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Baylor Scott & White Heart and Vascular Hospital Quality and Patient Safety
PATIENT SAFETY AND INFECTION PREVENTION
Annually , the team at Baylor Scott & White Heart and Vascular Hospital develops the patient safety plan along with the quality plan . The plan is presented to the board of managers and medical staff leadership for review and approval . All patient safety measures and key quality indicators are regularly reviewed at all levels . Employees are engaged in the hospital ’ s commitment to “ Zero Harm ” and hear from the president and chief nursing officer , Nancy Vish , PhD , RN , NEA-BC , no less than quarterly about the results of patient safety initiatives and safety goals . The Patient Safety Officer works with leadership and staff to promote “ Zero Harm ” culture .
Hospital-acquired condition performance ( FY20 ) Target Result
Reduction of hospital onset C . diff infection SIR 0.00 SIR 0.00 Reduction of hospital onset MRSA bacteremia SIR 0.00 SIR 0.00 Includes all inpatient NHSN operative procedures in patients >+ 18 years of age SIR is only calculated if numPred is >+ 1 . Lower bound of 95 % Confidence Interval only calculated if infection count > 0
• The number of predicted events is calculated based on national aggregate NHSN data . Document containing the list of risk factors used in risk adjustment for each procedure is available at :
CDC . gov / NHSN / 2015Rebaseline / Index . html Excludes all Superficial Incisional SSIs as well as Deep Incisional Secondary ( DIS ) SSIs Includes procedures and associated SSIs that are reported with either primary or other than primary closure technique Excludes SSI detected on follow-up admission to a different facility ( RO ) and SSIs detected through post-discharge surveillance efforts ( P )
• Source of aggregate data : NHSN SSI Data June 2020 .
FY20 and COVID-19
The health and safety of our patients and team members continue to be our top priority . As we remain dedicated to our Mission during the unprecedented time of COVID-19 , together with Baylor Scott & White , during the pandemic , hospital leadership announced new preventive safety measures and innovative care options as well as educational tools for patients grounded in the COVID-19 Safe Care plan .
Met
COVID-19 Safe Care plan objectives :
• Educate our communities about the many ways Baylor Scott & White Health is working to safeguard their health and well-being , protecting them from COVID-19
• Demonstrate how Baylor Scott & White Health is leading the state and paving the way in both virtual and in-person care options throughout the pandemic
• Reinforce there are potential unintended consequences for delaying care
• Demonstrate the commitment for educating our communities about the many ways we are working to safeguard our patients ’ health and well-being — as well as that of our caregivers — from COVID-19 . New measures and protections are in place across our hospitals , surgery centers and clinics , in accordance with CDC guidance and recommendations by our clinical experts
Plan elements include :
• COVID-19 testing of patients deemed appropriate through individual case review prior to in-hospital surgeries ; patient swabs collected via convenient drive-thru locations
• Where possible , virtual waiting rooms , allowing patients and loved ones of hospital or surgery center patients to receive updates about their care via calls and text messaging , minimizing time in common areas
• Virtual care options provided to patients before and after surgeries and procedures when appropriate , simplifying the experience
• Masking of patients , approved visitors and staff in hospitals , surgery centers and clinics
• Enhanced cleaning and touch-free protocols in hospitals , surgery centers and clinics , including UV-light disinfection and paperless registration
• COVID-19 home monitoring digital care journey , enabled through the MyBSWHealth app or website , offered to those diagnosed with COVID-19 so there is support by care teams while quarantined