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.
- National Registries:
- Society of Thoracic Surgeons (STS) – Gold Standard for Cardiac surgery
- American College of Cardiology (PCI) – Gold Standard for Percutaneous Coronary Interventions
- American College of Cardiology (CPMI) – Chest Pain MI Outcomes
- STS/ACC TVT – Gold Standard for Transcatheter Valve Procedures
- TAVR (aortic), M-TEER (mitral) and T-TEER (tricuspid)
- American College of Cardiology (LAAO) – Gold Standard for Left Atrial Appendage Occlusion Cases
- Society for Vascular Surgery (VQI) – 14 registries focused on improving vascular health care
- Other:
- American Heart Association Get with the Guidelines: Heart Failure
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 sites: Memorial Hermann Southeast Hospital, Memorial Hermann Southwest Hospital, Memorial Hermann-Texas Medical Center, Memorial Hermann Greater Heights Hospital, Memorial Hermann Memorial City Medical Center, Memorial Hermann The Woodlands Medical Center and, recently, Memorial Hermann Northeast Hospital, which started offering open-heart surgery services in August 2025.
As of December 2024, Memorial Hermann Southeast earned the registry's top ranking, an impressive three-star rating for the CABG Composite Quality Rating. Additionally, the Memorial Hermann umbrella report covering all sites received a three-star rating. All other participating Memorial Hermann acute care sites achieved a two-star rating and are working to achieve three stars.
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-Texas Medical Center has been honored with a three-star distinction in TAVR, the highest rating possible by the NCDR, for three consecutive years. Only 5% of facilities in the nation that participate in the STS/ACC TVT Registry have achieved a three-star rating in the TAVR program, and our Texas Medical Center location is the only heart facility in Texas to receive this recognition.
Left Atrial Appendage Occlusion (LAAO) Registry (Left Atrial Appendage Occlusion Procedure Outcomes)
Memorial Hermann is a participating member of the National Cardiovascular Data Registry (NCDR), administered by the American College of Cardiology (ACC). This registry collects data on left atrial appendage occlusion (LAAO) procedures with the purpose of evaluating real-world procedural outcomes, as well as short-term and long-term safety, comparative effectiveness and cost-effectiveness.
Affiliated physicians practicing at five Memorial Hermann facilities perform nearly 800 left atrial appendage occlusion (LAAO) procedures a year, making Memorial Hermann the busiest LAAO program in the region and country (as of July 2026).
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 2025, 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)
The ACC registry is available to all facilities performing Percutaneous Coronary Interventions (PCI), collecting data to evaluate adherence to ACC/AHA guidelines, procedural performance standards and appropriate use criteria for coronary revascularization.
Memorial Hermann facilities, including Memorial Hermann-Texas Medical Center, Memorial Hermann Southwest Hospital, Memorial Hermann Memorial City Medical Center, Memorial Hermann The Woodlands Medical Center and Memorial Hermann Southeast Hospital, earned the highest star rating of four stars across all measurable star rating metrics in 2024. Memorial Hermann Northeast Hospital was added for Fiscal Year 2026, coinciding with the launch of their open-heart program.
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 2025, the following Memorial Hermann facilities earned recognition through the ACC’s Chest Pain - MI Registry. The number of hospitals achieving Platinum distinction increased from six in 2024 to nine in 2025, demonstrating sustained improvement and high-quality cardiac care.
Platinum
- Memorial Hermann Cypress Hospital
- Memorial Hermann Greater Heights Hospital
- Memorial Hermann Memorial City Medical Center
- Memorial Hermann Northeast Hospital
- Memorial Hermann Southeast Hospital
- Memorial Hermann Southwest Hospital
- Memorial Hermann Sugar Land Hospital
- Memorial Hermann-Texas Medical Center
- Memorial Hermann The Woodlands Medical Center
Silver
- Memorial Hermann Katy Hospital
- Memorial Hermann Pearland 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, facilities are recognized at three levels based on the duration of demonstrated performance. Through a commitment to high-reliability care and the pursuit of excellence, ten of our facilities received the Gold Achievement Award and one facility received the Silver Achievement Award, reflecting significant improvement and dedication to delivering the highest 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 2025:
- Gold Plus Achievement:
- 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 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 Southeast Hospital
Learn more here about Get with the Guidelines- Stroke »
Healthgrades Award
As of 2026, Healthgrades awarded Memorial Hermann-Texas Medical Center 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.
Learn more about the Healthgrades Award »
Primary Care
At Memorial Hermann, personalized, integrated health care begins with your pimary 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 strives to utilize the latest research and technology to keep you healthy and to diagnose and manage illness when you are not.
ACO Quality Metrics in Primary Care
In our Accountable Care Organization (ACO), we track specific quality measures to help patients receive recommended preventive services and effective chronic disease management.
These measures include:
- Blood pressure control to reduce the risk of heart attack and stroke
- Breast, cervical and colorectal cancer screenings to detect cancer early, when it is most treatable
- Diabetes management, including HbA1c testing to monitor blood sugar levels, annual retinal eye exams to prevent vision loss and appropriate statin therapy to lower cardiovascular risk
By focusing on these ACO quality measures, we are able to help detect disease earlier, reduce preventable complications and lower avoidable hospitalizations across our community. This approach leads to improved overall population health and helps support the accessibility and sustainability of high-quality care for the communities we serve.
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 2024.
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.
Oncology
American College of Surgeons (ACoS) Quality Programs
Commission on Cancer (CoC)
The CoC recognizes programs for their commitment to providing comprehensive, high-quality and multidisciplinary patient-centered care. Memorial Hermann has been an accredited cancer program since 1989. In 2013, the program became an Integrated Network Cancer Program, officially the largest network of cancer programs in Texas. The locations include 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-Texas Medical Center and Memorial Hermann The Woodlands Medical Center.
Quality Improvement Projects:
- Breast cancer: More patients with early to mid-stage breast cancer are receiving their first treatment surgery faster after diagnosis.
- Colon cancer: For patients with advanced colon cancer (stage III) who had surgery, more are now receiving their follow-up chemotherapy on time.
- Stomach cancer: During surgery for stomach cancer, it is important to remove and test enough lymph nodes to understand how far the cancer has spread.
- Head and neck cancer: After surgery for head and neck cancer, radiation therapy should begin within six weeks for the best outcome..
National Accreditation Program for Breast Centers (NAPBC)
The National Accreditation Program for Breast Centers (NAPBC) is a quality program of the American College of Surgeons (ACoS) dedicated to breast health. It focuses on improving outcomes for patients with breast disease and breast cancer through coordinated, team-based care guided by evidence-based accreditation standards, along with education for both health care professionals and patients.
National Accreditation Program for Rectal Cancer (NAPRC)
The NAPRC was developed from the work between OSTRiCh Consortium (Optimizing the Surgical Treatment of Rectal Cancer) and the CoC. Based on significant treatment and patient outcome variabilities in the United States when compared to improved outcomes in Europe, this quality program was developed. Memorial Hermann Memorial City Medical Center, Memorial Hermann Southeast Hospital and Memorial Hermann The Woodlands Medical Center have been accredited programs since 2021.
Quality Improvement Projects:
- Rectal cancer: For patients with more advanced rectal cancer, radiation therapy should be completed within nine months before surgery for the best outcome.
System Awards and Recognition
Healthcare Associated Infections - C. difficile Infection
Memorial Hermann’s achievement of meeting this standard across all facilities reflects a strong commitment to patient safety and high-quality care. In particular, its performance in reducing C. difficile infections demonstrates high-quality infection prevention and control practices.
Using the CDC’s Standardized Infection Ratio (SIR), Memorial Hermann achieved a systemwide average of 0.20, outperforming the average-performing hospital benchmark of 0.401. While individual hospitals varied, all remained below the benchmark, indicating fewer infections than expected.
This accomplishment highlights the organization’s focus on evidence-based care, accountability and continuous quality improvement to help achieve safer outcomes for patients systemwide.
C. difficile Infection
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, 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, two 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.