STEEEP ®
Quality and Safety Program
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. STEEEP ® focuses on process improvements through six main elements:
STEEEP ®:
• 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
Leaders attend special STEEEP academy training and learn tools to assist in completing robust performance improvement projects. These projects are shared across the system.
Quality and Safety Program
Baylor Hamilton Heart and Vascular Hospital, together with Baylor University Medical Center at Dallas, select a multitude of quality indicators and annually develop a quality and safety plan approved by the Board of Managers. Monthly, all leaders – hospital leadership, Board of Managers, and medical leadership – review performance report cards, quality and safety initiatives and progress toward goals.
In addition, the Shared Governance Council structure provides excellent forums for identifying opportunities. During all-employee meetings, President Nancy Vish communicates results and ongoing activities and encourages all employees to become involved in improvement opportunities.
INFECTION PREVENTION AND CONTROL
The Infection Prevention & Control( IP & C) Plan delineates the interdisciplinary, systematic, and coordinated approach developed by Baylor Scott & White Health( BSWH) to reduce the risk of acquiring and transmitting infections among patients, employees, physicians and other licensed independent practitioners, contract employees, volunteers, students, and visitors. Ongoing evaluation of the IP & C Plan occurs throughout the year in response to significant changes, trends or issues that may impact the organization and the IP & C Program. A formal review of the IP & C Plan is conducted annually in consideration of and alignment with other key activities, plans and evaluations, including the:
• Infection Control Risk Assessment
• IP & C Program Goals & Evaluation
The IP & C Plan supports the organization’ s plan for provision of collaborative patient care, treatment and services and is organized, developed and implemented in order to positively impact the quality of and add value to the care and services provided at BSWH. Ultimately, this plan builds on the value propositions embraced by the organization and supports the mission, vision, strategy and organizational goals of the BSWH. The Mission of the BSWH IP & C Plan is to remain an exemplary leader in the health care specialty of epidemiology, infection prevention and control.
VACCINATIONS
Employees and Patients( FY16):
100 %
** Standardized Infection Ratio( SIR) 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. Note: If ratio is > 1, 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.
OUTCOMES 2016
23