Heart & Vascular
Continuous Quality Improvement and National Registries
Memorial Hermann Heart & Vascular is committed to quality outcomes and patient safety. We have embedded continuous quality improvement into our work and participate in several national registries which support our efforts to:
- Develop best practices through data analysis and conversation with other leading health care organizations
- Identify meaningful benchmarks
- Examine efficiency and opportunities for process and cost improvements
- Improve care through quality performance initiatives.
Our Heart & Vascular Care Participates in the Following Registries
Society of Thoracic Surgeons (STS) Registry (Cardiac Surgery Outcomes)
Our Memorial Hermann Heart & Vascular Service Line Medical Director was recently elected to serve on the Board of Directors of the Society of Thoracic Surgeons (STS) for 2022-2025.
The STS is responsible for creating the STS National Database for cardiac surgery which is the largest and longest running cardiac surgery quality initiative. The STS National Database was established in 1989 as an initiative for quality improvement and patient safety among cardiothoracic surgeons. The Database has four components—Adult Cardiac, General Thoracic, Congenital Heart Surgery, and the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) Database.
Memorial Hermann participates in the Adult Cardiac and INTERMACS registries at the following Memorial Hermann hospitals: Texas Medical Center, Southwest, Memorial City, The Woodlands, Southwest and Greater Heights. Northeast will officially join when the program launches in Summer 2025. (Please note: We do not participate in Thoracic or Congenital on the adult side at this time)
As of December 2023, all Memorial Hermann acute care sites scored 2 or 3 stars out of 3 stars in almost every category.
The STS/ACC TVT Registry, created through a collaboration between STS and the American College of Cardiology (ACC), monitors patient safety and real-world outcomes related to transcatheter valve replacement (TVT) and repair procedures – emerging treatments for valve disease patients. Employing state-of-the-art heart valve technology, transcatheter heart valve procedures provide treatment options for heart valve replacement or repair surgery.
Memorial Hermann-TMC achieved 3 Stars (the highest level) for TVT 2 years in a row and is the only Texas program to receive this highest recognition.
Left Atrial Appendage Occlusion (LAAO) Registry (Left Atrial Appendage Occlusion Procedure Outcomes)
Memorial Herman is a member of the American College of Cardiology (ACC) registry, which captures data on left atrial appendage occlusion procedures to assess real-world procedural outcomes, short and long-term safety, comparative effectiveness and cost effectiveness.
Society of Vascular Surgeons Vascular Quality Initiative (VQI) Registry (Vascular Surgery Outcomes)
The mission of Society of Vascular Surgeons VQI is to improve the quality, safety, effectiveness and affordability of vascular health care. The impact of VQI data on clinical practice and patient outcomes cannot be overstated, as evidenced by the numerous scientific publications and real-world improvements in care delivery. The collaborative efforts of VQI members have advanced the field of vascular diseases.
As of May 2024, the following Memorial Hermann sites were participants of the VQI Registry:
- Memorial Hermann Cypress Hospital
- Memorial Hermann Greater Heights Hospital
- Memorial Hermann Katy Hospital
- Memorial Hermann Memorial City Medical Center
- Memorial Hermann Northeast Hospital
- Memorial Hermann Southeast Hospital
- Memorial Hermann Southwest Hospital
- Memorial Hermann Sugar Land
- Memorial Hermann-Texas Medical Center
- Memorial Hermann The Woodlands Medical Center
American College of Cardiology (ACC) Public Reporting Registries
Cath PCI Registry (Cardiac Disease Patients Who Receive Diagnostic Catheterization and/or Percutaneous Coronary Intervention (PCI) Procedures Outcomes)
American College of Cardiology’s (ACC's) Public Reporting efforts help institutions bridge gaps between science and practice to improve the quality of cardiovascular care delivery. Hospitals participating in ACC's National Cardiovascular Data Registry (NCDR) programs have a unique opportunity to showcase publicly their commitment to continuous quality improvement, leading the way toward a more transparent health care system.
The American College of Cardiology (ACC) registry is available for any facility that performs PCI, captures the data that measure adherence to ACC/AHA clinical practice guideline recommendations, procedure performance standards and appropriate use criteria (AUC) for coronary revascularization.
Our team of affiliated physicians is developing and perfecting innovative techniques that continue to put Memorial Hermann at the forefront of advancing heart health in Houston. In fact, Memorial Hermann earned the highest star rating (4 stars) in every Percutaneous Coronary Intervention (PCI) metric during the 2022 calendar year.
Memorial Hermann’s active sites, including Texas Medical Center, Southwest, Memorial City, The Woodlands and Southeast, earned the highest star rating (4 stars) in every Percutaneous Coronary Intervention (PCI) metric during the 2023 calendar year.
Chest Pain MI Registry (Acute Myocardial Infraction Care Outcomes)
Memorial Hermann participates in the American College of Cardiology (ACC) Chest Pain - MI Registry™, which is a “trusted source for outcomes-based, continuous quality improvement and remains the go-to registry for hospitals and health systems applying American College of Cardiology (ACC) and American Heart Association (AHA) clinical guideline recommendations.”
As of May 2024, the following Memorial Hermann facilities were recognized as part ACC’s Chest Pain MI Registry:
- Platinum
- Memorial Hermann Cypress Hospital
- Memorial Hermann Greater Heights Hospital
- Memorial Hermann Memorial City Medical Center
- Memorial Hermann Southeast Hospital
- Memorial Hermann Sugar Land Hospital
- Memorial Hermann The Woodlands Medical Center
- Gold
- Memorial Hermann-Texas Medical Center
- Silver
- Memorial Hermann Northeast Hospital
- Memorial Hermann Pearland Hospital
- Memorial Hermann Southwest Hospital
Additionally, Memorial Hermann-Texas Medical Center has achieved the ACC accreditation for Advanced Chest Pain and Cath Lab certifications.
Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) (Mechanical Circulatory Support Outcomes)
The STS INTERMACS Database is a North American registry for the clinical outcomes of patients who receive an FDA-approved mechanical circulatory support (MCS) device to treat advanced heart failure. The INTERMACS Database includes longitudinal data for the life of a patient with an MCS device. Approximately 36,000 patients currently are enrolled at more than 200 sites.”
Scientific Registry of Transplant Recipients (SRTR) (Heart and Lung Transplant Outcomes)
“SRTR supports the transplant community with analyses, in an effort to better patient results and experience.”
Site specific reports are available publicly through SRTR at srtr.org.
Learn more about the Heart and Vascular services here.
Neuroscience
American Heart Association: Get with the Guidelines® – Stroke
Get with the Guidelines® – Stroke is an in-hospital program for improving stroke care by promoting consistent adherence to the latest scientific treatment guidelines. Numerous published studies demonstrate the program's success in improving patient outcomes.
Beyond participation, there are three levels of recognition, determined by the length of demonstrated performance. Our facilities have advanced from Silver to the Gold Achievement Award, reflecting improvement and a dedication to delivering high-quality care.
- Bronze recognizes performance of 90 consecutive days.
- Silver recognizes performance of 12 consecutive months.
- Gold recognizes performance of 24 consecutive months or more.
The following Memorial Hermann facilities were recognized in 2024:
- Gold Plus Achievement:
- Memorial Hermann Cypress Hospital
- Memorial Hermann Greater Heights Hospital
- Memorial Hermann Memorial City Medical Center
- Memorial Hermann Northeast Hospital
- Memorial Hermann Pearland Hospital
- Memorial Hermann Southwest Hospital
- Memorial Hermann Sugar Land Hospital
- Memorial Hermann-Texas Medical Center
- Memorial Hermann The Woodlands Medical Center
- Silver Plus Achievement:
- Memorial Hermann Katy Hospital
Click here for more information about Get with the Guidelines- Stroke.
Healthgrades Award
As of 2025, Healthgrades awarded Memorial Hermann-TMC with America’s 100 Best Hospitals for Stroke Care Award™, honoring its exceptional clinical outcomes in stroke treatment and care. Additionally, the hospital earned the Cranial Neurosurgery Excellence Award™ for outstanding results in cranial neurosurgery and the Neurosciences Excellence Award™ for superior clinical outcomes in both stroke care and cranial neurosurgery.
Primary Care
At Memorial Hermann, personalized, integrated health care begins with your primary care provider (PCP).
Whether you are looking for routine wellness care and prevention or chronic-disease management and coordination with specialists, a PCP is your dedicated health partner through each stage of your life. Your PCP utilizes the latest research and technology to keep you healthy, and to diagnose and manage illness when you are not.
Primary Care ACO Quality Measure: Colorectal Cancer Screening
Among cancers that affect both men and women, colorectal cancer is the second most common cancer and the second leading cause of cancer-related death in the United States.
The most effective way to reduce the risk of colorectal cancer is routine screening, beginning at age 45, for people who are at average risk. Screening tests can find precancerous polyps so they can be removed before they turn into cancer. Screening tests also can find colorectal cancer earlier, when treatment may be more effective.
Recognizing that management of colorectal cancer screening is critical to improving patient outcomes, Memorial Hermann developed multiple work efforts to detect colorectal earlier:
- Memorial Hermann Medical Group (MHMG) Open Access Colonoscopy Protocol
- Colon Cancer Screening Guidelines for Primary Care
Thanks to these efforts, the Memorial Hermann ACO demonstrated a trend of improvement.
CMS Quality Performance Results: ACO-19 Colorectal Cancer Screening
Primary Care ACO Quality Measure: Breast Cancer Screening
Breast cancer is the most common cancer diagnosed in women in the United States. While mammography screenings are proven to reduce breast cancer mortality rates, many women forgo the annual exams.
Recognizing that encouragement of breast cancer screening is critical to improving patient outcomes, Memorial Hermann developed campaigns to increase access to mammography screening for women.
Thanks to these efforts, the Memorial Hermann ACO demonstrated a trend of improvement in screening mammograms from 2016 through 2023.
CMS Quality Performance Results: ACO-20 Breast Cancer Screening
Trauma
The Trauma Service Line participates in the following registries:
American College of Surgeon National Trauma Databank (NTDB): Participation allows for the use of de-identified data collection from across the nation to be available for use of research.
American College of Surgeons Trauma Quality Improvement Program (TQIP): Participation in this program allows trauma programs to benchmark against other similar programs to identify areas for improvement and identify best practices.
Texas Trauma Quality Improvement Program Collaborative (TQIP): Participation allows facilities in Texas to collaborate to build best practice programs.
Southeast Texas Regional Trauma Advisory Council Registry: This registry allows a trauma programs in the region to collaborate and affect care in the region, thus assisting in development of care guidelines.
State of Texas Registry: Participation allows trauma programs to benchmark against other Texas Hospitals to identify areas for improvement and identify best practices.
Orthopedics
Nationally Recognized Outcomes
In recognition of its excellence, the orthopedics program at Memorial Hermann-Texas Medical Center has been nationally ranked among the top 50 orthopedic programs in the country by U.S. News & World Report.
Memorial Hermann offers joint care at multiple locations across Greater Houston specializing in hip and knee replacements, offering a multidisciplinary, affiliated team and advanced treatment options.
Advanced Total Knee and Hip Certification from the Joint Commission and AAOS
Memorial Hermann | Rockets Orthopedic Hospital and the Center for Advanced Orthopedics at Memorial Hermann Memorial City Medical Center have received the Advanced Total Knee and Hip Certification from the Joint Commission and American Academy of Orthopedic Surgeons.
System Awards and Recognition
Quality Leadership Award
Memorial Hermann Health System, Memorial Hermann-Texas Medical Center and Memorial Hermann The Woodlands Medical Center have each earned national recognition as top performers in delivering high-quality care by Vizient, Inc., the nation’s largest provider-driven health care performance improvement company.
In addition, Memorial Hermann-TMC and Memorial Hermann The Woodlands have been recognized among the top 10 hospitals in the nation with the prestigious Bernard A. Birnbaum, MD, Quality Leadership Ranking by Vizient in 2024, underscoring our commitment to high-reliability care and optimal patient outcomes.
Memorial Hermann-TMC ranked No. 6 out of 115 members in the Comprehensive Academic Medical Center cohort, and Memorial Hermann The Woodlands ranked No. 8 out of 177 members in the Large, Specialized Complex Care Medical Center cohort. The hospitals were recognized for excellence in delivering high-quality care based on the Vizient Quality and Accountability Study, conducted annually since 2005.
Recognized for Nursing Excellence
The Magnet Recognition Program from the American Nurses Credentialing Center recognizes health care organizations for quality patient care, nursing excellence and innovations in professional nursing practice.
Magnet® is the highest organizational credential granted by the American Nurses Credentialing Center (ANCC), the nation’s largest and most prominent nursing credentialing organization. According to the American Hospital Association, less than 10% of all registered hospitals in the United States have achieved this distinction, placing Memorial Hermann among a small and highly select group of U.S. health care organizations.
Nine Memorial Hermann hospitals have earned the American Nurses Credentialing Center (ANCC) Magnet Recognition, an affirmation of exemplary nursing professionalism, teamwork and excellence in patient care:
- Memorial Hermann Cypress Hospital
- Memorial Hermann Greater Heights Hospital
- Memorial Hermann Katy Hospital
- Memorial Hermann Memorial City Medical Center
- Memorial Hermann Southeast Hospital
- Memorial Hermann Pearland Hospital
- Memorial Hermann Southwest Hospital
- Memorial Hermann Sugar Land Hospital
- Memorial Hermann–Texas Medical Center
- Children’s Memorial Hermann Hospital
- Memorial Hermann | Rockets Orthopedic Spine Hospital
- Memorial Hermann The Woodlands Medical Center
In addition, three Memorial Hermann hospitals are ANCC Pathway to Excellence Program® designated, a precursor to Magnet® designation:
For more information about Memorial Hermann’s numerous nursing excellence recognitions, click here.