Quality Report


Quality Report

Baylor Regional Medical Center at Grapevine

DBA: Baylor Scott & White Medical Center- Grapevine
HCO ID: 9069
1650 W COLLEGE ST
Grapevine, TX, 76051-3565
(817) 329-2500
www.bswhealth.com/grapevine
Summary of Quality Information

Accreditation Programs

View Accreditation History
Gold Seal
Hospital
Accreditation Decision
Effective Date
3/11/2023
Last Full Survey Date
3/10/2023
Last On-Site Survey Date
3/10/2023

Advanced Certification Programs

View Certification History
Gold Seal
Primary Stroke Center
Certification Decision
Effective Date
12/1/2021
Last Full Survey Date
11/30/2021
Last On-Site Survey Date
11/30/2021
Gold Seal
Thrombectomy-Capable Stroke Center
Certification Decision
Effective Date
8/4/2023
Last Full Survey Date
5/16/2023
Last On-Site Survey Date
5/16/2023

Core Certification Programs

Gold Seal
Chest Pain
Certification Decision
Effective Date
2/18/2023
Last Full Survey Date
2/17/2023
Last On-Site Survey Date
2/17/2023

Sites

Baylor Regional Medical Center at Grapevine
DBA: Baylor Scott & White Cardiac Rehabilitation -Grapevine
1600 W College St, Ste 435, Ste 680
Grapevine, TX, 76051

Available Services

  • Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

  • Baylor Scott & White Specialty Center- Grapevine

Baylor Regional Medical Center at Grapevine
DBA: Baylor Scott & White Women's Imaging Center - Grapevine
1631 Lancaster Dr, Ste 130
Grapevine, TX, 76051-3586

Available Services

  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Baylor Regional Medical Center at Grapevine
DBA: Baylor Scott & White Pain Management Center – Grapevine
1615 Lancaster Dr, Ste 150
Grapevine, TX, 76051-2111

Available Services

  • Anesthesia (Outpatient )
  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Baylor Regional Medical Center at Grapevine
DBA: Baylor Scott & White Medical Center- Grapevine
1650 W College St
Grapevine, TX, 76051

Available Services

  • Cardiac Catheterization Lab (Surgical Services )
  • Cardiovascular Unit (Inpatient )
  • Coronary Care Unit (Inpatient )
  • CT Scanner (Imaging/Diagnostic Services )
  • Dialysis Unit (Inpatient )
  • Ear/Nose/Throat Surgery (Surgical Services )
  • EEG/EKG/EMG Lab (Imaging/Diagnostic Services )
  • Gastroenterology (Surgical Services )
  • GI or Endoscopy Lab (Imaging/Diagnostic Services )
  • Gynecological Surgery (Surgical Services )
  • Gynecology (Inpatient )
  • Hazardous Medication Compounding (Inpatient )
  • Hematology/Oncology Unit (Inpatient )
  • Inpatient Unit (Inpatient )
  • Interventional Radiology (Imaging/Diagnostic Services )
  • Labor & Delivery (Inpatient )
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services )
  • Medical /Surgical Unit (Inpatient )
  • Medical ICU (Intensive Care Unit )
  • Neurosurgery (Surgical Services )
  • Non-Sterile Medication Compounding (Inpatient )
  • Normal Newborn Nursery (Inpatient )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Orthopedic Surgery (Surgical Services )
  • Orthopedic/Spine Unit (Inpatient )
  • Outpatient Clinics (Outpatient )
  • Plastic Surgery (Surgical Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Sleep Laboratory (Sleep Laboratory )
  • Sterile Medication Compounding (Inpatient )
  • Surgical Unit (Inpatient )
  • Teleradiology (Imaging/Diagnostic Services )
  • Thoracic Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Chest Pain
  • Thrombectomy-Capable Stroke Center

Organization Commentary

Mr. Naman Mahajan, President

"JCAHO has chosen not to display Inpatient Mortality Rates and all Time Measures in this release of the information. This data was submitted to JCAHO by our hospital, but is not being displayed because the national and state data for mortality rates does not consistently consider patient risk factors and because there is currently no benchmark against which to compare the time measures." Baylor Medical Center @ Grapevine H9069

Cooperative Agreements

Hospital - Accredited by American College of Surgeons-Commission on Cancer (ACoS-COC)

National Patient Safety Goals and National Quality Improvement Goals

Symbol Key

  • starThis organization achieved the best possible results
  • plusThis organization's performance is better than the target range/value
  • checkThis organization's performance is similar to the target range/value
  • minusThis organization's performance is worse than the target range /value
  • naThis measure is not applicable for this organization
  • ndNot displayed

Measures Footnote Key

  1. The measure or measure set was not reported.
  2. The measure set does not have an overall result.
  3. The number is not enough for comparison purposes.
  4. The measure meets the Privacy Disclosure Threshold rule.
  5. The organization scored above 90% but was below most other organizations.
  6. The measure results are not statistically valid.
  7. The measure results are based on a sample of patients.
  8. The number of months with measure data is below the reporting requirement.
  9. The measure results are temporarily suppressed pending resubmission of updated data.
  10. Test Measure: a measure being evaluated for reliability of the individual data elements or awaiting National Quality Forum Endorsement.
  11. There were no eligible patients that met the denominator criteria.
  12. The measure rate is within optimal range.

Symbol Key

  • starThis organization achieved the best possible results
  • plusThis organization's performance is better than the target range/value
  • checkThis organization's performance is similar to the target range/value
  • minusThis organization's performance is worse than the target range/value
  • naThis measure is not applicable for this organization
  • ndNot displayed

Measures Footnote Key

  1. The measure or measure set was not reported.
  2. The measure set does not have an overall result.
  3. The number is not enough for comparison purposes.
  4. The measure meets the Privacy Disclosure Threshold rule.
  5. The organization scored above 90% but was below most other organizations.
  6. The measure results are not statistically valid.
  7. The measure results are based on a sample of patients.
  8. The number of months with measure data is below the reporting requirement.
  9. The measure results are temporarily suppressed pending resubmission of updated data.
  10. Test Measure: a measure being evaluated for reliability of the individual data elements or awaiting National Quality Forum Endorsement.
  11. There were no eligible patients that met the denominator criteria.
  12. The measure rate is within optimal range.

* This information can also be viewed at Hospital Compare.

**      Indicates per 1000 hours of patient care.
***   The measure was not in effect for this quarter.
----   Null value or data not displayed.

Hospital 2023 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Reporting Period: January 2022 - December 2022
Perinatal Care National Comparison: nd 2 Statewide Comparison: nd 2

New Changes to Quarterly Measure

Download Quarterly Measure Results

* State results are not calculated for the National Patient Safety Goals.