- National average 78
- 2,101 patients
- Period from 10/01/2024
Intensive Care Unit Venous Thromboembolism Prophylaxis 87
- State average 93.78 (computed here)
- National average 93.49 (computed here)
- 2,290 patients
- Period from 01/01/2024
Left before being seen 1
- State average 1
- National average 2
- 98,760 patients
- Period from 01/01/2024
Safe Use of Opioids - Concurrent Prescribing 10
- State average 14
- National average 15
- 4,249 patients
- Period from 01/01/2024
Septic Shock 3-Hour Bundle 86
- State average 74
- National average 73
- 37 patients
- Period from 10/01/2024
Septic Shock 6-Hour Bundle 90
- State average 89
- National average 87
- 29 patients
- Period from 10/01/2024
Severe Sepsis 3-Hour Bundle 93
- State average 83
- National average 81
- 148 patients
- Period from 10/01/2024
Severe Sepsis 6-Hour Bundle 96
- State average 93
- National average 93
- 98 patients
- Period from 10/01/2024
ST-Segment Elevation Myocardial Infarction (STEMI) 36
- State average 41.08 (computed here)
- National average 46.51 (computed here)
- 28 patients
- Period from 01/01/2024
Venous Thromboembolism Prophylaxis 71
- State average 78.56 (computed here)
- National average 82.23 (computed here)
- 8,042 patients
- Period from 01/01/2024

Measures CMS does not publish for this facility (12)

Anticoagulation Therapy for Atrial Fibrillation/Flutter — 5
Discharged on Antithrombotic Therapy — 5
Emergency department volume — very high
Global Malnutrition Composite Score — 5
Global Malnutrition Composite Score: Malnutrition Diagnosis Documented — 5
Global Malnutrition Composite Score: Malnutrition Risk Screening — 5
Global Malnutrition Composite Score: Nutrition Assessment — 5
Global Malnutrition Composite Score: Nutritional Care Plan — 5
Hospital Harm - Opioid Related Adverse Events — 5
Hospital Harm - Severe Hyperglycemia — 5
Hospital Harm - Severe Hypoglycemia — 5
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery — 5

Unplanned visits 10

Medicare Care Compare

Acute Myocardial Infarction (AMI) 30-Day Readmission Rate As expected15.1
- State average 14.48 (computed here)
- National average 14.4
- No different than the national rate
- 147 patients
- Period from 07/01/2023
Heart failure (HF) 30-Day Readmission Rate As expected21.1
- State average 21.26 (computed here)
- National average 21.3
- No different than the national rate
- 413 patients
- Period from 07/01/2023
Hospital return days for heart failure patients 13.1
- State average -1.32 (computed here)
- National average 4.02 (computed here)
- Average days per 100 discharges
- 123 patients
- Period from 07/01/2022
Hospital return days for pneumonia patients 32.5
- State average 2.42 (computed here)
- National average 5.65 (computed here)
- Average days per 100 discharges
- 160 patients
- Period from 07/01/2022
Pneumonia (PN) 30-Day Readmission Rate As expected17
- State average 17.32 (computed here)
- National average 17.3
- No different than the national rate
- 522 patients
- Period from 07/01/2023
Rate of readmission after hip/knee replacement As expected6.4
- State average 5.89 (computed here)
- National average 5.8
- No different than the national rate
- 123 patients
- Period from 07/01/2023
Rate of readmission for CABG As expected11
- State average 11.35 (computed here)
- National average 11
- No different than the national rate
- 38 patients
- Period from 07/01/2023
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients As expected21.6
- State average 19.85 (computed here)
- National average 20
- No different than the national rate
- 171 patients
- Period from 07/01/2023
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies) As expected13
- State average 13.1 (computed here)
- National average 13
- No different than the national rate
- 47 patients
- Period from 01/01/2022
Ratio of unplanned hospital visits after hospital outpatient surgery As expected1.2
- State average 1.02 (computed here)
- National average 1.01 (computed here)
- No different than expected
- 63 patients
- Period from 01/01/2024

Measures CMS does not publish for this facility (4)

Hospital return days for heart attack patients — 1
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR) — 4
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy — 1
Rate of inpatient admissions for patients receiving outpatient chemotherapy — 1

Sources for this page

Provider of Services: the certification, provider type, beds and status.
Medicare Care Compare: the star rating and every measure on this page, with the state and national rates CMS publishes beside them.
NPPES NPI Registry: the NPI records connected to this certification.

Better and worse are CMS's own comparison with the national rate, not ours: for most measures a low score is the good one (deaths, infections) and for others a high one is, so measures where CMS states no comparison are left uncoloured. The exception is star ratings, which are read against the national average here. Quality measures are published by CMS and are not adjusted or re-scored here. Averages marked “computed here” are the mean of every facility reporting that measure, worked out by NPIMap because CMS publishes no comparison for it. Confirm anything you rely on at Medicare Care Compare.