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​​​​​​​​​​​​Commitment to Quality

We know you have choices when deciding which hospital is best for you. In our quality web pages, we provide you with information about the quality and safety of the care we de​liver, and we hope to help you make informed decisions about where you go for health care services.

Quality Care Principles

Our guide for improving care practice.

STEEEP Care Improvement Model

STEEEP LogoBaylor Scott & White Health has embraced the aims of STEEEP health care. As defined by the Institute of Medicine, STEEEP health care is safe, timely, effective, efficient, equitable and patient-centered.

  1. Safe Care - avoids injuries to patients from care that is intended to help them, without accidental error or inadvertent exposures.
  2. Timely Care - reduces waits and harmful delays impacting the smooth delivery of care.
  3. Effective Care - is provided based on scientific knowledge or evidence to all who could benefit and refraining from providing services to those not likely to benefit (avoids overuse or underuse).
  4. Efficient Care - uses resources to create the best value by reducing waste, production and administrative costs.
  5. Equitable Care - does not vary in quality according to their personal characteristics such as their gender, income, ethnicity or location.
  6. Patient-Centered Care - is respectful of and responsive to individual patient and family preferences, needs and values.

the STEEEP Care Report

Reporting outcomes as of August, 2016

STEEEP Care Reporting Overview

Image of BuildingsEvery year the STEEEP Analytics team in our Quality Office recommends targets for our system Quality and Service improvement goals. They work closely with the STEEEP Governance Council (SGC) and our Clinical and Administrative leadership across the system to confirm areas to focus on, and the range of targets for each goal. New targets are based on statistical analysis that includes the prior year’s system and location performance, national benchmarks where available, improvement plans and resources. The STEEEP report is not meant to establish a standard of care, but rather, reflects our efforts to analyze targets and averages.

This report shows whether we are reaching our Targets or not, using the average of performance over the last 12 months. Statistical analysis helps us determine what goals are most likely achievable during the course of the year, for each location and our system as a whole. We set four levels of improvement success to reach for - Threshold, Intermediate, Target and Maximum. Success is based on average performance over the last 12 months because sustaining improvement is just as important as achieving it.

In all of our work, our commitment to providing high quality health care to residents of Texas has been our compass. Our primary focus is to continuously improve and provide high quality patient care. Above all, we aim to always do what is best for our patients. We know you have choices when deciding which hospital is best for you. In these quality web pages, we provide you with new information about the quality and safety of the care we deliver, and we hope to help you make informed decisions about where you go for health care services. Please explore our quality below and remember that patient-provider partnership is the key to achieving and sustaining quality care.

STEEEP Monthly Board Presentation

Please feel free to review our monthly presentation to the BSWH Board of Trustees. This presentation includes our performance of these reporting outcomes, as well as the full details of our monthly assessment and plan-of-action to improve our performance. This report is reviewed by leadership across our system as an essential component of our quality improvement efforts.

The quality measures and comparisons reported on this site come from patient chart information. These measures are divided into five categories: Patient Satisfaction, Hospital Readmissions, Hospital Acquired Conditions, Outpatient Diabetes Care, and Supportive & Palliative Care. Our hospitals use these measures to focus on improving key areas of care quality and safety and the overall care we provide.

Results are reported in timing with our fiscal year, which begins July 1st and ends June 30th. Each report presents outcomes from the month noted, aggregated with the results from prior months in the fiscal year. This reflects the most recent data available, and the time required for patient charts to close, for measure populations and calculations to be confirmed, and for the reports to be quality reviewed by the leadership teams.

The most recent presentations can be opened by clicking on these links:

Thank you for exploring quality, and for your feedback. Please let us know how we can continue to improve our transparency.

Appendix - STEEEP Care Reporting Definitions

  • AIP - Administrative Incentive Program.
  • AMI - Acute Myocardial Infarction (Heart Attack).
  • BP - Blood Pressure.
  • BSWH - Baylor Scott & White Health.
  • BSWQA - Baylor Scott & White Quality Alliance.
  • CABG - Coronary Artery Bypass Graft.
  • C-Diff - Clostridium difficile colitis.
  • CLABSI - Central Line-associated Bloodstream Infection.
  • CMS - Centers for Medicare & Medicaid Services.
  • CNO - Chief Nursing Officer.
  • COLON – Colon surgical site infections.
  • COPD - Chronic Obstructive Pulmonary Disorder.
  • CTX - Central Texas Locations.
  • D3 - The Diabetes measure bundle includes blood glucose, blood pressure, and tobacco cessation measures.
  • ED - Emergency Department.
  • EPIC - Patient charting and electronic health record system.
  • FY2017 – BSWH Fiscal Year 2017 began June 30, 2016 and closes June 30, 2017.
  • HAC - Hospital Acquired Condition.
  • HAI - Hospital Acquired Infection.
  • HbA1C - Glycated hemoglobin is a form of hemoglobin that is measured primarily to identify the three-month average plasma glucose concentration.
  • HF - Heart Failure.
  • HTPN/HTN - Health Texas Provider Network.
  • HYST - Infections related to Abdominal Hysterectomy procedures.
  • ICD-10 - the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD).
  • ICU - Intensive Care Unit.
  • KEY - holder.
  • MC - Medical Center.
  • MRSA - Methicillin-resistant Staphylococcus aureus bacterium.
  • NTX - North Texas locations.
  • OB-GYN - Obstetrics & Gynecology.
  • PCP - Primary Care Physician.
  • PIECES - holder.
  • PNE - Pneumonia.
  • PSI - 'Patient Safety Indicator' is composite measure of avoidance of hospital complications.
  • SPC - Supportive & Palliative Care.
  • THKA - Total Hip or Knee Arthroscopy.
  • YTD - Year-to-Date. Measures are reported monthly throughout the fiscal year. New monthly results are averaged together with prior months to create year-to-date reporting.
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