QUALITY
Patient Safety and Infection Prevention
Baylor Scott & White Heart and Vascular Hospital annually develops the patient safety plan along with the quality plan . Leading that effort is John F . Eidt , MD , RVT , RPVI , FACS , and John Jayachandran , MD , FACC , FHRS , as physician safety officers . The facility safety officer and quality manager is David G . Garner , BSN , RN . These plans are presented to the board of managers and medical staff leadership for review and approval . Promoting a culture of safety , the hospital leadership regularly reviews all patient safety measures and key quality indicators .
President Nancy Vish meets quarterly with all employees to review patient safety information and requests input . In the spirit of full transparency , all employees have the opportunity to hear about and contribute to patient safety goals and initiatives . The hospital safety officers meet with unit staff and conduct focus groups throughout the year . Annually , all employees , regardless of role , include patient safety as a part of their annual personal goals .
According to the National Database Nursing Quality Indicators ( NDNQI ) in fiscal year 2018 , Baylor Scott & White Heart and Vascular Hospital is cited at / or above the national mean for hospital falls , central line associated blood stream infections ( CLABSI ), catheter-associated bloodstream infections , and hospital-associated pressure injuries .
Top 10th Percentile for All Hospitals in the Magnet ® Hospital Comparison Group
• Falls With Injury – per 1,000 patient days
• Hospital Acquired Pressure Injuries – Stage 2 or Above
• Central Line Associated Blood Stream Infections – per 1,000 central line days
• Catheter Associated Urinary Tract Infections – per 1,000 catheter days
According to NDNQI data . Time frame is four quarters ending December 31 , 2017 .
NATIONAL HEALTHCARE SAFETY NETWORK - STANDARD INFECTION RATIO ( SIR ) FOR ADULT COMPLEX ADMISSION / READMISSION SURGICAL SITE INFECTION ( SIR ) DATA
Predicted Observed SIR
C . diff 2.478 2 0.807 Better than predicted MRSA 0.331 0 N / A ( less than 1 ) Better than predicted
VTE-6 : Hospital Acquired Potentially Preventable Venous Thromboembolism
( FY18 )
0 cases 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 infCount > 0
• The number of predicted events is calculated based on national aggregate NHSN data from 2015 . Document containing the list of risk factors used in risk adjustment for each procedure is available at :
https :// www . 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 : 2015 NHSN SSI Data ; generated 08082018 .