Chris Clarke

In 2007, the Tennessee Hospital Association established the Tennessee Center for Patient Safety with funding primarily from the BlueCross BlueShield of Tennessee Foundation. Since then, the Safety Center has made significant strides in reducing hospital-associated infections (HAIs) and never events, while simultaneously improving performance on key quality measures through the delivery of evidence-based care.

As senior vice president of Clinical and Professional Practices for the THA, Chris Clarke, RN, has oversight of the Tennessee Center for Patient Safety. With more than 90 percent of all Tennessee hospital beds represented by THA membership, Clarke said the association appreciated its unique opportunity to work collaboratively with facilities across the state to impact safety and quality. In fact, 122 of the state’s approximately 136 acute care hospitals partner with the Safety Center on one or more initiative.

From the beginning, the goal, Clarke said, was a straightforward one — “Keep patient safety in the forefront at all times so we’re always mindful of how we can prevent harm from reaching the patient.”

Conceptually, everyone was certainly on board, but turning broad concepts into everyday actions hasn’t been an easy task. “Hospitals are very much committed to improving quality and safety, but this is hard work in a very complex environment,” Clarke noted. “It really means re-learning and re-thinking how we deliver care.”

After receiving an initial three-year grant from the BCBST Foundation, which has since been renewed, one of the first moves was to contact renowned safety advocate Peter Pronovost, MD, medical director of the Quality and Safety Research Group at Johns Hopkins. “We were the second state that asked him to come and teach us the methods he used,” Clarke said.

Pronovost showed Tennessee hospitals a new … although simple … approach to addressing complex, multistep clinical interventions. “The first thing he did was bundle those individual steps and put them in a checklist format,” explained Clarke. “When you’re doing complex work, you need to have prompts. The checklist concept ensures that key steps are reminded and remembered.”

Although checklists have been widely used by pilots for years, she noted, “In medicine, that hasn’t been a traditional way of doing things.” Clarke said healthcare is beginning to borrow from other high-risk industries … including the nuclear and aviation industries … that have put high reliability processes in place to avert mistakes.

While a number of effective strategies have been added to the provider toolbox, Clarke said the most difficult has been the hard work required to change the traditional hierarchical structure of hospitals and create a new culture that fosters teamwork and communication across disciplines. Clarke also stressed the patient and family members are central figures in the safety team.

Part of the culture shift has also come from the way complications are viewed. “Years ago, complications in the Intensive Care Unit were sort of viewed as unavoidable. All the attention was on saving the patient’s life, and if a complication occurred as a result … well, that was unfortunate but unavoidable,” Clarke said. Today the mindset is to view complications as preventable. “It’s raised the bar. Not every complication is avoidable, but you can work like they are. If the goal is zero events, then work towards eliminating as many complications as possible. That wasn’t really in our scope of thinking 10 years ago.”

When the Safety Center released the state’s latest statistics last summer, the payoff for all the partners’ hard work was evident in significantly improved numbers across several key measures.

“When we first started, we focused primarily on hospital-associated infection … and specifically central line-associated bloodstream infections, also known as CLABSI,” said Clarke. “Between 2008 and 2010, for central lines in adult and pediatric ICUs, we had a 36 percent reduction in central line infections, and that has continued to improve through the end of 2010 and into 2011,” she said. “In the Neonatal Intensive Care Unit, they’ve had a 46 percent reduction over that same period of time,” Clarke continued.

Similarly, the Safety Center in partnership with the Department of Health and more than 60 hospitals statewide has made significant strides in reducing Methicillin-resistant Staphylococcus aureus, commonly referred to as MRSA. Clarke said the group reduced the number of hospital-onset cases by 315 from 2008 throughout 2010, a 21 percent reduction.

Another area of excitement has been the Tennessee Surgical Quality Collaborative, (TSQC) which rolled out in 2008 and is funded by a separate grant program from the BCBST Foundation. The initiative, Clarke explained, supports 10 hospitals in Tennessee that are part of the American College of Surgeons National Surgical Quality Improvement Program, which is the first nationally-validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care.

Prospectively using collected data to quantify 30-day, risk-adjusted outcomes, allows hospitals to make a valid comparison among participants. Clarke said TSQC participants track 22 complications, and she noted the group uses the “very robust clinical data to really understand our challenges in Tennessee and our opportunities to improve care. We’ve had incredible results.”

She continued, “Comparing 2009 to 2010 data, we’ve improved on five of those complications as a group; and on our most recent data, we’ve seen even greater improvement, and we’ve now improved on eight out of the 22 … and,” she continued, “we’ve decreased mortality.”

In fact, the success of TSQC was highlighted in a study published online in the Journal of the American College of Surgeons on Jan. 23, 2012. The highlighted improvements included a 25.1 percent reduction in acute renal failure, 60.5 percent reduction in graft/prosthesis/flap failure, and a 34.3 percent reduction in wound disruption.

In East Tennessee, TSQC participants are Erlanger, Johnson City Medical Center, Parkwest Medical Center and the University of Tennessee Medical Center. In Middle Tennessee, Vanderbilt University Hospital and Cookeville Regional Medical Center participate. In West Tennessee, the partners are Baptist Memorial, Methodist University, and St. Francis in Memphis plus Jackson Madison County General Hospital.

In terms of saving human lives and suffering, the value of the Safety Center’s multifaceted programming has been immeasurable. An added benefit, however, has been the cost reductions achieved along the way. At last count, the state had already saved more than $11 million in healthcare costs by addressing avoidable hospital-associated patient care conditions.

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