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Leadership Blog

Baylor St. Luke’s Medical Group Tops Overall Quality Measures

By Peter Bigler, MD, board-certified family medicine physician, Baylor St. Luke’s Medical Group - The Woodlands, Texas

August 09, 2023 Posted in: Leadership
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I like to think every hospital and medical group strives to provide quality care for their patients—that’s why we’re here. 

However, health care organizations and physicians who accept patients with Medicare must also follow rigorous care standards established by the Centers for Medicare & Medicaid Services (CMS). To see how well these standards are being followed, CMS performs regular reviews and publishes the results for the public to see. Those results allow hospitals and other medical organizations to see how they compare to similar organizations. Patients can also access this information to help them make health care decisions.

The guidelines developed by CMS are in place to ensure patients receive quality health care. Providers who follow the guidelines closely often deliver positive results for their patients, including:

  • Fewer hospitalizations

  • Health equity

  • Improved quality of life for patients and communities 

  • Longer life span

  • Symptomatic relief


Though health care organizations that don’t follow CMS’s quality measures may not be providing the best care, they can also face penalties and lose reimbursement for the services they provide. Clearly, that’s an incentive for hospitals and clinics to follow the standards

Baylor St. Luke’s Medical Group, part of CommonSpirit Health, consistently adheres to these standards because we believe it’s the right thing to do. As a nonprofit Catholic health system, our care is inspired by faith, driven by innovation and powered by our humanity. And our efforts have paid off. We currently rank at the top of CommonSpirit Health for high-quality primary care.

We Treat People

Quality care doesn’t start with disease—it starts with how we treat you. When you make your first scheduled appointment, you’ll be greeted by a warm and caring staff to answer your questions and guide your next steps. That care and consideration will continue throughout your care journey. Every clinician you come to meet has your best interest in mind. 

We know giving you the right, specialized care, delivered with kindness and compassion, is going to increase the likelihood that you’ll be able maintain or improve your health and well-being. Our goal is to help you live a quality life, so you can actively participate in the activities you love, like making it to your grandchildren’s ballgames, graduations and weddings. What’s meaningful to you is meaningful to us. 

We also hire professionals whose heart and primary mission are to positively impact the patients they treat. So, with the right people in place, meeting quality goals comes naturally for our health care team. 

Setting You Up for Success

Our ongoing commitment to every patient results in more people moving toward better health. Two areas we’re particularly excited about are:

  • Blood pressure management. The American Heart Association gave us Gold status for reaching the criteria set in their Target:BP program, which looks at how well we help patients with hypertension control their blood pressure levels. 

  • Blood sugar control. For people with diabetes, uncontrolled blood sugar (glucose) can increase risk of serious health problems, including heart and kidney disease, stroke, nerve conditions and more. Careful management is essential to reducing your risk and is something we take very seriously. 


Combined, our blood sugar and blood pressure management rank in the 93rd percentile of similar medical groups in America. So, while we’re following standards created by CMS, we’re also setting the standard in what quality care looks like.

Looking Out For You

Most health care organizations allow you to access your medical records through the internet or a phone app. Our patients have an electronic medical record (EMR) that also lets your doctor’s quickly review your medical history and contact specialists you’ve visited in the past. We also use the EMR in ways that put your health front and center.

With the EMR, we can review what steps you’ve taken to improve your health, and which ones you still need to take to achieve even better health. This information helps guide your care moving forward. When it’s time for a health screening or vaccination, the EMR system automatically notifies us—and you—so we’re all in the loop on your health needs.

EMR notifications may include:

  • Annual well visit reminders

  • Help managing blood pressure, blood sugar and cholesterol

  • Mammogram, colonoscopy, and other important cancer screenings

  • Vaccinations against flu, shingles, and other viruses


Still Getting Better

Every day, we work to improve the care we provide. On top of excellent blood sugar and blood pressure management, we discuss mental health with all patients and help manage cholesterol levels. Baylor St. Luke’s Medical Groups was recognized by the American Heart Association in 2021 and 2022 with a Gold Recognition of  the Check. Change. Control. Cholesterol Recognition Program for improving the quality of our high-cholesterol care.

We’re proud of our accomplishments, but we’re not finished yet. Despite our success, we know we’re not perfect, and we’re not afraid to admit it. That’s why we engage in continuous quality improvement. 

To continue enhancing the quality of care we provide, we’re working on creating a committee made up of patients and their family members who can provide feedback on their experience at Baylor St. Luke’s Medical Group. We want to learn from you so we can all continue to grow in a positive direction.

We’re always looking to find and remove barriers in the health system or the communities we serve that may be preventing you from getting the care you need. Whether we identify problems with how we’re communicating with our patients, or discover transportation or financial issues that prevent patients from getting care, our goal is to find solutions.

We sincerely welcome your feedback—good or bad. If you’ve had a positive or negative experience, please let us know. Partner with us to work toward a healthier future for you and your neighbors. 

If you’re looking for high-quality, holistic primary care, find a physician at Baylor St. Luke’s Medical Group.

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