The Heart Hospital Baylor Denton

Hospital in Denton, TX, Medicare certification number 450893. CMS publishes 40 quality measures for it.

Medicare certification

Provider of Services

CCN: 450893The 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: Physician
Control type: Hospital district or authority
Participating since: Mar 31, 2005
Last certification: May 20, 2023
Beds: 22
Overall star rating: 5 of 5Care Compare
Most recent change of ownership: May 31, 2013 (1 total)
Address: 2801 South Mayhill Road
Denton, TX 76208
(940) 220-0600

NPI records for this facility 1

Thhbp Management Company LLC
- General Acute Care Hospital
- Denton, TX
- NPI 1194753590
Medicare enrollment

Patient survey (HCAHPS) 9

Medicare Care Compare

Cleanliness - star rating Better4 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 Better5 of 5
- State average 3.07 (computed here)
- National average 3.31 (computed here)
- Period from 10/01/2024
Doctor communication - star rating Better4 of 5
- State average 2.96 (computed here)
- National average 3.12 (computed here)
- Period from 10/01/2024
Nurse communication - star rating Better5 of 5
- State average 3.28 (computed here)
- National average 3.43 (computed here)
- Period from 10/01/2024
Overall hospital rating - star rating Better5 of 5
- State average 3.32 (computed here)
- National average 3.29 (computed here)
- Period from 10/01/2024
Quietness - star rating Better4 of 5
- State average 3.82 (computed here)
- National average 3.27 (computed here)
- Period from 10/01/2024
Recommend hospital - star rating Better5 of 5
- State average 3.69 (computed here)
- National average 3.64 (computed here)
- Period from 10/01/2024
Summary star rating Better4 of 5
- State average 3.27 (computed here)
- National average 3.27 (computed here)
- Period from 10/01/2024

Complications and deaths 13

Medicare Care Compare

CMS Medicare PSI 90: Patient safety and adverse events composite As expected0.92
- State average 0.97 (computed here)
- National average 1
- No different than the national value
- Period from 07/01/2022
Death rate for CABG surgery patients As expected1.5
- State average 2.71 (computed here)
- National average 2.4
- No different than the national rate
- 288 patients
- Period from 07/01/2022
Death rate for heart attack patients As expected11.7
- State average 11.91 (computed here)
- National average 11.9
- No different than the national rate
- 51 patients
- Period from 07/01/2022
Death rate for heart failure patients As expected9.7
- State average 10.52 (computed here)
- National average 11.1
- No different than the national rate
- 104 patients
- Period from 07/01/2022
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate As expected3
- State average 3.89 (computed here)
- National average 3.9
- No different than the national rate
- 585 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
- 670 patients
- Period from 07/01/2022
In-hospital fall-associated fracture rate As expected0.26
- State average 0.26 (computed here)
- National average 0.27
- No different than the national rate
- 1,047 patients
- Period from 07/01/2022
Perioperative pulmonary embolism or deep vein thrombosis rate As expected3.53
- State average 3.34 (computed here)
- National average 3.52
- No different than the national rate
- 517 patients
- Period from 07/01/2022
Postoperative acute kidney injury requiring dialysis rate As expected1.21
- State average 1.62 (computed here)
- National average 1.67
- No different than the national rate
- 280 patients
- Period from 07/01/2022
Postoperative hemorrhage or hematoma rate As expected2
- State average 2.31 (computed here)
- National average 2.34
- No different than the national rate
- 358 patients
- Period from 07/01/2022
Postoperative respiratory failure rate As expected4.6
- State average 10.06 (computed here)
- National average 9.42
- No different than the national rate
- 293 patients
- Period from 07/01/2022
Postoperative sepsis rate As expected4.29
- State average 5.23 (computed here)
- National average 5.27
- No different than the national rate
- 294 patients
- Period from 07/01/2022
Pressure ulcer rate As expected1
- State average 0.52 (computed here)
- National average 0.63
- No different than the national rate
- 680 patients
- Period from 07/01/2022

Measures CMS does not publish for this facility (7)

Abdominopelvic accidental puncture or laceration rate — 1
Death rate among surgical inpatients with serious treatable complications — 1
Death rate for COPD patients — 1
Death rate for pneumonia patients — 1
Death rate for stroke patients — 5
Postoperative wound dehiscence rate — 1
Rate of complications for hip/knee replacement patients — 5

Infections 0

Medicare Care Compare

Measures CMS does not publish for this facility (6)

Catheter Associated Urinary Tract Infections (ICU + select Wards) — 12
Central Line Associated Bloodstream Infection (ICU + select Wards) — 12
Clostridium Difficile (C.Diff) — 13
MRSA Bacteremia — 13
SSI - Abdominal Hysterectomy — 5
SSI - Colon Surgery — 5

Outpatient imaging 0

Medicare Care Compare

Measures CMS does not publish for this facility (2)

Abdomen CT Use of Contrast Material — 1
Breast Cancer Screening Recall Rates — 7

Spending per patient 1

Medicare Care Compare

Medicare hospital spending per patient (Medicare Spending per Beneficiary) 1.06
- State average 1.03
- National average 0.99 (computed here)
- Period from 01/01/2024

Timely and effective care 11

Medicare Care Compare

Appropriate care for severe sepsis and septic shock 62
- State average 68
- National average 65
- 16 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 120
- State average 150
- National average 168
- 276 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 378
- State average 260
- National average 287
- 19 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 119
- State average 145
- National average 162
- 255 patients
- Period from 10/01/2024
Healthcare workers given influenza vaccination 92
- State average 74
- National average 78
- 1,283 patients
- Period from 10/01/2024
Intensive Care Unit Venous Thromboembolism Prophylaxis 99
- State average 93.78 (computed here)
- National average 93.49 (computed here)
- 781 patients
- Period from 01/01/2024
Left before being seen 0
- State average 1
- National average 2
- 2,505 patients
- Period from 01/01/2024
Safe Use of Opioids - Concurrent Prescribing 13
- State average 14
- National average 15
- 462 patients
- Period from 01/01/2024
Severe Sepsis 3-Hour Bundle 94
- State average 83
- National average 81
- 16 patients
- Period from 10/01/2024
Severe Sepsis 6-Hour Bundle 100
- State average 93
- National average 93
- 12 patients
- Period from 10/01/2024
Venous Thromboembolism Prophylaxis 79
- State average 78.56 (computed here)
- National average 82.23 (computed here)
- 787 patients
- Period from 01/01/2024

Measures CMS does not publish for this facility (19)

Anticoagulation Therapy for Atrial Fibrillation/Flutter — 5
Antithrombotic Therapy by End of Hospital Day 2 — 5
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better — 1
Discharged on Antithrombotic Therapy — 5
Emergency department volume — low
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients — 5
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 Hyperglycemia — 5
Hospital Harm - Severe Hypoglycemia — 5
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery — 5
Septic Shock 3-Hour Bundle — 1, 3
Septic Shock 6-Hour Bundle — 1, 3
ST-Segment Elevation Myocardial Infarction (STEMI) — 1

Unplanned visits 6

Medicare Care Compare

Acute Myocardial Infarction (AMI) 30-Day Readmission Rate As expected14.5
- State average 14.48 (computed here)
- National average 14.4
- No different than the national rate
- 97 patients
- Period from 07/01/2023
Heart failure (HF) 30-Day Readmission Rate As expected22.1
- State average 21.26 (computed here)
- National average 21.3
- No different than the national rate
- 125 patients
- Period from 07/01/2023
Hospital return days for heart attack patients 1.7
- State average 11.3 (computed here)
- National average 6.71 (computed here)
- Average days per 100 discharges
- 83 patients
- Period from 07/01/2022
Hospital return days for heart failure patients 36.7
- State average -1.32 (computed here)
- National average 4.02 (computed here)
- Average days per 100 discharges
- 105 patients
- Period from 07/01/2022
Rate of readmission for CABG As expected9.9
- State average 11.35 (computed here)
- National average 11
- No different than the national rate
- 261 patients
- Period from 07/01/2023
Ratio of unplanned hospital visits after hospital outpatient surgery As expected1.1
- State average 1.02 (computed here)
- National average 1.01 (computed here)
- No different than expected
- 97 patients
- Period from 01/01/2024

Measures CMS does not publish for this facility (8)

Hospital return days for pneumonia patients — 1
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR) — 4
Pneumonia (PN) 30-Day Readmission Rate — 1
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy — 5
Rate of inpatient admissions for patients receiving outpatient chemotherapy — 5
Rate of readmission after hip/knee replacement — 5
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients — 1
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies) — 5

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.