THA Tennessee Center for Patient Safety
- Chris Clarke, Senior Vice President for Clinical and Professional Services
- Patrice Mayo, Vice President for Operations
- Jackie Moreland, Clinical Quality Improvement Specialist
- Rhonda Dickman, Clinical Quality Improvement Specialist
- Jennifer McIntosh, Clinical Quality Data Manager
- Teresa Benedetti, Executive Assistant
The Tennessee Hospital Association’s Tennessee Center for Patient Safety (TCPS) was launched in 2007 to advance the adoption of proven evidence-based strategies that improve the reliability, safety, and quality of care received in Tennessee hospitals. The Tennessee Hospital Association (THA) Board of Directors is committed to a board aim of zero preventable harm and the Partnership for Patients goals of reducing hospital-acquired conditions by 20% and preventable readmissions by 12%. One hundred and twelve (112) Tennessee hospitals are participating in programs instituted by the TCPS, and those hospitals serve more than ninety percent of all patients admitted to hospitals in the state. The TCPS staff provides support to hospitals through education, coaching, site visits, best practice sharing, expert resources, and matching hospital mentors with hospitals on improvement efforts.
TCPS is guided by an advisory council comprised of hospital and health system CEOs, other leaders representing healthcare disciplines including medicine, quality, nursing, infection control, and risk management. The advisory council includes partner organizations, representing healthcare facilities, professional associations, the Tennessee Department of Health (TDH), and the state Quality Improvement Organization (QIO). This diversely representative advisory council has been critical to the center’s success and sustainability, yielding engaged and active partnerships among professional associations and helping to align priorities for stakeholders in designing statewide initiatives.
Hospital Improvement Innovation Network (HIIN)
THA belongs to AHA’s Health Research Education Trust (HRET) for the HIIN program, joining over 30 other state hospital associations. Nearly 80 hospitals have committed to work with the THA HIIN through 2019. THA HIIN provides hospitals with national resources, local expertise, and best practice sharing. Through the CMS’ Innovation Center Partnership for Patients (PFP), TCPS expanded its collaborative work to new topics and is providing a range of quality improvement support activities designed to meet hospitals’ needs for patient safety improvement projects to reduce hospital-acquired conditions along with patient safety culture tools. In addition to safety culture, leadership, and patient/family engagement, TCPS focuses on the following topics: adverse drug events (ADE), catheter-associated urinary tract infections (CAUTI), central line-associated blood stream infections (CLABSI), injuries from falls, pressure injuries, surgical-site infections (SSI), venous thromboembolism (VTE), ventilator-associated events (VAE), readmissions, Methicillin-resistant Staphylococcus aureus (MRSA), C. difficile, sepsis, and worker safety.
Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety (HSOPS)
The AHRQ HSOPS survey measures employee perceptions of patient safety and helps hospitals and healthcare systems assess the culture of patient safety at their organization. TCPS offers the culture survey to hospitals free of charge. Hospitals receive aggregate reports with comparisons to national benchmarks to identify strengths and opportunities for targeted improvements as well as tools to create an action plan. Tennessee hospitals have completed the survey 366 times, representing over 93,000 employee responses.
Tennessee Department of Health Breastfeeding Grant
THA was awarded a five-year subcontract from the TDH in 2013 to enhance breastfeeding education and support for Tennessee hospitals to improve breastfeeding adoption rates in Tennessee. THA provides free online breastfeeding education modules and has enrolled over 2,800 hospital staff and providers. The public relations and awareness campaign includes resources, materials, and a monthly OB education program.
Data Collection and Reporting
TCPS provides CEOs at acute care hospitals with a monthly scorecard showing their hospital performance over time on THA’s major quality improvement initiatives. Sources for data reporting include the Center for Disease Control (CDC) National Healthcare Safety Network (NHSN), THA claims data, and THA’s Report Distributor. As a NHSN group, TCPS has direct access to hospital data through conferral of rights for reportable infections including CLABSI, CAUTI, SSI, MRSA, C. difficile, and VAP/VAE. TCPS has worked to build collection tools for EED, falls, pressure injuries, and ADE through the THA Report Distributor, which not only provides hospitals with state and national benchmarks but allows the export of raw data and criteria selections to tailor preferences and design. The THA Board of Directors adopted a position in 2012 to transparently share hospital performance on key topics at the board meetings to drive improvement efforts. Board comparison slides are posted to the THA Report Distributor in advance of the board meetings for review by key leaders designated by the hospital.
Tennessee Surgical Quality Collaborative (TSQC)
TSQC is a statewide collaborative among surgeons and hospitals to measure and improve surgical care in Tennessee using the American College of Surgeons’ (ACS) National Surgical Quality Improvement Program (NSQIP), the first nationally validated, risk-adjusted, outcomes-based program. The collaborative is a unique partnership between the Tennessee Chapter of the American College of Surgeons (TnACS) and THA's TCPS. The collaborative has grown to 23 hospitals in 2017. Initial funding for the collaborative was provided by the Blue Cross Blue Shield of Tennessee Health Foundation. THA provides support for the collaborative staffing and infrastructure and participation stipends to hospitals. The TSQC hospitals have shown significant improvements in both morbidity and mortality over the past 5 years. The mortality rate has improved by 34 percent since the inception of monitoring in January 2009 through 2015. TSQC has shown significant reductions in postoperative complications for surgical site infections, acute renal failure, sepsis, pneumonia and other respiratory complications, and urinary tract infections. Total morbidity has been reduced by 33.5% since 2009. The avoided costs from reducing complications are estimated at $2,357,707 per 1,000 cases or in 2015, $59.04 million. TSQC has been recognized nationally for the collaborative model and the improvements achieved.
Patient Safety Organization (PSO)
The TCPS Patient Safety Organization (PSO) provides a separate, secure environment where TCPS PSO member organizations can engage voluntarily in sharing and analysis of patient safety events and near misses without the threat of disclosure or increased liability. Through its listing as a federally certified PSO, the program provides expert analysis and feedback designed to identify trends, offer best practice approaches and other proven strategies to reduce risk and support improvement in the quality and safety of patient care. To date, 60 healthcare facilities are members of the TCPS PSO.
IHI Open School for Health Professionals
TCPS has purchased a group subscription and is providing free access to the Institute for Healthcare Improvement (IHI) Open School, as a benefit to employees and trustees of our safety partner hospitals. The purpose of the program is to best equip Tennessee hospitals with the tools and education necessary to improve the quality of care they provide. The Open School offers a range of online courses in the areas of quality improvement, patient safety, patient- and family-centered care, managing healthcare operations, and leadership. Users are able to select and complete as few or as many courses as they are interested in and earn certification or continuing education credit with over 30 continuing education hours for physicians, nurses, and pharmacists.
http://www.tnpatientsafety.com/ July 25, 2018