Quality Report


Quality Report

Baptist Health System
HCO ID: 9209
111 Dallas Street
San Antonio, TX, 78205
(210) 297-7600
www.baptisthealthsystem.com
Summary of Quality Information

Accreditation Programs

View Accreditation History
Gold Seal
Hospital
Accreditation Decision
Effective Date
12/8/2023
Last Full Survey Date
5/12/2023
Last On-Site Survey Date
12/8/2023

Advanced Certification Programs

View Certification History
Gold Seal
Advanced Total Hip and Total Knee Replacement
Certification Decision
Effective Date
12/19/2022
Last Full Survey Date
10/21/2022
Last On-Site Survey Date
10/21/2022
Gold Seal
Primary Stroke Center
Certification Decision
Effective Date
5/27/2023
Last Full Survey Date
5/26/2023
Last On-Site Survey Date
5/26/2023

Core Certification Programs

Gold Seal
Fragility Fracture
Certification Decision
Effective Date
8/4/2022
Last Full Survey Date
6/8/2022
Last On-Site Survey Date
6/8/2022
Gold Seal
Joint Replacement - Hip
Certification Decision
Effective Date
3/31/2023
Last Full Survey Date
3/30/2023
Last On-Site Survey Date
3/30/2023
Gold Seal
Joint Replacement - Knee
Certification Decision
Effective Date
4/1/2023
Last Full Survey Date
3/31/2023
Last On-Site Survey Date
3/31/2023
Gold Seal
Spine Surgery
Certification Decision
Effective Date
8/3/2022
Last Full Survey Date
6/9/2022
Last On-Site Survey Date
6/9/2022

Sites

Baptist Breast Center - North Central
502 Madison Oak Drive, Suite 450
San Antonio, TX, 78258

Available Services

  • Single Specialty Practitioner (Outpatient )

Baptist Medical Center
111 Dallas Street
San Antonio, TX, 78205

Available Services

  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult )
  • Brachytherapy (Imaging/Diagnostic Services )
  • Cardiac Catheterization Lab (Surgical Services )
  • Cardiac Surgery (Surgical Services )
  • Cardiothoracic Surgery (Surgical Services )
  • Cardiovascular Unit (Inpatient )
  • CT Scanner (Imaging/Diagnostic Services )
  • Dialysis Unit (Inpatient )
  • EEG/EKG/EMG Lab (Imaging/Diagnostic Services )
  • Gastroenterology (Surgical Services )
  • GI or Endoscopy Lab (Imaging/Diagnostic Services )
  • Gynecological Surgery (Surgical Services )
  • Inpatient Unit (Inpatient )
  • Interventional Radiology (Imaging/Diagnostic Services )
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services )
  • Medical /Surgical Unit (Inpatient )
  • Medical ICU (Intensive Care Unit )
  • Neuro/Spine Unit (Inpatient )
  • Neurosurgery (Surgical Services )
  • Non-Sterile Medication Compounding (Inpatient )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Ophthalmology (Surgical Services )
  • Orthopedic Surgery (Surgical Services )
  • Orthopedic/Spine Unit (Inpatient )
  • Outpatient Clinics (Outpatient )
  • Plastic Surgery (Surgical Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Rehabilitation Unit (Inpatient )
  • Rehabilitation Unit (24-hour Acute Care/Crisis Stabilization )
  • Sterile Medication Compounding (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Surgical Unit (Inpatient )
  • Teleradiology (Imaging/Diagnostic Services )
  • Thoracic Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Primary Stroke Center

HealthLink Bitters Road
288 W. Bitters Rd
San Antonio, TX, 78216

Available Services

  • Outpatient Clinics (Outpatient )

HealthLink Camp Bullis
19787 IH-10 West, #101
San Antonio, TX, 78257

Available Services

  • Outpatient Clinics (Outpatient )

HealthLink Downtown
730 N. Main, # 107
San Antonio, TX, 78205

Available Services

  • Outpatient Clinics (Outpatient )

HealthLink Hausman .
8230 N. Loop 1604 W. Suite 201
San Antonio, TX, 78249

Available Services

  • Outpatient Clinics (Outpatient )

HealthLink Ingram
7616 Culebra, # 115
San Antonio, TX, 78251

Available Services

  • Outpatient Clinics (Outpatient )

HealthLink Medical Center
5410 Fredericksburg, #100
San Antonio, TX, 78229

Available Services

  • Outpatient Clinics (Outpatient )

HealthLink Mission Trail
3158 SE Military Drive #C102
San Antonio, TX, 78223

Available Services

  • Outpatient Clinics (Outpatient )

Healthlink New Braunfels
545 Creekside Crossing, Suite 155
New Braunfels, TX, 78130

Available Services

  • Outpatient Clinics (Outpatient )

HealthLink Northeast
8711 Village Drive, #109
San Antonio, TX, 78217

Available Services

  • Outpatient Clinics (Outpatient )

HEALTHLINK OUTPATIENT REHAB
DBA: HealthLink Outpatient Cardiac Rehab New Braunfels
545 Creekside Crossing, Suite 138
New Braunfels, TX, 78130-4271

Available Services

  • Outpatient Clinics (Outpatient )

HealthLink Overlook
25615 US Hwy 281, #201
San Antonio, TX, 78258

Available Services

  • Outpatient Clinics (Outpatient )

HealthLink Pediatric
Remington Oaks Bldg. 525 Oak Centre Suite #440
San Antonio, TX, 78258

Available Services

  • Outpatient Clinics (Outpatient )

HealthLink Schertz
6051 FM 3009, #200
Schertz, TX, 78154

Available Services

  • Outpatient Clinics (Outpatient )

HealthLink Southwest
7719 Interstate 35 S #213
San Antonio, TX, 78224

Available Services

  • Outpatient Clinics (Outpatient )

HealthLink Stone Oak
525 Oak Centre, #450
San Antonio, TX, 78258

Available Services

  • Outpatient Clinics (Outpatient )

HealthLink Westover Hills
5630 W Loop 1604 N, #105
San Antonio, TX, 78251

Available Services

  • Outpatient Clinics (Outpatient )

Healthy Women's Center at Mission Trail Baptist
3327 Research Plaza, Suite 103
San Antonio, TX, 78235

Available Services

  • Single Specialty Practitioner (Outpatient )

Healthy Women's Center Commerce
2614 West Commerce, Suite 300
San Antonio, TX, 78207

Available Services

  • Single Specialty Practitioner (Outpatient )

Healthy Women's Center Fredericksburg
3534 Fredericksburg Road, Suite 20
San Antonio, TX, 78201

Available Services

  • Single Specialty Practitioner (Outpatient )

Healthy Women's Center Rigsby
2000 SE Loop 410, Suite 128
San Antonio, TX, 78220

Available Services

  • Single Specialty Practitioner (Outpatient )

Healthy Women's Center Walzem
5253 Walzem Road, Suite 1
San Antonio, TX, 78218

Available Services

  • Single Specialty Practitioner (Outpatient )

Healthy Women's Center Westover Hills
5630 West Loop 1604 N., Suite 111
San Antonio, TX, 78251

Available Services

  • Single Specialty Practitioner (Outpatient )

Mission Trail Baptist Hospital
3333 Research Plaza
San Antonio, TX, 78235

Available Services

  • Cardiac Catheterization Lab (Surgical Services )
  • CT Scanner (Imaging/Diagnostic Services )
  • Dialysis Unit (Inpatient )
  • EEG/EKG/EMG Lab (Imaging/Diagnostic Services )
  • Gastroenterology (Surgical Services )
  • GI or Endoscopy Lab (Imaging/Diagnostic Services )
  • Gynecological Surgery (Surgical Services )
  • Gynecology (Inpatient )
  • Inpatient Unit (Inpatient )
  • Interventional Radiology (Imaging/Diagnostic Services )
  • Labor & Delivery (Inpatient )
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services )
  • Medical /Surgical Unit (Inpatient )
  • Medical ICU (Intensive Care Unit )
  • Non-Sterile Medication Compounding (Inpatient )
  • Normal Newborn Nursery (Inpatient )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Orthopedic Surgery (Surgical Services )
  • Orthopedic/Spine Unit (Inpatient )
  • Plastic Surgery (Surgical Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Sterile Medication Compounding (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Surgical Unit (Inpatient )
  • Teleradiology (Imaging/Diagnostic Services )
  • Thoracic Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Fragility Fracture
  • Joint Replacement - Hip
  • Joint Replacement - Knee
  • Primary Stroke Center

Mission Trail Centers for Wound Healing & Hyperbaric Medicin
3327 Research Plaza, Suite 407
San Antonio, TX, 78235

Available Services

  • Outpatient Clinics (Outpatient )

North Central Baptist Hospital
520 Madison Oak
San Antonio, TX, 78258-3113

Available Services

  • Cardiac Catheterization Lab (Surgical Services )
  • Cardiac Surgery (Surgical Services )
  • Cardiothoracic Surgery (Surgical Services )
  • Cardiovascular Unit (Inpatient )
  • CT Scanner (Imaging/Diagnostic Services )
  • Ear/Nose/Throat Surgery (Surgical Services )
  • EEG/EKG/EMG Lab (Imaging/Diagnostic Services )
  • Gastroenterology (Surgical Services )
  • GI or Endoscopy Lab (Imaging/Diagnostic Services )
  • Gynecological Surgery (Surgical Services )
  • Gynecology (Inpatient )
  • Hazardous Medication Compounding (Inpatient )
  • Hematology/Oncology Unit (Inpatient )
  • Inpatient Unit (Inpatient )
  • Interventional Radiology (Imaging/Diagnostic Services )
  • Labor & Delivery (Inpatient )
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services )
  • Medical /Surgical Unit (Inpatient )
  • Medical ICU (Intensive Care Unit )
  • Neuro/Spine Unit (Inpatient )
  • Neurosurgery (Surgical Services )
  • Non-Sterile Medication Compounding (Inpatient )
  • Normal Newborn Nursery (Inpatient )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Orthopedic Surgery (Surgical Services )
  • Orthopedic/Spine Unit (Inpatient )
  • Outpatient Clinics (Outpatient )
  • Pediatric Unit (Inpatient )
  • Plastic Surgery (Surgical Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Rehabilitation Unit (Inpatient )
  • Rehabilitation Unit (24-hour Acute Care/Crisis Stabilization )
  • Sterile Medication Compounding (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Surgical Unit (Inpatient )
  • Teleradiology (Imaging/Diagnostic Services )
  • Thoracic Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Advanced Total Hip and Total Knee Replacement
  • Fragility Fracture
  • Primary Stroke Center
  • Spine Surgery

Northeast Baptist Hospital
8811 Village Drive
San Antonio, TX, 78217-5440

Available Services

  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult )
  • Brachytherapy (Imaging/Diagnostic Services )
  • Cardiac Catheterization Lab (Surgical Services )
  • Cardiac Surgery (Surgical Services )
  • Cardiothoracic Surgery (Surgical Services )
  • Cardiovascular Unit (Inpatient )
  • CT Scanner (Imaging/Diagnostic Services )
  • Dialysis Unit (Inpatient )
  • Ear/Nose/Throat Surgery (Surgical Services )
  • EEG/EKG/EMG Lab (Imaging/Diagnostic Services )
  • Gastroenterology (Surgical Services )
  • GI or Endoscopy Lab (Imaging/Diagnostic Services )
  • Gynecological Surgery (Surgical Services )
  • Hematology/Oncology Unit (Inpatient )
  • Inpatient Unit (Inpatient )
  • Interventional Radiology (Imaging/Diagnostic Services )
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services )
  • Medical /Surgical Unit (Inpatient )
  • Medical ICU (Intensive Care Unit )
  • Neuro/Spine Unit (Inpatient )
  • Neurosurgery (Surgical Services )
  • Non-Sterile Medication Compounding (Inpatient )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Orthopedic Surgery (Surgical Services )
  • Orthopedic/Spine Unit (Inpatient )
  • Outpatient Clinics (Outpatient )
  • Plastic Surgery (Surgical Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Rehabilitation Unit (Inpatient )
  • Rehabilitation Unit (24-hour Acute Care/Crisis Stabilization )
  • Sterile Medication Compounding (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Teleradiology (Imaging/Diagnostic Services )
  • Thoracic Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Advanced Total Hip and Total Knee Replacement

Sleep Lab
DBA: Sleep Lab - Northeast Baptist Hospital
8715 Village Drive, Suite 521
San Antonio, TX, 78217

Available Services

  • Outpatient Clinics (Outpatient )

St. Luke's Baptist Hospital
7930 Floyd Curl Drive
San Antonio, TX, 78229-3950

Available Services

  • Cardiac Catheterization Lab (Surgical Services )
  • Cardiac Surgery (Surgical Services )
  • Cardiothoracic Surgery (Surgical Services )
  • CT Scanner (Imaging/Diagnostic Services )
  • Dialysis Unit (Inpatient )
  • Ear/Nose/Throat Surgery (Surgical Services )
  • EEG/EKG/EMG Lab (Imaging/Diagnostic Services )
  • Gastroenterology (Surgical Services )
  • GI or Endoscopy Lab (Imaging/Diagnostic Services )
  • Gynecological Surgery (Surgical Services )
  • Gynecology (Inpatient )
  • Hazardous Medication Compounding (Inpatient )
  • Hematology/Oncology Unit (Inpatient )
  • Inpatient Unit (Inpatient )
  • Interventional Radiology (Imaging/Diagnostic Services )
  • Labor & Delivery (Inpatient )
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services )
  • Medical /Surgical Unit (Inpatient )
  • Medical ICU (Intensive Care Unit )
  • Neuro/Spine Unit (Inpatient )
  • Neurosurgery (Surgical Services )
  • Non-Sterile Medication Compounding (Inpatient )
  • Normal Newborn Nursery (Inpatient )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Ophthalmology (Surgical Services )
  • Orthopedic Surgery (Surgical Services )
  • Orthopedic/Spine Unit (Inpatient )
  • Plastic Surgery (Surgical Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Rehabilitation Unit (Inpatient )
  • Rehabilitation Unit (24-hour Acute Care/Crisis Stabilization )
  • Sterile Medication Compounding (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Surgical Unit (Inpatient )
  • Teleradiology (Imaging/Diagnostic Services )
  • Thoracic Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Joint Replacement - Hip
  • Joint Replacement - Knee

St. Luke's Centers for Wound Healing & Hyperbaric Medicine
7940 Floyd Curl Drive, Suite 100
San Antonio, TX, 78229

Available Services

  • Outpatient Clinics (Outpatient )

Cooperative Agreements

Hospital - Accredited by American College of Surgeons-Commission on Cancer (ACoS-COC)

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 2023 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Reporting Period: January 2022 - December 2022
Perinatal Care National Comparison: nd 2 Statewide Comparison: nd 2

New Changes to Quarterly Measure

Download Quarterly Measure Results

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