• Injury fall rate : injury falls per 1,000 patient days
• Central line associated blood stream infections ( CLABSI ) per 1,000 central line days
• Catheter-associated urinary tract infections per 1,000 catheter days
• Percent of surveyed patients with hospital acquired medical device related and any injury
• Hospital acquired pressure injury – medical device related
• C . diff rate – New event , healthcare acquired per 1,000 patient days
• New healthcare onset MRSA per 1,000 patient days
• The Joint Commission Performance Measurement Initiative : QualityCheck . org
• CMS via Hospital Compare : Medicare . gov / HospitalCompare
7
Top 10th percentile - Magnet hospital inpatient comparison group
Baylor Scott & White Heart and Vascular Hospital remains in the top 10th percentile for all hospitals in the Magnet Hospital Inpatient Comparison Group for the prior four quarters pertaining to :
• Injury fall rate : injury falls per 1,000 patient days
• Central line associated blood stream infections ( CLABSI ) per 1,000 central line days
• Catheter-associated urinary tract infections per 1,000 catheter days
• Percent of surveyed patients with hospital acquired medical device related and any injury
stage 2 or higher
• Hospital acquired pressure injury – medical device related
• C . diff rate – New event , healthcare acquired per 1,000 patient days
• New healthcare onset MRSA per 1,000 patient days
* Source : NDNQI Q3 2023
Overall hospital quality rating * 5 out of 5 Stars
Hospitals that earn a CMS 5-Star Rating generally have better scores in the heavily weighted categories , i . e ., mortality , patient experience , safety , and readmission . Five stars is the highest attainable rating in the report .
Reporting of healthcare quality data is available to the public with in-depth discussions about methodologies . Information can be found at :
• The Joint Commission Performance Measurement Initiative : QualityCheck . org
• CMS via Hospital Compare : Medicare . gov / HospitalCompare
Leapfrog assigns 16th “ A ” grade for patient safety
Baylor Scott & White Heart and Vascular Hospital – Dallas received its sixteenth consecutive “ A ” grade . The Leapfrog Group , a nonprofit organization committed to driving quality , safety and transparency in the US healthcare system , assigned the “ A ” rating for the hospital ’ s commitment to reducing errors , infections and accidents that can harm patients . According to the Leapfrog Group ’ s information , “ Hospitals that earn top marks nationally in the Leapfrog Hospital Safety Grade have achieved the highest safety standards in the country .”
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 ).
Baylor Scott & White Heart and Vascular Hospital | PATIENT SATISFACTION , QUALITY AND PATIENT SAFETY
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 .
One of the Center for Medicare and Medicaid Services ’ ( CMS ) foundational measures of quality is the percentage of unplanned 30-day readmissions to the hospital . Not only do high unplanned readmission rates indicate less than the highest quality care , they also negatively impact reimbursement to the hospitals . Providers scoring better than the CMS national average rate are judged to be among the highest quality providers in the nation . In fiscal year 2023 , Baylor Scott & White Heart and Vascular Hospital - Dallas scored better than expected on two key indicators : Heart Failure and Hospital-Wide . The hospital ’ s Heart Failure 30-day readmission percentage was 14.7 % compared to the CMS average of 20.2 %. The hospital ’ s Hospital- Wide readmission percentage was 11.4 % compared to CMS ’ average of 14.6 %. Baylor Scott & White Heart and Vascular Hospital remains focused on all-cause , all-condition readmission rates as well as readmission rates associated with specific conditions such as vascular surgery , AMI , CHF , and others .