Aim: Advance the adoption of

proven strategies to improve the reliability, safety and quality of care received by patients in Tennessee hospitals

Tennessee Center for Patient SafetyObjectives Accelerate adoption of evidence based

strategies that improve the reliability, safety and quality of care received by patients

Focus on projects designed to measurably improve care and proactively position hospitals for pay for performance models

Provide training for hospital leaders to advance their organizations’ culture of safety

Provide visibility to hospital’s commitment to quality and patient safety

Initiatives 3 year grant from the BCBS TN Health

Foundation to fund the start-up of the center and two primary initiatives: Collaborative to reduce hospital acquired

infections Nursing Partnership on work environment

and patient safety

Ongoing support for IHI 5 Million Lives Campaign

TN NSQIP Surgical Consortium

Tennessee Nursing Partners Collaborative

Vision: Improving the quality and

reliability of care by focusing on the role of nursing in transforming care at the bedside Experienced nurses are the frontline

patient advocates for patient safety Culture of retention = Culture of safety

50% of new nurses leave within 2 yrs

The average age of an RN in TN is 48

2006 TN RN Vacancy Rate is 6% Over 1500 open RN positions

Only 20% of a nurse’s time is spent at the bedside – the rest is

filled with documentation, putting out “fires” and search

time

Tennessee Nursing Partners Collaborative

Focus Areas Building a Culture of Safety and Teamwork

AHRQ Culture of Safety Survey for Employees Leadership Development for Managers

Providing Staffing to Meet the Individual Needs of Patients

Fatigue, Mandatory Overtime Policy Aging Workforce

Sharing Hospital Performance Measures Turnover Nurse Sensitive Care Measures

Addressing the Workforce Shortage School/Provider Partnerships Retention – New Graduate Transitions

Collaborative on Reducing InfectionsLeading ChangeWhat makes this collaborative effort different from past projects?

National expert faculty and coaches Dr. Peter Pronovost Chris Goeschel, RN

Focus on the Universal Challenge of Technical and Adaptive Work Create safety culture Unit based teams

How can we improve

“Every system is perfectly designed to achieve the results it

gets”

Caregivers are not to blame

Technical Knowledge

based Scientific Clear Answers

Adaptive Requires a change

of value, beliefs or attitudes

Behavior based

Creating Change

Culture of Safety-Shared Accountability over

Autonomy

Journey 115 Hospitals have signed on as a safety

partner One or more intervention topics on infections

Technical vs Adaptive work Culture is the hardest

Networking Meetings – Learning Culture All teachers, all learners Practice values of culture of safety

teamwork, respect, open sharing,

Goals for the day

Meet 3 new people- swap emails Share one or more strategies that

have worked in your organization Share your failures and lessons

learned Ask for help, a different

perspective