Outcomes 2019 - Baylor Scott & White Heart and Vascular Hospital BSWHHVH_646_2019 Outcomes JOOMAG MOD | Page 10

10
PATIENT SAFETY
AND INFECTION
PREVENTION
Baylor Scott & White Heart and Vascular Hospital
annually develops the patient safety plan along
with the quality plan. This plan is 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. According to the National Database Nursing
Quality Indicators (NDNQI) in fiscal year 2019,
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.
To keep patient safety front and center and to
continually engage employees in the hospital’s
commitment to “Zero Harm,” President and
Chief Nursing Officer Nancy Vish, RN, PhD,
NEA-BC, meets quarterly with all employees to
review patient safety information and seek their
input into safety goals and initiatives. In addition,
the Patient Safety Officer works with staff and
conducts focus groups throughout the year to
promote a “Zero Harm” culture. 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, 2018.
Focus area
(FY19)
Reduction of
Hospital Onset
CDI
Reduction
of hospital
onset MRSA
bacteremia
Target Result
SIR 0.462 SIR 0.00
VTE-6: Hospital acquired potentially preventable
Venous Thromboembolism
Met
SIR 3.41
SIR 2.897
0 CASES
(FY19)
• Includes all inpatient NHSN operative procedures in patients >+18 years of age
is only calculated if numPred is >+1. Lower bound of 95% Confidence Interval only
• SIR
calculated if infCount>0
number of predicted events is calculated based on national aggregate NHSN
• The
data from 2015. Document containing the list of risk factors used in risk adjustment
for each procedure is available at: cdc.gov/nhsn/2015rebaseline/index.html
• Excludes all Superficial Incisional SSIs as well as Deep Incisional Secondary (DIS) SSIs
procedures and associated SSIs that are reported with either primary or
• Includes
other than primary closure technique
SSI detected on follow-up admission to a different facility (RO) and SSIs
• Excludes
detected through post-discharge surveillance efforts (P)
Source
of
aggregate data: 2015 NHSN SSI Data; generated 08082018
•