Quality Report


Quality Report

The Institute for Rehabilitation and Research

DBA: TIRR Memorial Hermann
HCO ID: 9103
1333 Moursund Avenue
Houston, TX, 77030-3405
(713) 799-5000
www.memorialhermann.org
Summary of Quality Information

Accreditation Programs

View Accreditation History
Gold Seal
Hospital
Accreditation Decision
Effective Date
12/23/2021
Last Full Survey Date
12/22/2021
Last On-Site Survey Date
12/22/2021

Sites

Memorial Hermann Health System
DBA: TIRR Memorial Hermann
1333 Moursund Street
Houston, TX, 77030-3405

Available Services

  • CT Scanner (Imaging/Diagnostic Services )
  • EEG/EKG/EMG Lab (Imaging/Diagnostic Services )
  • Hazardous Medication Compounding (Inpatient )
  • Inpatient Unit (Inpatient )
  • Non-Sterile Medication Compounding (Inpatient )
  • Outpatient Clinics (Outpatient )
  • Pediatric Unit (Inpatient )
  • Rehabilitation Unit (Inpatient )
  • Rehabilitation Unit (24-hour Acute Care/Crisis Stabilization )
  • Sleep Laboratory (Sleep Laboratory )
  • Sterile Medication Compounding (Inpatient )
  • Ultrasound (Imaging/Diagnostic Services )

TIRR Memorial Hermann Adult Outpatient Rehabilitation
2455 South Braeswood
Houston, TX, 77030

Available Services

  • Outpatient Clinics (Outpatient )

TIRR Memorial Hermann at West University
2909 West Holcombe Blvd
Houston, TX, 77025

Available Services

  • Outpatient Clinics (Outpatient )

TIRR Memorial Hermann Outpatient Rehab - Memorial City
10125 Katy Freeway Suite 108
Houston, TX, 77024

Available Services

  • Outpatient Clinics (Outpatient )

TIRR Memorial Hermann Outpatient Rehabilitation- Southeast
300 Rogers
Webster, TX, 77598

Available Services

  • Outpatient Clinics (Outpatient )

TIRR Memorial Hermann Pediatric Outpatient Rehabilitation
2453 South Braeswood
Houston, TX, 77030

Available Services

  • Outpatient Clinics (Outpatient )

TIRR Memorial Hermann Sugar Land - Outpatient
1111 Highway 6 Suite 195
Sugar Land, TX, 77478

Available Services

  • Outpatient Clinics (Outpatient )

TIRR Memorial Hermann The Woodlands Outpt Rehabilitation
920 Medical Plaza Drive, Suite 270 & 500
Shenandoah, TX, 77380

Available Services

  • Outpatient Clinics (Outpatient )

National Patient Safety Goals and National Quality Improvement Goals

Symbol Key

  • starThis organization achieved the best possible results
  • plusThis organization's performance is better than the target range/value
  • checkThis organization's performance is similar to the target range/value
  • minusThis organization's performance is worse than the target range /value
  • naThis measure is not applicable for this organization
  • ndNot displayed

Measures Footnote Key

  1. The measure or measure set was not reported.
  2. The measure set does not have an overall result.
  3. The number is not enough for comparison purposes.
  4. The measure meets the Privacy Disclosure Threshold rule.
  5. The organization scored above 90% but was below most other organizations.
  6. The measure results are not statistically valid.
  7. The measure results are based on a sample of patients.
  8. The number of months with measure data is below the reporting requirement.
  9. The measure results are temporarily suppressed pending resubmission of updated data.
  10. Test Measure: a measure being evaluated for reliability of the individual data elements or awaiting National Quality Forum Endorsement.
  11. There were no eligible patients that met the denominator criteria.
  12. The measure rate is within optimal range.

Symbol Key

  • starThis organization achieved the best possible results
  • plusThis organization's performance is better than the target range/value
  • checkThis organization's performance is similar to the target range/value
  • minusThis organization's performance is worse than the target range/value
  • naThis measure is not applicable for this organization
  • ndNot displayed

Measures Footnote Key

  1. The measure or measure set was not reported.
  2. The measure set does not have an overall result.
  3. The number is not enough for comparison purposes.
  4. The measure meets the Privacy Disclosure Threshold rule.
  5. The organization scored above 90% but was below most other organizations.
  6. The measure results are not statistically valid.
  7. The measure results are based on a sample of patients.
  8. The number of months with measure data is below the reporting requirement.
  9. The measure results are temporarily suppressed pending resubmission of updated data.
  10. Test Measure: a measure being evaluated for reliability of the individual data elements or awaiting National Quality Forum Endorsement.
  11. There were no eligible patients that met the denominator criteria.
  12. The measure rate is within optimal range.

* This information can also be viewed at Hospital Compare.

**      Indicates per 1000 hours of patient care.
***   The measure was not in effect for this quarter.
----   Null value or data not displayed.

Hospital 2021 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na

New Changes to Quarterly Measure

Download Quarterly Measure Results

* State results are not calculated for the National Patient Safety Goals.