2022_Outcomes_Digi | Page 15

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READMITS COMPARISON TABLE

Heart Failure 21.3 % 20.6 % 8.8 % 19.2 % 12.6 % AMI 15 % 15.6 % 4.93 % 15 % 13 % CABG 11.9 % NA NA 11.8 % 8.12 % Hospital-wide 15 % 14.4 % 8.12 % 14.1 % 9.63 %

BETTER THAN EXPECTED

Performance report elements disclosed on a monthly basis include :

Care transition measures are reviewed by location — Dallas , Fort Worth and Waxahachie — and include PCI ASA at discharge , PCI anti-platelet ordered at discharge , PCI cholesterol lowering meds at discharge , tobacco cessation instructions at discharge , Afib anticoagulant at discharge , Afib patient follow-up , Afib smoking cessation , and unplanned transfers .

Gylcemic control events and American Heart Association ’ s Get With The Guidelines are monitored and reported . In fiscal year 2022 , all metrics with one exception were at or exceeded the goal .

Patient safety measures As a part of National Patient Safety Goals , the scorecard includes the measurement and documentation of staff communication ; improvement of the safety of using medication , including reconciliation ; infection prevention measures , including hand hygiene and influenza vaccine utilization ; risks associated with medication scanning ; making certain two patient identifiers are checked ; observation of time-outs in procedural areas ; screening 100 % of patients for risk of suicide ; as well as pre-off verification processes . All of these metrics were at or above target in fiscal year 2022 .

Hospital acquired conditions ( HACs ) are reported including any surgical site infections for pacemaker implants , lower extremity bypass , carotid endarterectomy , AAA repair , onset MRSA , onset CDI , hospital acquired VTE-6 , hospital-acquired pressure ulcer ( Prevalence study Stage II , III , IV ), catheter associated urinary tract infection ( CAUTI ), and central line associated blood stream infection ( CLABSI ).

HOSPITAL-ACQUIRED CONDITION PERFORMANCE FY22 * TARGET RESULT

Reduction of hospital onset C . diff infection SIR 0.354 SIR 0.00 Reduction of hospital onset MRSA bacteremia SIR 3.546 SIR 2.773

This report includes facility-wide inpatient data from acute care hospitals for 2015 forward The SIR is only calculated if number predicted is ≥1 . Lower bound of 95 % Confident Interval only calculated when number of observed events > 0 .

• The number of predicted events is calculated based on national 2015 NHSN data . It is adjusted for inpatient community-onset CDI prevalence rate , ED / OBS reporting , CDI test type , medical school teaching status , facility type , number of beds , and number of ICU beds .

*

• Events from rehabilitation wards and behavioral health / psych wards with unique CCN are excluded . Information on how to determine which events are counted in the SIR can be found here : http // www . cdc . gov / nhsn / pdfs / ps-analysis-reources / mrsacdi _ tips . pdf

• If any risk factor data are missing , the record is excluded from the SIR .

MET

Baylor Scott & White Heart and Vascular Hospital | Quality and Patient Safety