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William P. Clements Jr. University Hospital

6201 Harry Hines Blvd
Dallas, Texas 75390

Survey Submission Date: September 13, 2024

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Patient Safety

Patient Rights and Ethics

Measure name	Leapfrog’s Standard	Hospital’s Progress
Billing Ethics	Hospitals should provide patients with complete billing information and access to a representative that can quickly resolve billing issues. In addition, hospitals should not sue patients over late or unpaid bills. more	ACHIEVED THE STANDARD
	Show more on this hospital’s performance Show less This hospital provides a detailed bill within 30 days of receiving insurance payments: Yes This hospital provides access to a representative who can quickly investigate billing errors and establish payment plans: Yes This hospital sues patients: No
Health Care Equity	Hospitals should examine their own data to identify any differences in processes or outcomes for patients of different races and ethnicities, and patients who speak different languages. Hospitals should also put action plans in place if differences are identified. more	CONSIDERABLE ACHIEVEMENT
Informed Consent	Hospitals should ensure that all patients are fully aware of risks and alternatives prior to procedures. more	SOME ACHIEVEMENT
	Show more on this hospital’s performance Show less All staff involved in the informed consent process achieve the appropriate training: No Doctors explain expected difficulties and recovery time and allow patients to ask questions: Yes Doctors involved in the procedure are listed on the consent form, and patients are notified if the doctor will be absent and if trainees will be involved: Yes Consent forms are written at a 6th grade reading level: No, all forms are at a 9th grade reading level or lower Staff ask patients about their preferred language for decision-making and make a trained medical interpreter available if appropriate: Yes Doctors use the "teach back method" to ensure patients understand what will be performed and what are the risks: Yes
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	ACHIEVED THE STANDARD

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Patient and Family Caregiver Initiated Rapid Response Team	This hospital does not have a patient and family caregiver initiated rapid response team. more
Protocol to collect and respond to patient-reported concerns about care	This hospital does have a protocol to collect and respond to patient-reported concerns about care. more

Preventing Patient Harm

Measure name

Leapfrog’s Standard

Hospital’s Progress

Nursing and Bedside Care for Patients

Hospitals should have nurse staffing plans in place that ensure there are enough nurses of all types (i.e., registered nurses, licensed practical nurses, or unlicensed assistive personnel) to provide direct care to patients in medical, surgical, or med-surg units each day.

ACHIEVED THE STANDARD

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Nursing Care for Patients

Hospitals should have nurse staffing plans in place that ensure there are enough registered nurses (RNs) to provide direct care to patients in medical, surgical, or med-surg units each day.

ACHIEVED THE STANDARD

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Percentage of Nursing Staff who are Registered Nurses (RNs)

Hospitals should have nurse staffing plans in place that ensure the proportion of nursing hours performed by registered nurses (RNs) is adequate.

CONSIDERABLE ACHIEVEMENT

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Percentage of Registered Nurses (RNs) who have a Bachelor’s Degree in Nursing

Hospitals should have a high proportion of highly trained and skilled registered nurses (RNs) who have an advanced nursing degree.

ACHIEVED THE STANDARD

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.

CONSIDERABLE ACHIEVEMENT

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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.

ACHIEVED THE STANDARD

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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.

ACHIEVED THE STANDARD

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Medication Safety

Measure name

Leapfrog’s Standard

Hospital’s Progress

Safe Medication Ordering

Hospitals should enter at least 85% of inpatient medication orders through the CPOE system, and should fully demonstrate their CPOE system meets the national safety standard for decision support.

ACHIEVED THE STANDARD

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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.

ACHIEVED THE STANDARD

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Safe Medication Administration

Hospitals should have nurses and other clinicians use BCMA in all medical/surgical units, intensive care units, labor and delivery units, pre-operative and post-anesthesia care 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.

ACHIEVED THE STANDARD

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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.

SOME ACHIEVEMENT

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Healthcare-Associated Infections

Measure name	Leapfrog’s Standard	Hospital’s Progress
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	ACHIEVED THE STANDARD
	Show more on this hospital’s performance Show less This hospital’s standardized infection ratio (SIR) is: 0.370
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	CONSIDERABLE ACHIEVEMENT
	Show more on this hospital’s performance Show less This hospital’s standardized infection ratio (SIR) is: 0.680
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	ACHIEVED THE STANDARD
	Show more on this hospital’s performance Show less This hospital’s standardized infection ratio (SIR) is: 0.375
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	ACHIEVED THE STANDARD
	Show more on this hospital’s performance Show less This hospital’s standardized infection ratio (SIR) is: 0.222
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	LIMITED ACHIEVEMENT
	Show more on this hospital’s performance Show less This hospital’s standardized infection ratio (SIR) is: 1.410

Specialty Care

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 have 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	ACHIEVED THE STANDARD
	Show more on this hospital’s performance Show less This hospital achieved the standard using on-site intensivist coverage.

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 Pediatric Abdomen/Pelvis Scans	Hospitals should have an average radiation dose for routine pediatric CT scans of the abdomen and pelvis that falls within national benchmarks. more	DECLINED TO RESPOND
Radiation Dose for Pediatric Head Scans	Hospitals should have an average radiation dose for routine pediatric CT scans of the head that falls within national benchmarks. 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	DOES NOT APPLY

Maternity Care

Measure name	Leapfrog’s Standard	Hospital’s Progress
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	CONSIDERABLE ACHIEVEMENT
Cesarean Sections	This is defined as first-time mothers giving birth to a single baby, at full-term, in the head-down position who deliver their babies through a C-section. Hospitals should have a rate of C-sections of 23.6% or less. more	SOME ACHIEVEMENT
	Show more on this hospital’s performance Show less This hospital's rate of Cesarean sections is 29.5%
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	ACHIEVED THE STANDARD
	Show more on this hospital’s performance Show less This hospital's rate of episiotomies is 1.1%
Screening Newborns for Jaundice Before Discharge	Hospitals should screen at least 90% of babies for jaundice. more	ACHIEVED THE STANDARD
	Show more on this hospital’s performance Show less This hospital's rate of screening newborns for jaundice before discharge is 100.0%
Preventing Blood Clots in Women Undergoing Cesarean Section	At least 90% of women undergoing a cesarean section receive treatment to prevent blood clots. more	LIMITED ACHIEVEMENT
	Show more on this hospital’s performance Show less This hospital's rate of preventing blood clots in women undergoing cesarean section is 89.7%

More Information

Number of Live Births	The hospital had 2,094 live births (i.e., liveborn infants) at this hospital location for the reporting time period. more
Midwives	This hospital does have certified nurse-midwives and/or certified midwives deliver newborns. more
Doulas	This hospital allows patients to bring their own doulas. more
Lactation Services	This hospital offers lactation services in the hospital and outpatient setting. more
Vaginal Delivery After Cesarean Section (VBAC)	This hospital does offer vaginal delivery after cesarean section (VBAC). more
Tubal Ligation	This hospital does offer tubal ligation during the labor and delivery admission. more
Policy to Prevent Early Elective Deliveries	This hospital does not have a policy to prevent early elective deliveries. more

Surgery

Complex Adult Surgery

Measure name	Leapfrog’s Standard	Hospital’s Progress
Carotid Endarterectomy	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	CONSIDERABLE ACHIEVEMENT
	Show more on this hospital’s performance Show less This hospital performed 39 carotid artery surgeries compared to Leapfrog’s standard of 20 procedures annually. As part of their process for privileging surgeons, this hospital does not ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 10 procedures annually for carotid artery surgery.
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	ACHIEVED THE STANDARD
	Show more on this hospital’s performance Show less This hospital performed 175 mitral valve repairs and replacements compared to Leapfrog’s standard of 40 procedures annually. As part of their process for privileging surgeons, this hospital does not ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 20 procedures annually for mitral valve repair and replacement. This hospital does participate in the Society of Thoracic's Surgeons Adult Cardiac Surgery Database. This hospital's outcome (absence of mortality and major morbidity) for mitral valve repairs and replacements is: Better than Expected.
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	CONSIDERABLE ACHIEVEMENT
	Show more on this hospital’s performance Show less This hospital performed 83 open aortic procedures compared to Leapfrog’s standard of 10 procedures annually. As part of their process for privileging surgeons, this hospital does not ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 7 procedures annually for open aortic procedures.
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	SOME ACHIEVEMENT
	Show more on this hospital’s performance Show less This hospital performed 2 bariatric surgeries for weight loss compared to Leapfrog’s standard of 50 procedures annually. As part of their process for privileging surgeons, this hospital does ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 20 procedures annually for bariatric surgeries for weight loss.
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	LIMITED ACHIEVEMENT
	Show more on this hospital’s performance Show less This hospital performed 12 esophageal resections for cancer compared to Leapfrog’s standard of 20 procedures annually. As part of their process for privileging surgeons, this hospital does not ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 7 procedures annually for esophageal resection for cancer.
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	CONSIDERABLE ACHIEVEMENT
	Show more on this hospital’s performance Show less This hospital performed 83 lung resections for cancer compared to Leapfrog’s standard of 40 procedures annually. As part of their process for privileging surgeons, this hospital does not ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 15 procedures annually for lung resection for cancer.
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	CONSIDERABLE ACHIEVEMENT
	Show more on this hospital’s performance Show less This hospital performed 56 pancreatic resections for cancer compared to Leapfrog’s standard of 20 procedures annually. As part of their process for privileging surgeons, this hospital does not ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 10 procedures annually for pancreatic resection for cancer.
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	CONSIDERABLE ACHIEVEMENT
	Show more on this hospital’s performance Show less This hospital performed 43 rectal cancer surgeries compared to Leapfrog’s standard of 16 procedures annually. As part of their process for privileging surgeons, this hospital does not ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 6 procedures annually for rectal cancer surgery.
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	CONSIDERABLE ACHIEVEMENT
	Show more on this hospital’s performance Show less This hospital performed 200 total knee replacement surgeries compared to Leapfrog’s standard of 50 procedures annually. As part of their process for privileging surgeons, this hospital does not ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 25 procedures annually for total knee replacement surgeries.
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	CONSIDERABLE ACHIEVEMENT
	Show more on this hospital’s performance Show less This hospital performed 141 total hip replacement surgeries compared to Leapfrog’s standard of 50 procedures annually. As part of their process for privileging surgeons, this hospital does not ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 25 procedures annually for total hip replacement surgeries.
Safe Surgery Checklist - Complex Surgery	Hospitals should go through all the elements of a complete safe surgery checklist on all patients every time a surgery is performed. more	LIMITED ACHIEVEMENT

Elective Outpatient Surgery - Adult

Gastroenterology (Stomach and Digestive)

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Procedure	Number of Procedures Performed Annually
Lower GI Endoscopies	48
Upper GI Endoscopies	127

General Surgery

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Procedure	Number of Procedures Performed Annually
Cholecystectomies and Common Duct Explorations	310
Hemorrhoid Procedures	57
Inguinal and Femoral Hernia Repairs	300
Laparoscopies	117
Lumpectomies and Quadrantectomies of Breast	15
Mastectomies	362
Other Hernia Repairs	200

Neurosurgery

Procedure	Number of Procedures Performed Annually
Spinal Fusion Procedures	68

Obstetrics and Gynecology

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Procedure	Number of Procedures Performed Annually
Cervix Procedures	46
Hysteroscopies	369
Uterus and Adnexa Laparoscopies	275

Ophthalmology (Eyes)

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Procedure	Number of Procedures Performed Annually
Anterior Segment Eye Procedures	350
Posterior Segment Eye Procedures	223
Other Eye Procedures	624

Orthopedic (Bones and Joints)

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Procedure	Number of Procedures Performed Annually
Finger, Hand, Wrist, Forearm, and Elbow Procedures	563
General Orthopedic Procedures	24
Hip Procedures (Does not include total hip replacements – see Total Joint Replacement)	2
Knee Procedures (Does not include total hip replacements – see Total Joint Replacement)	216
Shoulder Procedures	545
Spine Procedures	174
Toe, Foot, Ankle, and Leg Procedures	357

Otolaryngology (Ear, Nose, Mouth, and Throat)

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Procedure	Number of Procedures Performed Annually
Ear Procedures	236
Mouth Procedures	131
Nasal and Sinus Procedures	803

Plastic and Reconstructive Surgery

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Procedure	Number of Procedures Performed Annually
Breast Repairs and Reconstructions	801
Skin Grafts and Repairs	517

Urology (Urinary Tract, Male Reproductive)

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Procedure	Number of Procedures Performed Annually
Circumcisions	40
Cystourethroscopies	1,108
Male Genital Procedures	73
Urethra Procedures	66
Vaginal Repair Procedures	147

Elective Outpatient Surgery - Pediatric

Orthopedic (Bones and Joints)

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Procedure	Number of Procedures Performed Annually
Finger, Hand, Wrist, Forearm, and Elbow Procedures	6
General Orthopedic Procedures	0
Knee Procedures	11
Shoulder Procedures	6
Toe, Foot, Ankle, and Leg Procedures	3

Otolaryngology (Ear, Nose, Mouth, and Throat)

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Procedure	Number of Procedures Performed Annually
Ear Procedures	7
Mouth Procedures	45
Nasal and Sinus Procedures	45
Pharynx, Adenoid, and Tonsil Procedures	0

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 is present and immediately available while an adult patient is present until discharge.

ACHIEVED THE STANDARD

Elective Outpatient Surgery Recovery Staffing - Pediatric

Hospitals should ensure that a specially certified clinician is present and immediately available while pediatric patient is present until discharge.

ACHIEVED THE STANDARD

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.

LIMITED ACHIEVEMENT

Experience of Patients Undergoing Elective Outpatient Surgery

Hospitals should perform better than most on four (4) areas including regarding the experience of adult patients: (a) facilities and staff (b) communication about the procedure, (c) patients’ overall rating of the facility, and (d) patients' willingness to recommend the facility.

ACHIEVED THE STANDARD

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Unplanned Hospital Visits after Colonoscopy

Unplanned hospital visits can occur when patients experience complications after a colonoscopy procedure. Facilities should have a rate of unplanned hospital visits that is lower than most hospitals and surgery centers.

ACHIEVED THE STANDARD

William P. Clements Jr. University Hospital

6201 Harry Hines Blvd
Dallas, Texas 75390

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