Q
Safety and Infection Prevention
quality indicators. President Nancy Vish meets quarterly
with all employees to review patient safety information
and asks for input. The medical director of patient
safety and the patient safety officer meet regularly with
departments to discuss any safety initiatives as well as
concerns of direct care leaders and staff. In addition, the
Shared Governance Council structure provides forums for
identifying opportunities for improvement. Transparency
in reporting is strongly encouraged and built into every
aspect of leadership communication.
Baylor Hamilton Heart and Vascular Hospital, together
with Baylor University Medical Center at Dallas, annually
develops the patient safety plan along with the quality
plan. These plans are presented to the Board of Managers
and medical staff leadership for review and approval.
Monthly, all leaders including hospital leadership and
medical leadership, review performance report cards,
quality and safety initiatives, and progress toward goals.
In promoting a Culture of Safety, the hospital leadership
regularly reviews all patient safety measures and key
According to the National Database Nursing Quality Indicators (NDNQI) in fiscal year 2017,
Baylor Hamilton Heart and Vascular Hospital is cited at/or above the 90th percentile outranking
the national mean for hospital falls, central line associated blood stream infections (CLABSI),
catheter associated bloodstream infections, and hospital associated pressure ulcers.
Baylor Hamilton Heart and
Vascular Hospital (FY17)
Pacemaker Surgery
Infection Rate
Benchmark: 2009
Benchmark: 2009 CDC/
Total
Per 100 Surgeries CDC/NHSN Pooled NHSN Pooled Mean (risk
Procedures
Not Risk Adj
Mean – Not Risk Adj index category 0/1,2,3)
1,706
0.44
0.44
Shunt for dialysis 315 0.0 1.27 1.27
Limb Amputation 116 0.86 1.25 1.25/3.04
Total
Procedures Standardized
Infection Ratio
(SIR) Risk Adj*
Carotid Endarterectomy 122 0.00
Peripheral Vascular Bypass Surgery** 98 UC
Open Abdominal Aorta Replacement** 5 0.00
Baylor Hamilton Heart and
Vascular Hospital (FY17)
28
0.18
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. Leaders attend special
STEEEP academy training and
learn tools to assist in completing
robust performance improvement
projects. These projects are shared
across the system.
*Standardized Infection Ratio 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. If ratio is >1 then 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.
**Unable to calculate due to the number of expected infections <1.
®
STEEEP® focuses on process improvements through six
main elements:
• 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