Baylor Scott and White All Saints Medical Center

Hospital in Fort Worth, TX, Medicare certification number 450137. CMS publishes 64 quality measures for it.

Medicare certification

Provider of Services

CCN: 450137The 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: May 6, 2024
Beds: 538
Overall star rating: 4 of 5Care Compare
Address: 1400 Eighth Ave
Fort Worth, TX 76104
(817) 926-2544

NPI records for this facility 1

Baylor All Saints Medical Center
- General Acute Care Hospital
- Fort Worth, TX
- NPI 1669472387
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 Better3 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 As expected3 of 5
- State average 2.96 (computed here)
- National average 3.12 (computed here)
- Period from 10/01/2024
Nurse communication - star rating Better4 of 5
- State average 3.28 (computed here)
- National average 3.43 (computed here)
- Period from 10/01/2024
Overall hospital rating - star rating Better4 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

Complications and deaths 19

Medicare Care Compare

Abdominopelvic accidental puncture or laceration rate As expected1.12
- State average 1.03 (computed here)
- National average 1.06
- No different than the national rate
- 1,855 patients
- Period from 07/01/2022
CMS Medicare PSI 90: Patient safety and adverse events composite As expected1.23
- 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 expected189.05
- State average 166 (computed here)
- National average 173.3
- No different than the national rate
- 111 patients
- Period from 07/01/2022
Death rate for CABG surgery patients As expected2.1
- State average 2.71 (computed here)
- National average 2.4
- No different than the national rate
- 84 patients
- Period from 07/01/2022
Death rate for COPD patients As expected8.8
- State average 8.7 (computed here)
- National average 8.6
- No different than the national rate
- 132 patients
- Period from 07/01/2022
Death rate for heart attack patients As expected12.2
- State average 11.91 (computed here)
- National average 11.9
- No different than the national rate
- 60 patients
- Period from 07/01/2022
Death rate for heart failure patients As expected8.3
- State average 10.52 (computed here)
- National average 11.1
- No different than the national rate
- 266 patients
- Period from 07/01/2022
Death rate for pneumonia patients As expected12.4
- State average 14.69 (computed here)
- National average 15.2
- No different than the national rate
- 229 patients
- Period from 07/01/2022
Death rate for stroke patients As expected11.1
- State average 12.01 (computed here)
- National average 11.9
- No different than the national rate
- 168 patients
- Period from 07/01/2023
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate Better2.7
- State average 3.89 (computed here)
- National average 3.9
- Better than the national rate
- 3,123 patients
- Period from 07/01/2024
Iatrogenic pneumothorax rate As expected0.14
- State average 0.21 (computed here)
- National average 0.21
- No different than the national rate
- 6,891 patients
- Period from 07/01/2022
In-hospital fall-associated fracture rate As expected0.24
- State average 0.26 (computed here)
- National average 0.27
- No different than the national rate
- 7,520 patients
- Period from 07/01/2022
Perioperative pulmonary embolism or deep vein thrombosis rate As expected2.72
- State average 3.34 (computed here)
- National average 3.52
- No different than the national rate
- 1,865 patients
- Period from 07/01/2022
Postoperative acute kidney injury requiring dialysis rate As expected1.55
- State average 1.62 (computed here)
- National average 1.67
- No different than the national rate
- 794 patients
- Period from 07/01/2022
Postoperative hemorrhage or hematoma rate As expected2.39
- State average 2.31 (computed here)
- National average 2.34
- No different than the national rate
- 1,660 patients
- Period from 07/01/2022
Postoperative respiratory failure rate Worse15.84
- State average 10.06 (computed here)
- National average 9.42
- Worse than the national rate
- 771 patients
- Period from 07/01/2022
Postoperative sepsis rate As expected7.31
- State average 5.23 (computed here)
- National average 5.27
- No different than the national rate
- 878 patients
- Period from 07/01/2022
Postoperative wound dehiscence rate As expected1.86
- State average 1.77 (computed here)
- National average 1.77
- No different than the national rate
- 401 patients
- Period from 07/01/2022
Pressure ulcer rate As expected0.78
- State average 0.52 (computed here)
- National average 0.63
- No different than the national rate
- 5,896 patients
- Period from 07/01/2022

Measures CMS does not publish for this facility (1)

Rate of complications for hip/knee replacement patients — 1

Infections 6

Medicare Care Compare

Catheter Associated Urinary Tract Infections (ICU + select Wards) As expected0.52
- State average 0.35
- National average 1
- No different than national benchmark
- Period from 10/01/2024
Central Line Associated Bloodstream Infection (ICU + select Wards) As expected0.52
- State average 0.48
- National average 1
- No different than national benchmark
- Period from 10/01/2024
Clostridium Difficile (C.Diff) Better0.08
- 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 expected0.33
- State average 0.92
- National average 1
- No different than national benchmark
- Period from 10/01/2024
SSI - Colon Surgery As expected0.29
- State average 0.73
- National average 1
- No different than national benchmark
- Period from 10/01/2024

Outpatient imaging 1

Medicare Care Compare

Abdomen CT Use of Contrast Material 3.7
- State average 7.72 (computed here)
- National average 5.83 (computed here)
- Period from 07/01/2024

Measures CMS does not publish for this facility (1)

Breast Cancer Screening Recall Rates — 7

Spending per patient 1

Medicare Care Compare

Medicare hospital spending per patient (Medicare Spending per Beneficiary) 1.02
- State average 1.03
- National average 0.99 (computed here)
- Period from 01/01/2024

Timely and effective care 16

Medicare Care Compare

Appropriate care for severe sepsis and septic shock 80
- State average 68
- National average 65
- 157 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 232
- State average 150
- National average 168
- 358 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 233
- State average 145
- National average 162
- 343 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 208
- State average 233
- National average 257
- 14 patients
- Period from 10/01/2024
Discharged on Antithrombotic Therapy 99
- State average 93.64 (computed here)
- National average 96.1 (computed here)
- 137 patients
- Period from 01/01/2024
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients 96
- State average 92
- National average 93
- 68 patients
- Period from 01/01/2024
Head CT results 94
- State average 67
- National average 69
- 16 patients
- Period from 10/01/2024
Healthcare workers given influenza vaccination 93
- State average 74
- National average 78
- 4,134 patients
- Period from 10/01/2024
Intensive Care Unit Venous Thromboembolism Prophylaxis 88
- State average 93.78 (computed here)
- National average 93.49 (computed here)
- 2,584 patients
- Period from 01/01/2024
Left before being seen 1
- State average 1
- National average 2
- 51,580 patients
- Period from 01/01/2024
Safe Use of Opioids - Concurrent Prescribing 10
- State average 14
- National average 15
- 7,983 patients
- Period from 01/01/2024
Septic Shock 3-Hour Bundle 64
- State average 74
- National average 73
- 33 patients
- Period from 10/01/2024
Septic Shock 6-Hour Bundle 100
- State average 89
- National average 87
- 16 patients
- Period from 10/01/2024
Severe Sepsis 3-Hour Bundle 90
- State average 83
- National average 81
- 157 patients
- Period from 10/01/2024
Severe Sepsis 6-Hour Bundle 95
- State average 93
- National average 93
- 57 patients
- Period from 10/01/2024
Venous Thromboembolism Prophylaxis 80
- State average 78.56 (computed here)
- National average 82.23 (computed here)
- 9,234 patients
- Period from 01/01/2024

Measures CMS does not publish for this facility (14)

Anticoagulation Therapy for Atrial Fibrillation/Flutter — 5
Antithrombotic Therapy by End of Hospital Day 2 — 5
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better — 1
Emergency department volume — 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
ST-Segment Elevation Myocardial Infarction (STEMI) — 5

Unplanned visits 12

Medicare Care Compare

Acute Myocardial Infarction (AMI) 30-Day Readmission Rate As expected15
- State average 14.48 (computed here)
- National average 14.4
- No different than the national rate
- 129 patients
- Period from 07/01/2023
Heart failure (HF) 30-Day Readmission Rate As expected20.9
- State average 21.26 (computed here)
- National average 21.3
- No different than the national rate
- 549 patients
- Period from 07/01/2023
Hospital return days for heart attack patients 66.7
- State average 11.3 (computed here)
- National average 6.71 (computed here)
- More days than average per 100 discharges
- 63 patients
- Period from 07/01/2022
Hospital return days for heart failure patients 26.8
- State average -1.32 (computed here)
- National average 4.02 (computed here)
- Average days per 100 discharges
- 330 patients
- Period from 07/01/2022
Hospital return days for pneumonia patients 12
- State average 2.42 (computed here)
- National average 5.65 (computed here)
- Average days per 100 discharges
- 249 patients
- Period from 07/01/2022
Pneumonia (PN) 30-Day Readmission Rate As expected18.5
- State average 17.32 (computed here)
- National average 17.3
- No different than the national rate
- 358 patients
- Period from 07/01/2023
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy As expected5.3
- State average 5.29 (computed here)
- National average 5.4
- No different than the national rate
- 49 patients
- Period from 01/01/2024
Rate of inpatient admissions for patients receiving outpatient chemotherapy As expected11.1
- State average 10.89 (computed here)
- National average 10.7
- No different than the national rate
- 49 patients
- Period from 01/01/2024
Rate of readmission for CABG As expected11.3
- State average 11.35 (computed here)
- National average 11
- No different than the national rate
- 117 patients
- Period from 07/01/2023
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients As expected19.7
- State average 19.85 (computed here)
- National average 20
- No different than the national rate
- 374 patients
- Period from 07/01/2023
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies) As expected14.2
- State average 13.1 (computed here)
- National average 13
- No different than the national rate
- 377 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
- 326 patients
- Period from 01/01/2024

Measures CMS does not publish for this facility (2)

Hybrid Hospital-Wide All-Cause Readmission Measure (HWR) — 4
Rate of readmission after hip/knee replacement — 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.