Baylor Medical School and Baylor Scott and White

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Preventing and Responding to Patient Harm

Measure name	Leapfrog's Standard	Hospital's Progress
Effective Leadership to Prevent Errors	Hospitals should take meaningful steps to raise awareness about patient safety, hold leadership accountable for reducing unsafe practices, provide resources to implement a patient safety program, and develop systems and structures to support action to improve patient safety. more	DECLINED TO RESPOND
Staff Work Together to Prevent Errors	Hospitals should assess their culture of safety and hold leadership accountable for implementing policies, procedures, and staff education to improve the culture of safety. more	DECLINED TO RESPOND
Support for Nursing Workforce	Hospitals should assess their nursing staff levels and core competencies, included nurses in leadership, and develop and implement plans to address any areas of improvement. more	DECLINED TO RESPOND
Handwashing	Hospitals should regularly monitor hand hygiene practices for everyone interacting with patients, and give feedback to ensure compliance. Hospitals should foster a culture of good hand hygiene, offer training and education, and provide equipment, such as paper towels, soap dispensers, and hand sanitizer. more	DECLINED TO RESPOND
Responding to Never Events	Hospitals should have a never events policy that includes all nine (9) actions that should occur following a "never event," which includes apologizing to the patient and not charging for costs associated with the never event. more	DECLINED TO RESPOND

Medication Safety

Measure name	Leapfrog's Standard	Hospital's Progress
Safe Medication Administration	Hospitals should have nurses and other clinicians use BCMA in all medical/surgical units, intensive care units, and labor and delivery units to scan the patient and medication prior to administration at least 95% of the time. The BCMA system includes decision support to prevent errors and the hospital has processes to prevent workarounds. more	DECLINED TO RESPOND
Safe Medication Ordering	Hospitals should enter at least 85% of inpatient medication orders through the CPOE system. more	DECLINED TO RESPOND
Medication Reconciliation	Hospitals should have a rate of unintentional medication discrepancies per medication that is lower than or equal to the 50th percentile (where lower performance is better) nationally. more	DECLINED TO RESPOND
Medication Documentation for Elective Outpatient Surgery Patients	Hospitals should document 90% or more of home medications, visit medications, and allergies/adverse reaction(s) in the patients' clinical record. more	DECLINED TO RESPOND

Healthcare Associated Infections

Measure name	Leapfrog's Standard	Hospital's Progress
Infection in the Blood	Hospitals should have fewer than expected central-line associated blood stream infections. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC's National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given various factors. A number lower than one means fewer infections than expected; a number more than one means more infections than expected. more	DECLINED TO RESPOND
	Show more on this hospital's performance Show less This hospital was asked to report its infection data directly to The Leapfrog Group and chose not to. However, some information about this hospital's infection record may be available through the Centers for Medicare and Medicaid Services.
Infection in the Urinary Tract	Hospitals should have fewer than expected catheter-associated urinary tract infections. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC's National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given various factors. A number lower than one means fewer infections than expected; a number more than one means more infections than expected. more	DECLINED TO RESPOND
C. difficile Infection	Hospitals should have fewer than expected colon infections from C. diff bacteria. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC's National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given various factors. A number lower than one means fewer infections than expected; a number more than one means more infections than expected. more	DECLINED TO RESPOND
	Show more on this hospital's performance Show less This hospital was asked to report its infection data directly to The Leapfrog Group and chose not to. However, some information about this hospital's infection record may be available through the Centers for Medicare and Medicaid Services.
MRSA Infection	Hospitals should have fewer than expected antibiotic resistant bacterial infections. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC's National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given various factors. A number lower than one means fewer infections than expected; a number more than one means more infections than expected. more	DECLINED TO RESPOND
	Show more on this hospital's performance Show less This hospital was asked to report its infection data directly to The Leapfrog Group and chose not to. However, some information about this hospital's infection record may be available through the Centers for Medicare and Medicaid Services.
Surgical Site Infection After Colon Surgery	Hospitals should have fewer than expected surgical site infections after major colon surgery. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC's National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given various factors. A number lower than one means fewer infections than expected; a number more than one means more infections than expected. more	DECLINED TO RESPOND
	Show more on this hospital's performance Show less This hospital was asked to report its infection data directly to The Leapfrog Group and chose not to. However, some information about this hospital's infection record may be available through the Centers for Medicare and Medicaid Services.

Maternity Care

Measure name	Leapfrog's Standard	Hospital's Progress
Cesarean Sections	This is defined as first-time mothers giving birth to a single baby, at full-term, in the head-down position deliver their babies through a C-section. Hospitals should have a rate of C-sections of 23.6% or less. more	DECLINED TO RESPOND
Early Elective Deliveries	This is defined as mothers being scheduled for cesarean sections or medication inductions prior to 39 weeks gestation without a medical reason. Hospitals should have a rate of early elective deliveries of 5% or less. more	DECLINED TO RESPOND
Episiotomies	This is defined as mothers having an incision made in the perineum (the birth canal) during childbirth. Hospitals should have a rate of episiotomies of 5% or less. more	DECLINED TO RESPOND
Screening Newborns for Jaundice Before Discharge	Hospitals should screen at least 90% of babies for jaundice. more	DECLINED TO RESPOND
Preventing Blood Clots in Women Undergoing Cesarean Section	At least 90% of women undergoing a cesarean section receive treatment to prevent blood clots. more	DECLINED TO RESPOND
High-Risk Deliveries	Hospitals should deliver at least 50 very-low birth weight babies per year OR the hospital must maintain a lower-than-average morbidity/mortality rate for very-low birth weight babies. more	DECLINED TO RESPOND

Pediatric Care

Measure name	Leapfrog's Standard	Hospital's Progress
Experience of Children and Their Parents	Hospitals should perform better than most hospitals in five (5) areas: Communication with Parent – Communication about your child's medicines Communication with Parent – Keeping you informed about your child's care Communication with Child – How well nurses communicate with your child Communication with Child – How well doctors communicate with your child Attention to Safety and Comfort – Preventing mistakes and helping you report concerns. more	DECLINED TO RESPOND
Radiation Dose for Abdomen/Pelvis Scans	Hospitals should use a CT radiation dose for routine CT scans of the abdomen and pelvis that falls within national benchmarks. more	DECLINED TO RESPOND
Radiation Dose for Head Scans	Hospitals should have an average radiation dose for routine CT scans of the head that falls within national benchmarks. more	DECLINED TO RESPOND

Critical Care

Measure name	Leapfrog's Standard	Hospital's Progress
Specially Trained Doctors Care for Critical Care Patients	Hospitals should have intensivists present on-site at least eight hours a day, seven days per week or has intensivists present via 24/7 telemedicine with some on-site intensivist presence. When not in the ICU, the intensivist immediately responds to calls and has another physician or trained clinician who can immediately reach the patient. more	DECLINED TO RESPOND

Complex Adult and Pediatric Surgery

Measure name	Leapfrog's Standard	Hospital's Progress
Carotid Artery Surgery	Hospitals should perform at least 20 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 10 procedures annually. more	DECLINED TO RESPOND
Mitral Valve Repair and Replacement	Hospitals should perform at least 40 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 20 procedures annually. In addition, hospitals should participate in a national clinical registry and achieve the same or better outcomes when compared to others who also perform this procedure. more	DECLINED TO RESPOND
Open Aortic Procedures	Hospitals should perform at least 10 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 7 procedures annually. more	DECLINED TO RESPOND
Bariatric Surgery for Weight Loss	Hospitals should perform at least 50 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 20 procedures annually. more	DECLINED TO RESPOND
Esophageal Resection for Cancer	Hospitals should perform at least 20 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 7 procedures annually. more	DECLINED TO RESPOND
Lung Resection for Cancer	Hospitals should perform at least 40 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 15 procedures annually. more	DECLINED TO RESPOND
Pancreatic Resection for Cancer	The hospital performs at least 20 procedures annually, and as part of their process for privileging surgeons, ensures that each surgeon performs at least 10 procedures annually. more	DECLINED TO RESPOND
Rectal Cancer Surgery	Hospitals should perform at least 16 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 6 procedures annually. more	DECLINED TO RESPOND
Total Hip Replacement Surgery	Hospitals should perform at least 50 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 25 procedures annually. more	DECLINED TO RESPOND
Total Knee Replacement Surgery	Hospitals should perform at least 50 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 25 procedures annually. more	DECLINED TO RESPOND
Congenital Heart Surgery for Infants (Norwood Procedure)	Hospitals should perform at least 8 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 5 procedures annually. more	DECLINED TO RESPOND

Care for Elective Outpatient Surgery Patients

Measure name	Leapfrog's Standard	Hospital's Progress
Elective Outpatient Surgery Recovery Staffing - Adult	Hospitals should ensure that a specially certified clinician and at least one physician or nurse anesthetist are present and immediately available while an adult patient is present until discharge. more	DECLINED TO RESPOND
Elective Outpatient Surgery Recovery Staffing - Pediatric	Hospitals should ensure that a specially certified clinician and at least one physician or nurse anesthetist are present and immediately available while a pediatric patient is present until discharge. more	DECLINED TO RESPOND
Safe Surgery Checklist - Elective Outpatient Surgery	Hospitals should go through all the elements of a complete safe surgery checklist on all patients every time a procedure is performed. more	DECLINED TO RESPOND
Experience of Patients Undergoing Elective Outpatient Surgery	Hospitals should perform better than most on four (4) areas including: (a) facilities and staff (b) communication about the procedure, (c) patients' overall rating of the facility, and (d) patients willingness to recommend the facility. more	DECLINED TO RESPOND

Baylor Scott & White Medical Center - College Station

700 Scott & White Drive
College Station, Texas 77845

Baylor Medical School and Baylor Scott and White

Source: https://ratings.leapfroggroup.org/facility/details/67-0088/baylor-scott-white-medical-center---college-station-college-station-tx

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