Mother Frances Hospital Regional Health Care Center

Doing business as Christus Mother Frances Hospital

Hospital in Tyler, TX, Medicare certification number 450102. CMS publishes 68 quality measures for it.

Medicare certification

Provider of Services

CCN: 450102The 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: Voluntary non-profit - Private
Control type: Private (not for profit)
Participating since: Jul 1, 1966
Last certification: Aug 12, 2024
Beds: 612
Overall star rating: 4 of 5Care Compare
Address: 800 East Dawson
Tyler, TX 75701
(903) 593-8441

NPI records for this facility (CCN to NPI Mapping) 1

Mother Frances Hospital Regional Health Care Center

dba Christus Mother Frances Hospital Tyler
- General Acute Care Hospital
- Tyler, TX
- NPI 1679578439
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 Worse3 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 Worse3 of 5
- State average 3.28 (computed here)
- National average 3.43 (computed here)
- Period from 10/01/2024
Overall hospital rating - star rating Worse3 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 Better4 of 5
- State average 3.69 (computed here)
- National average 3.64 (computed here)
- Period from 10/01/2024
Summary star rating Worse3 of 5
- State average 3.27 (computed here)
- National average 3.27 (computed here)
- Period from 10/01/2024

Affiliated providers 1,543

Page 1 of 62Medicare Care Compare

Clinicians who list this facility as a hospital or facility affiliation in Care Compare.

Enyinnaya Ugochukwu Abarikwu, MD
- Internal Medicine Physician
- Tyler, TX
- NPI 1174788178
Khabeer Abdul
- Family Nurse Practitioner
- Edmonton, KY
- NPI 1992252266
Eyoel T Abebe, M.D.
- Internal Medicine Physician
- Frisco, TX
- NPI 1992098719
Jordan William Abel, M.D.
- Infectious Disease Physician
- San Antonio, TX
- NPI 1417273301
Warren Allen Abrameit, MD
- Surgery Physician
- Tyler, TX
- NPI 1225013915
Julie Adams, NP
- Nurse Practitioner
- Tyler, TX
- NPI 1023164456
July Adams
- Physician Assistant
- Fort Worth, TX
- NPI 1457723207
Susan Ann Addie, N.P.
- Nurse Practitioner
- Tyler, TX
- NPI 1083596118
Kasi M. Addison, DO
- Emergency Medicine Physician
- Shreveport, LA
- NPI 1679034870
Neil H Adelman, M.D
- Addiction Medicine (Internal Medicine) Physician
- Tyler, TX
- NPI 1902848120
Adebayo Adewale, M.D
- Nephrology Physician
- Palestine, TX
- NPI 1245509108
Sara Adibi, M.D.
- Emergency Medicine Physician
- Saginaw, MI
- NPI 1114280401
Phillip L Admire III, MD
- Emergency Medicine Physician
- Canton, TX
- NPI 1700828118
Hassan Ahmed, MD
- Surgical Oncology Physician
- Plano, TX
- NPI 1295020386
Nabeel K Ahmed, M.D.
- Nephrology Physician
- Tyler, TX
- NPI 1003965906
Rahman Ahmed, DO
- Internal Medicine Physician
- Tyler, TX
- NPI 1912644279
Rukhsaar Ahmed, PA
- Physician Assistant
- Grapevine, TX
- NPI 1407500457
Saeem Akhtar, MD
- Internal Medicine Physician
- Fort Smith, AR
- NPI 1619497435
Keerthana Akkineni, M.D.
- Neurology Physician
- Tampa, FL
- NPI 1275928715
Ali Al-Nahi, DO
- Family Medicine Physician
- Fort Worth, TX
- NPI 1053061564
Abdl-Rawf Al-Nowaylati, M.D.
- Plastic and Reconstructive Surgery Physician
- Atlanta, GA
- NPI 1770921983
Kashif Alauddin, M.D.
- Internal Medicine Physician
- Tyler, TX
- NPI 1659506509
Shawn K Alberti, CRNA
- Certified Registered Nurse Anesthetist
- Little Rock, AR
- NPI 1659349892
Joel W Alderson, DO
- Anatomic Pathology & Clinical Pathology Physician
- Wichita, KS
- NPI 1629121686
Jarrett Desmond Aldinger, MD
- Anesthesiology Physician
- San Angelo, TX
- NPI 1689934788

Complications and deaths 20

Medicare Care Compare

Abdominopelvic accidental puncture or laceration rate As expected1.32
- State average 1.03 (computed here)
- National average 1.06
- No different than the national rate
- 2,851 patients
- Period from 07/01/2022
CMS Medicare PSI 90: Patient safety and adverse events composite As expected0.83
- 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 expected156.58
- State average 166 (computed here)
- National average 173.3
- No different than the national rate
- 247 patients
- Period from 07/01/2022
Death rate for CABG surgery patients As expected2.7
- State average 2.71 (computed here)
- National average 2.4
- No different than the national rate
- 320 patients
- Period from 07/01/2022
Death rate for COPD patients As expected9.4
- State average 8.7 (computed here)
- National average 8.6
- No different than the national rate
- 251 patients
- Period from 07/01/2022
Death rate for heart attack patients As expected12.4
- State average 11.91 (computed here)
- National average 11.9
- No different than the national rate
- 420 patients
- Period from 07/01/2022
Death rate for heart failure patients As expected12.1
- State average 10.52 (computed here)
- National average 11.1
- No different than the national rate
- 862 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
- 1,279 patients
- Period from 07/01/2022
Death rate for stroke patients As expected11.7
- State average 12.01 (computed here)
- National average 11.9
- No different than the national rate
- 948 patients
- Period from 07/01/2023
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate As expected4
- State average 3.89 (computed here)
- National average 3.9
- No different than the national rate
- 8,010 patients
- Period from 07/01/2024
Iatrogenic pneumothorax rate As expected0.19
- State average 0.21 (computed here)
- National average 0.21
- No different than the national rate
- 12,567 patients
- Period from 07/01/2022
In-hospital fall-associated fracture rate As expected0.29
- State average 0.26 (computed here)
- National average 0.27
- No different than the national rate
- 13,169 patients
- Period from 07/01/2022
Perioperative pulmonary embolism or deep vein thrombosis rate As expected2.44
- State average 3.34 (computed here)
- National average 3.52
- No different than the national rate
- 3,829 patients
- Period from 07/01/2022
Postoperative acute kidney injury requiring dialysis rate As expected1.82
- State average 1.62 (computed here)
- National average 1.67
- No different than the national rate
- 1,287 patients
- Period from 07/01/2022
Postoperative hemorrhage or hematoma rate Worse4
- State average 2.31 (computed here)
- National average 2.34
- Worse than the national rate
- 3,304 patients
- Period from 07/01/2022
Postoperative respiratory failure rate As expected11.11
- State average 10.06 (computed here)
- National average 9.42
- No different than the national rate
- 1,185 patients
- Period from 07/01/2022
Postoperative sepsis rate As expected3.8
- State average 5.23 (computed here)
- National average 5.27
- No different than the national rate
- 1,206 patients
- Period from 07/01/2022
Postoperative wound dehiscence rate As expected1.89
- State average 1.77 (computed here)
- National average 1.77
- No different than the national rate
- 791 patients
- Period from 07/01/2022
Pressure ulcer rate Better0.08
- State average 0.52 (computed here)
- National average 0.63
- Better than the national rate
- 11,282 patients
- Period from 07/01/2022
Rate of complications for hip/knee replacement patients As expected5.6
- State average 4.14 (computed here)
- National average 4.1
- No different than the national rate
- 41 patients
- Period from 04/01/2023

Infections 6

Medicare Care Compare

Catheter Associated Urinary Tract Infections (ICU + select Wards) Better0.06
- 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) Better0.3
- State average 0.48
- National average 1
- Better than the national benchmark
- Period from 10/01/2024
Clostridium Difficile (C.Diff) Better0.14
- State average 0.24
- National average 1
- Better than the national benchmark
- Period from 10/01/2024
MRSA Bacteremia As expected0.6
- State average 0.6
- National average 1
- No different than national benchmark
- Period from 10/01/2024
SSI - Abdominal Hysterectomy As expected1.12
- State average 0.92
- National average 1
- No different than national benchmark
- Period from 10/01/2024
SSI - Colon Surgery As expected1.08
- 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 14.7
- State average 7.72 (computed here)
- National average 5.83 (computed here)
- Period from 07/01/2024
Breast Cancer Screening Recall Rates 28.1
- 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) 1.1
- State average 1.03
- National average 0.99 (computed here)
- Period from 01/01/2024

Timely and effective care 17

Medicare Care Compare

Antithrombotic Therapy by End of Hospital Day 2 91
- State average 92.48 (computed here)
- National average 92.79 (computed here)
- 640 patients
- Period from 01/01/2024
Appropriate care for severe sepsis and septic shock 84
- State average 68
- National average 65
- 292 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 105
- State average 150
- National average 168
- 815 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 265
- 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 102
- State average 145
- National average 162
- 782 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 132
- State average 233
- National average 257
- 21 patients
- Period from 10/01/2024
Discharged on Antithrombotic Therapy 96
- State average 93.64 (computed here)
- National average 96.1 (computed here)
- 765 patients
- Period from 01/01/2024
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients 100
- State average 92
- National average 93
- 105 patients
- Period from 01/01/2024
Healthcare workers given influenza vaccination 83
- State average 74
- National average 78
- 4,611 patients
- Period from 10/01/2024
Hospital Harm - Severe Hyperglycemia 3
- State average 6.38 (computed here)
- National average 8.08 (computed here)
- 43,325 patients
- Period from 01/01/2024
Left before being seen 0
- State average 1
- National average 2
- 175,508 patients
- Period from 01/01/2024
Safe Use of Opioids - Concurrent Prescribing 14
- State average 14
- National average 15
- 9,478 patients
- Period from 01/01/2024
Septic Shock 3-Hour Bundle 88
- State average 74
- National average 73
- 97 patients
- Period from 10/01/2024
Septic Shock 6-Hour Bundle 94
- State average 89
- National average 87
- 62 patients
- Period from 10/01/2024
Severe Sepsis 3-Hour Bundle 90
- State average 83
- National average 81
- 292 patients
- Period from 10/01/2024
Severe Sepsis 6-Hour Bundle 100
- State average 93
- National average 93
- 132 patients
- Period from 10/01/2024
ST-Segment Elevation Myocardial Infarction (STEMI) 56
- State average 41.08 (computed here)
- National average 46.51 (computed here)
- 45 patients
- Period from 01/01/2024

Measures CMS does not publish for this facility (13)

Anticoagulation Therapy for Atrial Fibrillation/Flutter — 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
Head CT results — 1
Hospital Harm - Opioid Related Adverse Events — 5
Hospital Harm - Severe Hypoglycemia — 5
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery — 5
Intensive Care Unit Venous Thromboembolism Prophylaxis — 5
Venous Thromboembolism Prophylaxis — 5

Unplanned visits 13

Medicare Care Compare

Acute Myocardial Infarction (AMI) 30-Day Readmission Rate As expected15.3
- State average 14.48 (computed here)
- National average 14.4
- No different than the national rate
- 758 patients
- Period from 07/01/2023
Heart failure (HF) 30-Day Readmission Rate As expected20.7
- State average 21.26 (computed here)
- National average 21.3
- No different than the national rate
- 1,645 patients
- Period from 07/01/2023
Hospital return days for heart attack patients 0.3
- State average 11.3 (computed here)
- National average 6.71 (computed here)
- Average days per 100 discharges
- 469 patients
- Period from 07/01/2022
Hospital return days for heart failure patients 14.8
- State average -1.32 (computed here)
- National average 4.02 (computed here)
- Average days per 100 discharges
- 998 patients
- Period from 07/01/2022
Hospital return days for pneumonia patients 8.6
- State average 2.42 (computed here)
- National average 5.65 (computed here)
- Average days per 100 discharges
- 1,341 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
- 2,103 patients
- Period from 07/01/2023
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy As expected5.1
- State average 5.29 (computed here)
- National average 5.4
- No different than the national rate
- 162 patients
- Period from 01/01/2024
Rate of inpatient admissions for patients receiving outpatient chemotherapy As expected9.2
- State average 10.89 (computed here)
- National average 10.7
- No different than the national rate
- 162 patients
- Period from 01/01/2024
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
- 45 patients
- Period from 07/01/2023
Rate of readmission for CABG As expected9.2
- State average 11.35 (computed here)
- National average 11
- No different than the national rate
- 443 patients
- Period from 07/01/2023
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients As expected21.3
- State average 19.85 (computed here)
- National average 20
- No different than the national rate
- 496 patients
- Period from 07/01/2023
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies) Better10.2
- State average 13.1 (computed here)
- National average 13
- Better than the national rate
- 6,782 patients
- Period from 01/01/2022
Ratio of unplanned hospital visits after hospital outpatient surgery As expected0.9
- State average 1.02 (computed here)
- National average 1.01 (computed here)
- No different than expected
- 1,944 patients
- Period from 01/01/2024

Measures CMS does not publish for this facility (1)

Hybrid Hospital-Wide All-Cause Readmission Measure (HWR) — 4

Other hospitals in Tyler, TX

Baylor Scott & White Texas Spine & Joint Hospital
Exceptional Healthcare Tyler terminated
University of Texas Health Science Center at Tyler 11937 US Highway 271
University of Texas Health Science Center at Tyler 11937 US Highway 271
Ut Health East Texas Specialty Hospital terminated
Ut Health East Texas Tyler Regional Hospital

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, and the clinicians who list this facility as an affiliation.
NPPES NPI Registry: the NPI records connected to this certification and the names of the providers listed above.

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.