STEEEP ®
Quality and Safety Program
STEEEP ®
The leadership , clinicians and staff of Baylor Heart and Vascular Services at Dallas and at Fort Worth routinely participate in process improvement projects through Baylor Scott & White Health ’ s Achieving Best Care program and the STEEEP ® Academy . STEEEP ® focuses on process improvements through six main elements :
STEEEP ® :
• Safe – avoids injuries to patients from care that is intended to help them
• Timely – reduces waits and delays for both those who receive care and those who give care
• Effective – based on scientific knowledge , extended to all likely to benefit , while avoiding underuse and overuse
• Equitable – provides consistent quality , without regard to personal characteristics such as gender , ethnicity , geographic location , and socioeconomic status
• Efficient – avoids waste , including waste of equipment , supplies , ideas , and energy
• Patient centered – respects and responds to individual patient preferences , needs , and values , ensuring that patient values guide all clinical decisions
Leaders attend special STEEEP academy training and learn tools to assist in completing robust performance improvement projects . These projects are shared across the system .
Quality and Safety Program
Baylor Hamilton Heart and Vascular Hospital , together with Baylor University Medical Center at Dallas , select a multitude of quality indicators and annually develop a quality and safety plan approved by the Board of Managers . Monthly , all leaders – hospital leadership , Board of Managers , and medical leadership – review performance report cards , quality and safety initiatives and progress toward goals .
In addition , the Shared Governance Council structure provides excellent forums for identifying opportunities . During all-employee meetings , President Nancy Vish communicates results and ongoing activities and encourages all employees to become involved in improvement opportunities .
INFECTION PREVENTION AND CONTROL
The Infection Prevention & Control ( IP & C ) Plan delineates the interdisciplinary , systematic , and coordinated approach developed by Baylor Scott & White Health ( BSWH ) to reduce the risk of acquiring and transmitting infections among patients , employees , physicians and other licensed independent practitioners , contract employees , volunteers , students , and visitors . Ongoing evaluation of the IP & C Plan occurs throughout the year in response to significant changes , trends or issues that may impact the organization and the IP & C Program . A formal review of the IP & C Plan is conducted annually in consideration of and alignment with other key activities , plans and evaluations , including the :
• Infection Control Risk Assessment
• IP & C Program Goals & Evaluation
The IP & C Plan supports the organization ’ s plan for provision of collaborative patient care , treatment and services and is organized , developed and implemented in order to positively impact the quality of and add value to the care and services provided at BSWH . Ultimately , this plan builds on the value propositions embraced by the organization and supports the mission , vision , strategy and organizational goals of the BSWH . The Mission of the BSWH IP & C Plan is to remain an exemplary leader in the health care specialty of epidemiology , infection prevention and control .
VACCINATIONS
Employees and Patients ( FY16 ):
100 %
** Standardized Infection Ratio ( SIR ) is a risk adjusted summary measure that compares the observed number of infections to the expected number of infections based on National Healthcare Safety Network ( NHSN ) aggregate data . Note : If ratio is > 1 , the facility is performing worse than the standard population . If ratio is < 1 , then the facility is performing better than the standard population . SIR not calculated if expected infection is < 1 .
OUTCOMES 2016
23