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QUALITY AND PATIENT SAFETY
CULTURE OF “ ZERO HARM ”
As part of its comprehensive annual quality planning , the team at Baylor Scott & White Heart and Vascular Hospital develops action items related to areas needing attention or improvement , and / or as a result of stated Baylor Scott & White Health system initiatives . The combined patient safety and infection prevention annual plan , including the scorecard , is presented to the medical leadership group . Upon its approval , the plan and related documents are presented to the Board of Managers for their annual approval .
Key quality indicators and patient safety measures are regularly reviewed at all levels of the organization . In fact , the president and chief nursing officer , Nancy Vish , PhD , RN , NEA-BC , FACHE , hosts quarterly hospital-wide , all-employee Zero Harm meetings to openly review any concerns as well as to seek input on how to maintain a “ Zero Harm ” culture .
With great transparency , all employees understand the organization ’ s attention to a “ Zero Harm ” culture and , should an issue arise , a multidisciplinary group led by the Patient Safety Officer identifies the root cause and prepares formalized action plans to minimize any further occurrence .
8.1 % All-cause
readmission rate ( FY22 )
READMISSION RATE
Unplanned 30-day readmission rates are a marker of quality patient care across many disciplines . Baylor Scott & White Heart and Vascular Hospital focuses on all-cause , all-condition readmission rates as well as readmission rates associated with specific conditions ( vascular surgery , AMI , CHF ).
Efforts to reduce readmissions start with the pre-admission call . Patients receive daily rounding by a multidisciplinary team . Plans for high-risk patients are developed at the weekly multidisciplinary team meeting . The team also reviews opportunities and lessons learned from any patient who has an unplanned return to the hospital . The team works with post-discharge organizations ( including home health agencies and skilled nursing facilities ) to build and maintain relationships focused on quality outcomes and smooth transitions .
DISCHARGE CARE CALL PROGRAM
The care transition period following hospitalization is a potentially vulnerable time for patients . The Discharge Care Call Program extends connection and support as patients transition to home after discharge by ensuring quality of care , safety and patient experience . All of our patients receive a follow-up call within 72 hours of discharge by the Discharge Care Call-Back Team of experienced cardiovascular registered nurses . The team consists of experienced cardiovascular registered nurses who reach out to 100 % of our patients utilizing both phone and electronic communication via the EPIC MyChart patient portal . The team consistently maintains a contact rate of 80-85 % by attempting up to three calls / messages per patient . The objectives for these calls are :
• Identifying and mitigating post-discharge complications leading to readmission
• Ensuring patient compliance with new medications
• Assessing patient ’ s understanding of care through the teach-back method
• Validating successful transition to home and post-discharge appointment follow-up
• Execution of a closed-loop system for any issues needing escalation
Should any issues and concerns arise , real-time contact is made with providers and / or their office with patients transferred during business hours or an immediate next business day , monitoring for rapid response and resolution for patients .