Acute Care Hospital

Baylor Surgical Hospital at Las Colinas

400 West Lyndon B Johnson Suite 101b, Irving, TX 75063
24/7 Emergency Services

Quality measures

Mortality

Same as National Average

Measures the rate at which patients die within 30 days of hospital admission for specific conditions. A lower mortality rate indicates better outcomes.

Underlying measures: Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate No Different Than the National Rate Hospital score: 4.10 95% interval: 2.50 – 6.70 Sample size: 93 Reporting period: 07/01/2023 – 06/30/2024 CMS measure id: Hybrid_HWM Death rate for CABG surgery patients Not Available Hospital score: — Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_CABG Death rate for COPD patients Not Available Hospital score: — Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_COPD Death rate for heart attack patients Not Available Hospital score: — Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_AMI Death rate for heart failure patients Not Available Hospital score: — Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_HF Death rate for pneumonia patients Not Available Hospital score: — Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_PN Death rate for stroke patients Not Available Hospital score: — Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_STK

Safety of Care

Same as National Average

Tracks hospital-acquired infections, surgical complications, and other patient safety indicators. Lower rates indicate better safety practices.

Underlying measures: Abdominopelvic accidental puncture or laceration rate No Different Than the National Rate Hospital score: 1.04 95% interval: 0.00 – 2.13 Sample size: 169 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_15 Iatrogenic pneumothorax rate No Different Than the National Rate Hospital score: 0.21 95% interval: 0.00 – 0.44 Sample size: 281 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_06 Rate of complications for hip/knee replacement patients No Different Than the National Rate Hospital score: 3.30 95% interval: 1.80 – 6.20 Sample size: 57 Reporting period: 04/01/2021 – 03/31/2024 CMS measure id: COMP_HIP_KNEE In-hospital fall-associated fracture rate No Different Than the National Rate Hospital score: 0.27 95% interval: 0.05 – 0.48 Sample size: 279 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_08 Postoperative hemorrhage or hematoma rate No Different Than the National Rate Hospital score: 2.53 95% interval: 0.84 – 4.23 Sample size: 271 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_09 Perioperative pulmonary embolism or deep vein thrombosis rate No Different Than the National Rate Hospital score: 3.16 95% interval: 0.65 – 5.67 Sample size: 278 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_12 Postoperative acute kidney injury requiring dialysis rate No Different Than the National Rate Hospital score: 1.65 95% interval: 0.00 – 3.37 Sample size: 271 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_10 Postoperative respiratory failure rate No Different Than the National Rate Hospital score: 7.85 95% interval: 0.00 – 17.16 Sample size: 277 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_11 Postoperative sepsis rate No Different Than the National Rate Hospital score: 4.87 95% interval: 0.68 – 9.06 Sample size: 271 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_13 Pressure ulcer rate No Different Than the National Rate Hospital score: 0.62 95% interval: 0.00 – 1.96 Sample size: 30 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_03 CMS Medicare PSI 90: Patient safety and adverse events composite No Different Than the National Value Hospital score: 0.93 95% interval: 0.42 – 1.43 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_90 Postoperative wound dehiscence rate No Different Than the National Rate Hospital score: 1.76 95% interval: 0.23 – 3.30 Sample size: 89 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_14 Clostridium Difficile (C.Diff) Not Available Hospital score: — SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_6_SIR Catheter Associated Urinary Tract Infections (ICU + select Wards) Not Available Hospital score: — SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_2_SIR Central Line Associated Bloodstream Infection (ICU + select Wards) Not Available Hospital score: — SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_1_SIR MRSA Bacteremia Not Available Hospital score: — SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_5_SIR SSI - Abdominal Hysterectomy Not Available Hospital score: — SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_4_SIR SSI - Colon Surgery Not Available Hospital score: — SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_3_SIR Death rate among surgical inpatients with serious treatable complications Not Available Hospital score: — Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_04

Readmissions

Same as National Average

Measures how often patients return to the hospital within 30 days of discharge. Lower readmission rates suggest effective treatment and discharge planning.

Underlying measures: 30-day Readmission, Hip/Knee Replacement Worse than expected Hospital score: 1.29 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-HIP-KNEE-HRRP 30-day Readmission, Bypass Surgery Hospital score: — Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-CABG-HRRP 30-day Readmission, COPD Hospital score: — Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-COPD-HRRP 30-day Readmission, Heart Attack Hospital score: — Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-AMI-HRRP 30-day Readmission, Heart Failure Hospital score: — Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-HF-HRRP 30-day Readmission, Pneumonia Hospital score: — Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-PN-HRRP

Patient Experience

Same as National Average

Based on the HCAHPS survey — patient satisfaction with communication, cleanliness, pain management, and discharge information.

Patient survey detail — the questions feeding the Patient Experience domain above expand ↓

CMS computes the Patient Experience domain from the federal HCAHPS survey. Each bar below is one survey question; the percentage is the share of Baylor's recent patients who gave the most positive response. HCAHPS percentages aren't directly comparable across all measures — see the methodology page for how CMS weights them.

  • Communication with Nurses 78%
  • Communication with Doctors 82%
  • Hospital Cleanliness 78%
  • Hospital Quietness 72%
  • Staff Responsiveness N/A
  • Discharge Information 88%
  • Overall Hospital Rating (9 or 10) 73%
  • Would Recommend Hospital 76%

Percentages represent patients who gave the most positive response. Survey conducted by CMS through the HCAHPS program.

Timely & Effective Care

Better than National Average

Measures how quickly the hospital provides important treatments such as antibiotics for pneumonia or interventions for heart attacks.

Underlying measures: 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 Better than ~75% of hospitals Hospital score: 71.00 min National median: 148.00 min (lower is better) Sample size: 223 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: OP_18b 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 Better than ~75% of hospitals Hospital score: 74.00 min National median: 154.00 min (lower is better) Sample size: 236 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: OP_18a Left before being seen Better than ~75% of hospitals Hospital score: 1.00 % National median: 1.00 % (lower is better) Sample size: 974 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: OP_22 Hospital Harm - Severe Hyperglycemia Better than ~75% of hospitals Hospital score: 2.00 % National median: 8.00 % (lower is better) Sample size: 204 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: HH_HYPER Hospital Harm - Severe Hypoglycemia Better than ~75% of hospitals Hospital score: 0.00 % National median: 1.00 % (lower is better) Sample size: 162 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: HH_HYPO Venous Thromboembolism Prophylaxis Better than ~75% of hospitals Hospital score: 99.00 % National median: 90.00 % (higher is better) Sample size: 327 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: VTE_1 Healthcare workers given influenza vaccination Near the national median Hospital score: 82.00 % National median: 79.00 % (higher is better) Sample size: 512 Reporting period: 10/01/2024 – 03/31/2025 CMS measure id: IMM_3 Safe Use of Opioids - Concurrent Prescribing Worse than ~75% of hospitals Hospital score: 20.00 % National median: 15.00 % (lower is better) Sample size: 85 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: SAFE_USE_OF_OPIOIDS

Clinical Staff

Baylor Surgical Hospital at Las Colinas has 86 CMS-affiliated clinicians on its roster — physicians, advanced practice providers, and other Medicare-enrolled professionals who list this hospital as an affiliated facility.

Top specialties

  • Anesthesiology 29
  • Orthopedic Surgery 11
  • Ophthalmology 9
  • Diagnostic Radiology 8
  • Physician Assistant 8
  • Urology 5
  • Internal Medicine 4
  • General Surgery 2

Self-reported primary specialty in the CMS Doctors & Clinicians dataset. Many clinicians serve multiple facilities.

Practice characteristics

Accept Medicare assignment
76 (88%)

Bill Medicare directly at the approved rate — patients only owe co-insurance/deductible.

Offer telehealth
11 (13%)

Indicated by the clinician in their CMS profile as routinely providing virtual visits.

Medicare quality scoring (MIPS)

56 of these clinicians have a published Merit-based Incentive Payment System (MIPS) final score. Of those, 36 (64%) score above the national median of 85.5.

MIPS scoring is heavily compressed at the top of the 0–100 range, so individual scores are not a reliable consumer signal. We surface roster-level coverage and the share above the national median instead.

Source: CMS Doctors and Clinicians (Care Compare) national downloadable file and MIPS Performance Year final scores, as of 2026-05-27. Affiliations from the CMS Facility Affiliations dataset. About 16% of small facilities (critical access, rural emergency, freestanding psych, IRF/LTCH) do not appear in the affiliations file and therefore have no panel.

Find a Doctor

Search the 86 clinicians affiliated with Baylor Surgical Hospital at Las Colinas. Each name links to that clinician's official Medicare Care Compare profile, where you can see their credentials, secondary specialties, group affiliations, and (when applicable) MIPS quality scores.

Showing 30 of 86 clinicians (alphabetical)

Roster from CMS Doctors and Clinicians (Care Compare), updated 2026-05-27. A clinician may also practice at other facilities; "affiliated" means this hospital is on their CMS profile, not that they exclusively work here.

Pricing & Costs

Facility Information

Facility type
Acute Care Hospitals
Ownership
Proprietary
Emergency services
Yes — 24/7

Nearby Hospitals

Acute Care Hospital

Legent Orthopedic Hospital Carrollton

Grapevine, TX

Not rated · CMS Overall Hospital Quality Star Rating Not enough data to calculate a star rating. Individual quality measures may be available.
About this data

Quality and ratings data are sourced from the U.S. Centers for Medicare & Medicaid Services (CMS) Hospital Compare program. Star ratings are CMS's own calculation; CareRanks does not modify or re-weight them. Facility-level details (address, beds, ownership, teaching status) come from CMS provider files and the CMS Provider of Services file.

Pricing data, where shown, is drawn from the hospital's own Machine-Readable File (MRF) published under the federal Hospital Price Transparency Rule. See our methodology for the full update cadence and limitations.

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