TO: TCPS Safety Partners
FROM: Craig Becker
SUBJECT: THA Board Aim of Zero Preventable Harm
DATE: March 15, 2010
In 2008, Tennessee hospitals reported 490 central line infections. Statistically, this means hospitals potentially contributed to 59 patient deaths. Each one of these patients has a face, a family and aspirations for a long, full life.
The THA board of directors agrees these statistics are totally unacceptable, especially when these central line infections, like a lot of hospital-acquired infections, are preventable.
In addition, the media has picked up on this unacceptable problem. The recent release of the Consumer Report’s article, “Deadly Infections,” serves as a stark reminder to all safety partners, CEOs and their communities that hospitals have the obligation to make hospital care safer.
In December 2009, the THA board adopted a strategic aim of zero preventable harm and set aggressive, but attainable, incremental goals for reducing harm by focusing on hospital-acquired infections. The board set specific targets for central line infections, hospital onset of MRSA and surgical care improvement strategies. These targets align with THA’s TennesseeCenter for Patient Safety initiatives and your work underway to support hospitals’ ongoing efforts to reduce infections.
The THA board outlined steps that should be taken by individual hospitals and health systems. THA staff, under the direction of the board, also has been asked to meet these infection reduction targets. It is the board’s belief that Tennessee hospitals can achieve a zero hospital-acquired infection rate with a renewed effort by all hospital safety partners.
Over the next several weeks, hospitals will be receiving a state scorecard and specific information about their organization’s performance from THA. The board hopes hospitals will pay attention to their own numbers and focus on zero harm initiatives.
In order to have current data, the THA board is asking hospitals to share monthly data for all the safety center initiatives – CLBSI, MRSA and SCIP – in order to provide timely feedback and updates to CEOs and the THA board on hospitals’ progress. In order to share best practices, the board has recommended that all data be unblinded in reports to the board. It is understood that sharing hospital-specific data requires your CEO’s permission and must be done on a voluntary basis. CEOs have been asked to sign a permission agreement and return the form by March 22 to llee@tha.com.
The TennesseeCenter for Patient Safety will continue to provide collaboratives, tools and resources to support hospital teams in their improvement work. THA is taking steps to make this important work more visible by engaging medical staff leaders through the newly formed chief medical officer (CMO) networking group, discussing quality and safety at district meetings, and highlighting successful teams and strategies through various THA publications.
CEOs’ leadership is mission critical in achieving these aims. Your CEO has been asked to review the THA board’s recommendations below and create an action plan to eliminate preventable harm at their hospitals.
CEO Leadership:
· Every CEO commit to making changes in their own organization to achieve the aim and specific targets.
· Every CEO communicate aim and focus to all within their organization.
· Every CEO take personal responsibility/accountability for aim and meeting targets.
· Every CEO work to achieve a culture of safety where staff are encouraged and supported to learn from errors.
· Every CEO be available to share best practices to expedite learning.
· Devote 25 percent of hospital board meetings to quality and safety.
· Performance data for key targets (CLBSI, MRSA, and SCIP) added to organization scorecards, leadership and trustee reports and regular feedback provided to all staff.
· Report patients harmed, not just rates/benchmarks.
· Commit time and resources to support needed system changes.
Should you have any questions, please call me at 615-401-7431, Chris Clarke at 615-401-7437 or Darlene Swart at 615-401-7460.
Let’s all work together to eradicate preventable hospital-acquired infections!
Click here to read the board recommendations from the THA Board Taskforce on Quality and Patient Safety