MEASURING INNOVATION IN HEART AND VASCULAR CARE

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2 Contents Medical Leadership... 4 Board of Managers... 5 BHCS Circle of Care... 6 Accreditations, Awards and Accolades... 8 Admissions and Registrations QUALITY Centers for Medicare and Medicaid Services Cardiovascular Surgical Procedures Performance Report Readmissions Interdisciplinary Quality and Safety Committee.. 19 Patient Falls Hospital-Acquired Conditions INNOVATIONS Research Initiatives Center For Valve Disorders Electrophysiology Heart Failure Program Temporary Cardiac Support Open Heart Procedures Vascular Surgery Cardiac Rehab Non-Invasive Imaging and Radiology Research and Publications Physician Publications SERVICE Patient Satisfaction Community Outreach Website PEOPLE Employee Incentives Employee Retention Employee Awards and Accolades Nurse Certification Shared Governance Graduate Medical Education MEASURING INNOVATION IN HEART AND VASCULAR CARE 2 BAYLOR HEART AND VASCULAR SERVICES AT DALLAS

3 Nancy Vish, PhD, RN, NEA-BC, FACHE President and Chief Nursing Officer Since the inception of Baylor Jack and Jane Hamilton Heart and Vascular Hospital (BHVH) 11 years ago, we have taken a collaborative approach to providing quality patient care. Our employees and the physicians on our medical staff have worked seamlessly together to provide our patients with not only advanced heart and vascular treatments but tremendous service. In FY 2013, we were fortunate to collaborate with our colleagues in the heart surgery program at Baylor University Medical Center at Dallas to form one cohesive heart and vascular team under the brand, Baylor Heart and Vascular Services (BHVS) at Dallas. Joining forces has not only benefitted our team members, but ultimately it is benefitting our patients and their families. American poet Mattie Stepanek once said, Unity is strength... when there is teamwork and collaboration, wonderful things can be achieved. We are proud to say in FY 13 our team accomplished some wonderful things. BHVS is honored to have achieved the highest rating for heart surgery according to The Society of Thoracic Surgeons. Also, both Baylor University Medical Center at Dallas and Baylor Hamilton Heart and Vascular Hospital received Heart Failure Accreditation from the Society of Cardiovascular Patient Care in FY12. We also worked together with the American Heart Association and other health care providers as part of the Caruth Initiative. This collaborative project, funded by a $3.5 million grant from the W.W. Caruth, Jr. Foundation, expedited care for heart attack patients in Dallas-Ft. Worth. In FY 13, we were honored to be named to Modern Healthcare s Best Places to Work in Healthcare list for a second consecutive year, receive a fourth straight Press Ganey Patient Satisfaction Award and win the Beacon Award for Outstanding Intensive Care Nursing. These awards help affirm the dedication to our goals of clinical excellence, patient and family satisfaction, health care team satisfaction and fiscal responsibility to help provide a quality patient experience. As part of our continuing focus on education, BHVS at Dallas offers fellowships in cardiology, electrophysiology and a vascular surgery residency program that are fully accredited by the Accreditation Council for Graduate Medical Education. Research remains a pillar of our organization. Investigation into the use of adult stem cells to improve heart function in patients with congestive heart failure and in treating heart attacks continues. Also, BHVS at Dallas remained among the highest enrollers nationwide in the CoreValve transcatheter aortic valve implantation clinical trial, and the Symplicity trial studying uncontrolled hypertension. FY 13 was an exciting year of accomplishment and expanded collaboration. Joining forces to create BHVS at Dallas has already proven to be a great benefit for our team members and our patients. We believe this new relationship enhances our ability to offer advanced heart and vascular treatments with a focus on quality and outstanding service for our patients and their families. MEASURING INNOVATION IN HEART AND VASCULAR CARE 3 BAYLOR HEART AND VASCULAR SERVICES AT DALLAS

4 Medical Leadership Kenneth Ausloos, MD Medical Director, Lung Transplant Department and the Pulmonary Hypertension Clinic Rafic Berbarie, MD Medical Director of Cardiac Rehab William Dockery, MD Medical Director of Radiology Cara East, MD Medical Director, Soltero Cardiovascular Research Center Gonzalo V. Gonzalez- Stawinski, MD Surgical Director of Cardiothoracic Transplantation and Mechanical Circulatory Support Paul Grayburn, MD, FACC Medical Director of Non-Invasive Cardiology Shelley Hall, MD Medical Director of Cardiac Transplant and Mechanical Circulatory Support Baron Hamman, MD Medical Director of Cardiac Surgery Robert Hebeler, MD Surgical Chair, Clinical Cardiovascular Research Center Albert C. Henry, MD Medical Director of Cardiovascular Surgery Quality Stephen Hohmann, MD, FACS Medical Director of Patient Safety Edward Mays, MD Medical Director of Laboratory Gregory Pearl, MD, FACS Medical Director of Vascular Surgery Michael Ramsay, MD, FRCA Medical Director of Anesthesia Services Jeffrey Schussler, MD, FACC, FSCAI, FSCCT Medical Director of Critical Care Bertram Smith, MD, FACS Medical Director of Non-Invasive Vascular Robert Stoler, MD, FACC, FSCAI Co-Medical Director of Cardiology; Medical Director of Catheterization Lab Carlos Velasco, MD Medical Director of Cardiology Quality Kevin Wheelan, MD Chief-of-Staff; Co-Medical Director of Cardiology MEASURING INNOVATION IN HEART AND VASCULAR CARE 4 BAYLOR HEART AND VASCULAR SERVICES AT DALLAS

5 Board of Managers HOSPITAL HOSPITAL LEADERSHIP LEADERSHIP Michael Graham, J.D. Chairman John Schumacher, MD J. Kent Newsom, J.D. Robert C. Kowal, MD, PhD Timothy Owens Kevin Wheelan, MD Don Wills, J.D. Brad R. Grimsley, MD, FACS John McWhorter, III, DSc, MHA C.T. Beckham Richard Lockwood James Shelton, MD Tim Bilbrey Cardiac Rehabilitation Team Leader Sabrina Bortey Financial Analyst Chris Callahan Marketing Team Leader Kishore Chukkala, BBA, RRT-NPS, CPFT Team Leader/Manager Respiratory Care Renee Cooper Nutrition Team Leader Mike Davis, ThM Pastoral Care Team Leader Sandra DeJong, BSN, RN, BC Electrophysiology/Non-Invasive Supervisor Jacie Edelstein SCU Supervisor Rodney Fuller, LP, HEM Environmental Safety Team Leader Amanda Gonzalez Administration Office Team Leader Angelina Hernandez Access Services Supervisor Mia Hupert Care Coordination Team Leader Mini Iype, MSN/MHA, RN-BC Specialty Care Unit Supervisor - Nights Brenda Keeton Service Excellence Manager Kim Krause, PHR Human Resources Team Leader Jennifer Lenge Magnet Coordinator and SCU Supervisor Laura Linker, BSN, RN-CNOR Team Leader/Manager Surgical Services Kim Newman Epidemiology Team Leader Tracy Ordrop, MSN, RN, NE-BC Scheduling Team Leader Julio Perez Access Services Team Leader Leda Perez Environmental Services Team Leader Diana Pitts Accounting Manager Susan Riley Materials Management Team Leader Mark Sanders, MSN, RN, NEA-BC Specialty Care Unit/ICU/ Recovery Room Team Leader Art Signo, MS, RN-BC Education Team Leader Andres Sisneros, RT(R), ARRT Invasive Cardiology/Radiology Team Leader Mindy Smart, BSN, RN-BC Catheterization Lab Supervisor Jacob Thomas, RN, BSN Manager Clinical Informatics Terri Thompson Health Information Management Team Leader Rema Thyagarajan Pharmacy Team Leader Henry Viejo, BSN, RN-BC Specialty Care Unit Supervisor - Weekends Chris Wahlenmaier Physician Liaison, Marketing and PR Consultant Mike Walsh, MSN, RN-BC Electrophysiology/Non-Invasive Team Leader Deborah White, MHA, BSCLS Laboratory Team Leader Trey Wicke Vice President of Finance Jeff Wilcox, RN-BC, CPAN Recovery Room Supervisor Robert Williams, MBA, RN, NEA-BC Specialty Care Unit/ICU/ Recovery Room Manager Annabelle Zakarian, MSN, RN, CVRN Care Coordination/Health Care Improvement Team Leader MEASURING INNOVATION IN HEART AND VASCULAR CARE 5 BAYLOR HEART AND VASCULAR SERVICES AT DALLAS

6 Baylor Health Care System Circle of Care Our Circle of Care encompasses our mission, vision, and priorities, and places our patients front and center. Our mission supports this patient-centered approach. We recognize that there are four key areas of excellence that must be in place to ensure that patients are our number one priority: people, quality, service and fiscal stewardship. What does this mean? It means that Baylor Health Care System supports and cares for patients as individuals. We promote a healing environment in which the members of the health care team work together as one, for the benefit of the patient. To do that, Baylor adopts best practices and industry standards that support and sustain a patient-centered culture. When these are put into place, we not only enhance patient safety and quality of care, we also increase our level of performance as a health care system. During the strategic planning process, Baylor Heart and Vascular Services at Dallas leadership uses the Circle of Care as a framework to identify the principal factors that determine success relative to competitors and sustainability for its key stakeholders. MEASURING INNOVATION IN HEART AND VASCULAR CARE 6 BAYLOR HEART AND VASCULAR SERVICES AT DALLAS

7 Clinical Excellence (Quality) Patient & Family Satisfaction (Service) Health Care Team Satisfaction (People) Fiscal Responsibility (Finance) Quality Care results in People s Expectations Exceeded results in Satisfaction, Excellence & Trust FOUNDING PRINCIPLES: Honesty + Respectfulness + Integrity + Compassion + Communication + Positive Attitude Our Vision To redefine the relationship between physicians and the hospital with an integrated heart and vascular delivery system focused on high quality, cost effective care. Our Mission To operate an integrated heart and vascular health care delivery system, founded as a Christian Ministry of healing, that exists to serve people by offering a continuum of quality service committed to quality care and patient safety, medical education, research and community service. Our Values Baylor Hamilton Heart and Vascular Hospital values guide our actions as we remain faithful to our mission and work toward our vision. Integrity: Conducting ourselves in an ethical and respectful manner. Servanthood: Serving with an attitude of unselfish concern. Quality: Meeting the needs and striving to exceed the expectations of those we serve through continuous improvement. Innovation: Consistently exploring, studying and researching new concepts and opportunities. Stewardship: Managing resources entrusted to us in a responsible manner. Our Care Model Our founding principles define the qualities we look for in our team members. We believe that if we work to exceed people s expectations, the results will be satisfaction, care excellence, and a trusting relationship. Our goals are: clinical excellence (Quality), patient and family satisfaction (Service), health care team satisfaction (People), and fiscal responsibility (Finance). We review our model of care at our hospital team meetings and the metrics associated with the goals we have set. MEASURING INNOVATION IN HEART AND VASCULAR CARE 7 BAYLOR HEART AND VASCULAR SERVICES AT DALLAS

8 Accreditations, Awards and Accolades ACCREDITATIONS ACE Accredited for PCI Baylor Hamilton Heart and Vascular Hospital has been fully accredited for percutaneous coronary intervention by Accreditation for Cardiovascular Excellence, an organization dedicated to ensuring adherence to the highest quality standards for cardiovascular and endovascular care. ACE accreditation is a professional review of an organization s structure, internal processes, patient safety practices, and clinical outcomes to determine if it meets the standards established by experts in cardiac and endovascular care. American College of Radiology Accreditation for Computed Tomography (CT) The American College of Radiology awarded Baylor Hamilton Heart and Vascular Hospital accreditation for the achievement of high practice standards after a peer-review evaluation of the practice. Intersocietal Commission for the Accreditation of Echo Laboratories (ICAEL) The ICAEL accreditation review process is a means by which echocardiography laboratories can evaluate and demonstrate the level of patient care they provide. After a laboratory submits the application to ICAEL, the application undergoes a confidential peer-review by ICAEL s trained reviewers, including both physicians and sonographers. MEASURING INNOVATION IN HEART AND VASCULAR CARE 8 BAYLOR HEART AND VASCULAR SERVICES AT DALLAS

9 Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL) The purpose of ICAVL is to provide a mechanism for accreditation of facilities which perform comprehensive testing for vascular disease with non-invasive testing modalities. ICAVL assesses every aspect of a lab s daily operation and its impact on the quality of health care provided to patients. Heart Failure Accreditation Baylor Hamilton Heart and Vascular Hospital and Baylor University Medical Center at Dallas have received Heart Failure Accreditation from the Society of Cardiovascular Patient Care, an international not-for-profit organization that focuses on transforming cardiovascular care by assisting facilities in their effort to create communities of excellence that bring together quality, cost and patient satisfaction. American Heart Association s Get With The Guidelines Gold Plus Award BHVH was recognized with the Gold Plus Award for heart failure. BHVH achieved at least 90 consecutive days of 85 percent or higher adherence to the Heart Failure Performance Achievement indicators to improve quality of patient care outcomes. Get With The Guidelines SM (GWTG) is the premier hospital-based quality improvement program for the American Heart Association and the American Stroke Association. It empowers health care provider teams to consistently treat heart and stroke patients according to the most up-to-date guidelines. The Society of Thoracic Surgeons Three-Star Rating Baylor Heart and Vascular Services at Dallas is one of only 24 hospitals in the United States to have earned the highest rating for both valve and coronary artery bypass surgeries according to the Society of Thoracic Surgeons for the first six months of AWARDS American College of Cardiology Foundation s NCDR ACTION Registry GWTG Platinum Performance Achievement Award Baylor Hamilton Heart and Vascular Hospital is one of only 164 hospitals nationwide to receive this award, which recognizes BHVH s commitment and success in implementing a higher standard of care for heart attack patients, and signifies that BHVH has reached an aggressive goal of treating these patients to standard levels of care as outlined by the American College of Cardiology/American Heart Association clinical guidelines and recommendations. American Heart Association Mission Lifeline Gold AHA recognizes Baylor Hamilton Heart and Vascular Hospital for achieving 85 percent or higher composite adherence to all Mission: Lifeline STEMI Receiving Center Performance Achievement indicators for consecutive 12-month intervals and 75 percent or higher compliance on all Mission: Lifeline STEMI Receiving Center quality measures to improve the quality of care for STEMI patients. MEASURING INNOVATION IN HEART AND VASCULAR CARE 9 BAYLOR HEART AND VASCULAR SERVICES AT DALLAS

10 Innovation Award from the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) This award acknowledges programs that have enhanced their delivery of care for a patient population in a unique and creative way, beyond the traditional model of cardiac and pulmonary rehabilitation. AACVPR is dedicated to reducing morbidity, mortality and disability from cardiovascular and pulmonary disease through education, prevention, rehabilitation, research and disease management winner of the Press Ganey Beacon Award. The Beacon Award is an added distinction and to achieve this award, the hospital must be among the top 3 in its class of 95th percentile achievers for the previous 3 years of 12 quarters. There are approximately 1,800 hospitals in the inpatient survey database and about 1,500 emergency departments in the All Press Ganey database. Receiving this award is truly a testimony to the efforts of these leaders and their teams, says Terri Nuss, vice president of patient centeredness for Baylor Health Care System. START! Fit-Friendly Gold Award The American Heart Association awarded Baylor Hamilton Heart and Vascular Hospital the Start! Fit-Friendly Award. Companies reach Gold-level status by implementing various activities and programs for their employees to encourage physical activity, nutrition and culture enhancements such as on-site walking routes, healthy food choices in cafeterias and vending machines, annual employee health risk assessments and online tracking tools. Magnet Award for Excellence in Nursing Services The Magnet Recognition Program was developed by the American Nurses Credentialing Center to recognize health care organizations that provide nursing excellence. The program also provides a vehicle for disseminating successful nursing practices and strategies. Both Baylor Hamilton Heart and Vascular Hospital and Baylor University Medical Center at Dallas are Magnet recognized facilities. Press Ganey Patient Satisfaction Award Fourth Year in a Row Baylor Hamilton Heart and Vascular Hospital is a winner of the 2010, 2011 and 2012 Press Ganey Summit Award, one of Press Ganey s most prestigious honors, and the Texas Health Care Quality Improvement Awards Award of Excellence Winners of this non-competitive award are measured by the frequency of best care practices utilized on patients with specific conditions, including acute myocardial infarction, heart failure, and pneumonia, as well as surgical infection prevention. VHA Leadership Award in Clinical Excellence The award honors health care organizations that have differentiated themselves around national performance standards by achieving performance at the 90 percent level or above on clinical core measures. Baylor Hamilton Heart and Vascular Hospital won the award for acute myocardial infarction treatment, heart failure and surgical infection prevention. Beacon Award for Excellence for ICU Patient Care A significant milestone on the path to exceptional patient care and a healthy work environment. The award recognizes unit caregivers who successfully improve patient outcomes and align practices with the American Association of Critical-care Nurses s six standards for a healthy work environment. Units that achieve this three-year, threelevel award with gold, silver and bronze designations meet MEASURING INNOVATION IN HEART AND VASCULAR CARE 10 BAYLOR HEART AND VASCULAR SERVICES AT DALLAS

11 national criteria consistent with Magnet Recognition, the Malcolm Baldrige National Quality Award and the National Quality Healthcare Award. Baylor Hamilton Heart and Vascular Hospital attained silver designation. ACCOLADES Becker s Hospital Review 50 Physician-Owned Hospitals to Know Baylor Hamilton Heart and Vascular Hospital is listed in Becker s Hospital Review s 50 Physician-Owned Hospitals to Know, recognizing high-performing facilities in patient care and clinical quality. To compile this list, the Becker s Hospital Review editorial team analyzed and reviewed research and data from sources including U.S. News & World Report, HealthGrades, Press Ganey, CareChex and Thomson Reuters to identify leading hospitals. Becker s Hospital Review 130 Women Hospital and Health System Leaders to Know BHVH President Nancy Vish is one of 130 hospital leaders featured on this list. The honorees demonstrated a proven ability to lead their respective organizations in the midst of healthcare s challenging environment. They have demonstrated considerable skill and promise despite times of uncertainty and unprecedented change in the industry. The Joint Commission Top-Performers on Key Quality Measures Baylor Hamilton Heart and Vascular Hospital is among 620 hospitals being recognized as a top performer for This represents the top 18 percent of Joint Commission accredited hospitals reporting core measure performance-data for Top-performing hospitals achieved a performance of 95 percent or above on two measurements. Becker s Hospital Review BHVH Named Among Nation s Best Cardiovascular Programs Baylor Hamilton Heart and Vascular Hospital is one of 25 hospitals and health care systems nationwide to be recognized in Becker s Hospital Review for having a great Cardiovascular Program. The facilities featured are among hospitals with the highest distinctions and awards given from other organizations and publications for heart care. They also feature some of the most advanced technology, highest quality of care and best reputations in the specialty. Becker s Hospital Review Top 51 Hospitals Patients Would Definitely Recommend Baylor Hamilton Heart and Vascular Hospital is one of 51 hospitals nationwide to be recognized in Becker s Hospital Review as being a hospital patients would definitely recommend. The list is based on HCAHPS survey results reported in CMS Hospital Compare database and covers the period October 2011 through September Modern Healthcare Best Places to Work in Healthcare Baylor Hamilton Heart and Vascular Hospital has been named to the Modern Healthcare list of the Best Places to Work in Healthcare for two consecutive years. Quality Texas Foundation Achievement Level Recognition Recognized for organizational excellence with welldeployed, effective, systematic approaches to organizational management with good performance levels and trends evaluated against industry standards. MEASURING INNOVATION IN HEART AND VASCULAR CARE 11 BAYLOR HEART AND VASCULAR SERVICES AT DALLAS

12 Admissions and Registrations HOSPITAL ADMISSIONS AND REGISTRATIONS NON-INVASIVE PROCEDURES (FY 2013) ,929 21,609 19,831 21,955 20,956 22,908 20,891 22,906 20,679 22,810 22,625 22,606 20,552 20,389 PROCEDURE COUNT Transthoracic Echocardiogram Stress Echocardiogram 287 Dobutamine Stress Echocardiogram Signal Average ECG 2 Metabolic Stress Test Holter Monitors ,680 2,124 1,952 2,015 2,131 2,073 2,217 Exercise Arterial Test FY2007 FY2008 FY2009 FY2010 FY2011 FY2012 FY2013 Transesophageal Echocardiogram 1132 Inpatient Outpatient Total Cerebrovascular Studies 284 Arterial Studies 888 Venous Studies 798 INPATIENT AVERAGE LENGTH OF STAY Visceral Studies 59 FISCAL YEAR LENGTH OF STAY (IN DAYS)* Dialysis Access Scan 51 TOTAL 11,891 FY FY FY FY FY FY FY *Intensive Care Unit (ICU) opened January 2010 MEASURING INNOVATION IN HEART AND VASCULAR CARE 12 BAYLOR HEART AND VASCULAR SERVICES AT DALLAS

13 Centers for Medicare and Medicaid Services - Quality Metrics Centers for Medicare & Medicaid Services (CMS) FY 2013 The core measures that the hospital tracks include acute myocardial infarction (AMI), heart failure (HF), and surgical care infection prevention (SCIP). In each of these measures, the hospital has exceeded national averages. Concurrent data acquisition is in place with data elements reviewed daily. Variances are also managed daily with education and/or process design review and modification. HEART ATTACK QUALITY INDICATOR HEART ATTACK (ACUTE MYOCARDIAL INFARCTION) NATIONAL TEXAS BHVH AMI Bundle 97% 97.5% 100% Aspirin at arrival 99% 100% 100% Aspirin at discharge 99% 100% 100% ACEI or ARB for LVSD 98% 100% 100% Adult smoking cessation advice/counseling 100% 100% 100% Beta blocker at discharge 98% 100% 100% SOURCE of National and State benchmarks: CMS Benchmark for Q HEART FAILURE QUALITY INDICATOR HEART FAILURE NATIONAL TEXAS BHVH CHF Bundle 97% 97% 100% All discharge instructions 94% 94% 100% Evaluation of LVS function 99% 100% 100% ACEI or ARB for LVSD 97% 100% 100% Adult smoking cessation advice/counseling 99% 99% 100% SOURCE of National and State benchmarks: CMS Benchmark for Q SURGICAL INFECTION QUALITY INDICATOR BHVH has exceeded state and national benchmarks in every core measure. SURGICAL INFECTION IMPROVEMENT PROJECT NATIONAL TEXAS BHVH SCIP All or None Bundle 96% 95% 100% Antibiotic received within one hour of incision 99% 100% 100% Antibiotic selection 99% 100% 100% Antibiotic discontinued within 24 hours 98% 100% 100% Appropriate hair removal 100% 100% 100% Beta blocker use preoperatively 97% 100% 100% 100% SOURCE of National and State benchmarks: CMS Benchmark for Q QUALITY 13 BAYLOR HEART AND VASCULAR SERVICES AT DALLAS

14 Cardiovascular Surgical Procedures Baylor Heart and Vascular Services at Dallas offers advanced surgical procedures and the highly specialized care required for treatment of complex cardiovascular issues. This includes several specialized programs and Centers of Excellence for specific cardiovascular conditions such as valve disorders, arrhythmia care and heart failure issues. Coronary Artery Disease Treatments Clampless proximal coronary artery bypass grafting (CABG) anastomosis surgeons on the medical staff of Baylor Dallas have pioneered methods and devices for making a proximal vein-to-aorta anastomosis without clamping the aorta. Clinical studies, some conducted at Baylor Dallas, have shown an association of this technique with fewer strokes in selected patients. Off-pump coronary artery bypass grafting an alternative to traditional bypass surgery (CABG) that can eliminate the use of the heart-lung machine. Surgeons on the medical staff of Baylor Dallas have researched methods that allow them to sew the bypass onto the heart while it continues to beat. Off-pump surgery may reduce the risk of bleeding and mortality in selected patients. Endoscopic vessel harvesting for appropriate bypass patients, research conducted at Baylor Dallas has shown that harvesting a leg vessel endoscopically can virtually eliminate leg discomfort and infection, as well as decrease length of hospital stay and time to begin walking again. Intraoperative fluorescence angiography surgeons on the medical staff of Baylor Dallas have adopted this technique that measures blood flow to the heart during an operation. Left ventricular remodeling surgeons on the medical staff of Baylor Dallas have championed the use of an inflatable heart model to guide surgeons in remodeling the left ventricle in cases where a patient has experienced a heart attack that leaves them with a portion of the left ventricle thin and even ballooning outward (a left ventricular aneurysm). Transmyocardial laser revascularization treatment aimed at improving blood flow to areas of the heart that cannot be treated by angioplasty or other surgery. Surgeons on the medical staff of Baylor Dallas use a special carbon dioxide laser to create small channels in the heart muscle, improving blood flow in the heart. QUALITY 14 BAYLOR HEART AND VASCULAR SERVICES AT DALLAS

15 SURGICAL PROCEDURES CARDIAC SURGERY VOLUME FY 2013 Valve Surgery 138 Coronary Artery Bypass Grafting (CABG Isolated and Concomitant) 251 HEART PORT SURGERY FY 2013 Total Heart Port Surgeries 23 Minimally Invasive Port Access AVR 16 ISOLATED CABG MORTALITY: PRIMARY VS RE-OPERATION BUMC Risk Adjusted STS Performance Primary Isolated ReOp 3.0% 1.9% Re-operation CABG ReOp 0.0% 3.7% AORTIC SURGERY VOLUMES FY 2013 Ascending and Arch Aneurysm 29 Thoracic and Descending Aneurysm 1 DISTRIBUTION OF SURGERIES TOTAL (2007 JUNE 2013) CAB+Valve 465 CAB other 182 CAB Oth CAB + Va DISTRIBUTION OF MITRAL VALVE REPLACEMENT (MVR) vs MITRAL VALVE REPAIR (MVRrp) 2007 JUNE 2013 FY 2013 Iso Valves 845 Iso CABG 2248 Iso Valve Iso CABG MVRrp 59.6% MVR 40.9% MVRrp 62.2% MVR 37.8% AVR SURGERY MVRpr MVR 2007 June MVRrp FY2013 MVR 137 QUALITY 15 BAYLOR HEART AND VASCULAR SERVICES AT DALLAS

16 Performance Report Performance Report FY 2013 Baylor Hamilton Heart and Vascular Hospital (BHVH) also monitors several other quality indicators in atrial fibrillation and percutaneous interventional cardiology. These diagnoses require several evidence-based measures to be in place to assure quality of care. The hospital s data is collected concurrently and reviewed daily. The hospital has exceeded national standards in these areas as well. BHVH also participates in preventive health measures through the American Heart Association. This program requires several indicators of preventive health to be monitored as part of secondary prevention of heart disease. The hospital has exceeded national averages in these areas. Metrics are incorporated into the pre-printed order sets that are utilized for patient care to assure that these elements of care are hardwired into our daily activities. BHVH leadership, clinicians and staff also routinely participate in process improvement projects through Baylor Health Care System 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 QUALITY 16 BAYLOR HEART AND VASCULAR SERVICES AT DALLAS

17 PERFORMANCE REPORT FY 2013 ATRIAL FIBRILLATION PERCENTAGE BETA BLOCKERS IN VASCULAR SURGERY PERCENTAGE Coumadin at discharge 100% Patient follow-up 100% Teaching smoking cessation 100% PERCUTANEOUS CORONARY INTERVENTION PERCENTAGE Lipid lowering medication at discharge 100% Plavix at discharge 100% ASA at discharge 99.8% Teaching smoking cessation at discharge 100% Prior to surgery 100% Recovery room 100% Speciality care room 100% At discharge 100% AHA GET WITH THE GUIDELINES PERCENTAGE HbA1c>7 outpatient diabetic referral 100% HbA1c>7 letter to PCP 100% ADA diet orders for diabetic patients 86% VACCINATIONS PERCENTAGE Pneumococcal vaccinations 96.65% Influenza vaccinations 98.66% IN-HOSPITAL MORTALITY FY 2013 EP/PACEMAKER/ICD CASE COUNT IN-LAB PERCENT POST PROCEDURE PERCENT Pacemaker Only % % Event Recorder % 0 0% ICD Only % % EP Cases % 0 0% TOTAL % % CATHETERIZATION LAB CASE COUNT IN-LAB PERCENT POST PROCEDURE PERCENT Diagnostic Cath Only % % Diagnostic Peripheral Only % % Cardiac Intervention % % Peripheral Intervention % % Peripheral Diagnostic w/ Cardiac Procedures % % TOTAL % % QUALITY 17 BAYLOR HEART AND VASCULAR SERVICES AT DALLAS

18 Readmissions READMISSIONS TO BHVH FY 2013 CAUSE/PROCEDURE NO. OF CASES PERCENT Lead Dislodgement % Pacemaker Infection % Another related procedure % Other % Re-ablation % EP Ablation Same site % Different site % Lead Dislodgement % ICD Only Infection % Another ICD related procedure % Other % Coronary Interventions Same Vessel % Coronary Angiogram Return for Intervention % Early readmission has been identified as a major source of unnecessary healthcare expenditures. At BHVH we have implemented focused programs on providing coordinated care pathways applying evidence based medicine to achieve quality clinical outcomes. Our care model is team based and we are very proud of the outcomes we provide for our patients. Kevin Wheelan, MD, Chief-of-Staff QUALITY 18 BAYLOR HEART AND VASCULAR SERVICES AT DALLAS

19 Interdisciplinary Quality and Safety Committee Interdisciplinary Quality and Safety Committee Baylor Heart and Vascular Hospital has selected multiple quality indicators, including nurse-sensitive indicators that are monitored and reported monthly on a performance report card. This report card is reviewed in multiple forums, including our shared governance councils and Medical Leadership meetings. This report is also reviewed in quarterly all-employee meetings. Actions are taken in areas identified as improvement opportunities. INFECTION REPORT FY 2013 NATIONAL HEALTHCARE SAFETY NETWORK (NHSN) NO. PROCEDURES BHVH (RATE PER 100 PROCEDURES) BENCHMARK* (RATE PER 100 PROCEDURES) Abdominal aortic aneurysm Carotid endarterectomy Peripheral vascular bypass Pacemaker/ICD *CDC/NHSN 2009 published risk stratified rates. **includes transplant patient population. National benchmarks were last published using a risk stratified rate in 2009 (included reported data). Rates are calculated by a risk score of 0-4 with 4 being the patient with the highest risk factors. Some procedures are reported as a combined rate as there is very little variance, and others are reported by a range as there is more variance. In the future, surgical site infection rates will be compared to a national standardized infection ratio (SIR) for benchmarking. We have identified a clustering of infections in both the carotid endarterectomies and pacemaker/icd procedures for this fiscal year and have completed a multi-disciplinary epidemiological investigation. We have investigated the following during the clusters: Sterile technique in the OR Sterile processing practices Comparison of current practices with Association of perioperative Registered Nurses (AORN) recommended practices Process for environmental disinfection American Institute of Architects (AIA) Ventilation standards Review of Healthcare Infection Control Practices Advisory Committee (HICPAC) Guidelines for Prevention of Surgical Site Infections CORE MEASURE IMMUNIZATION TX AVERAGE US AVERAGE BHVH IMM1-a: Pneumococcal Immunization Source of National and State benchmarks: CMS Benchmarks for Q QUALITY 19 BAYLOR HEART AND VASCULAR SERVICES AT DALLAS

20 Patient Falls Statistical process control charts are utilized to analyze the variance in fall incidence. The data subset has consistently trended below the NDNQI National Comparative Information mean for bed size <100. The fall rate is consistently below the NDNQI benchmark. In addition, the injury rate for the Med-Surg group has remained below the NDNQI benchmark. BHVH patient falls ARE FEWER THAN national benchmarks TOTAL FALLS PER 1,000 PATIENT DAYS Q11 3Q11 4Q11 1Q12 2Q12 3Q12 4Q12 1Q13 0 AVERAGE # OF FALLS Baylor Hamilton Heart and Vascular Hospital National Comparative Information - Bed Size <100 INJURY FALLS PER 1,000 PATIENT DAYS Q11 3Q11 4Q11 1Q12 Baylor Hamilton Heart and Vascular Hospital 2Q12 3Q12 4Q12 1Q13 National Comparative Information - Bed Size < AVERAGE # OF INJURY FALLS QUALITY 20 BAYLOR HEART AND VASCULAR SERVICES AT DALLAS