Quality & Safety

Quality in health care is generally described as collecting and analyzing clinical data over a period of time. Measuring quality data enables us to visualize area where we are providing the best care for our patients and identify areas where we can improve.

Our focus is to provide our patients with quality health care that is safe. A secure environment free of medical errors during stay.

• Effective: Health care provided based on scientific knowledge and best practice.
• Patient-centered: Health care that is truly considerate of patients’ cultural traditions, personal preferences and ideals, family conditions and lifestyles.
• Timely: Decreasing waits and sometimes harmful delays for those receiving and provide health care.
• Efficient: Avoiding waste, maximizing resource utilization including waste of equipment, supplies, ideas and energy.
• Equitable: Health care that is fair, unbiased and reasonable.

All hospitals are not the same. There are differences in experience, approach to patient care and level of the technologies and therapies. UT Medical Center’s quality outcomes are continually demonstrated through its experience, recognition and quality care based on our commitment to patient safety and quality as well as each person’s customer service experience.

Quality Questions to Ask Your Health Care Provider

Asking questions is the most important thing you can do when concerns arise about the quality of your health care.

• Is there quality data available for my hospital?
• Is the hospital accredited by the Joint Commission?
• How many patients has the hospital treated for my condition or procedure?
• How do other hospitals compare for my condition or procedure?
• Will my insurance cover the care at this hospital?

As an academic medical center, UT Medical Center must stay ahead of the curve. We take our quality of care, safety and service seriously. The results? Patient care excellence recognized by organizations across the country. We participate in a number of public surveys and quality assurance initiatives that have recognized the medical center’s high quality patient care and safety excellence.

NDNQI: Health Resources and Services Administration

Certificate of Recognition for meeting and exceeding standards as part of an organ donation and transplantation collaborative

Joint Commission

• Advanced Certification in Stroke
• Special Quality Awards
  –  2010 ACS Bariatric Surgery Center Network Accreditation – Level 2a
  –  2009 ACS National Surgical Quality Improvement Program

Voluntary Participation

• UT Medical Center Earns Distinguished Award for Performance and Quality
• Level I Comprehensive Accredited Education Institute (AEI) from the American College of Surgeons (ACS)
• Accreditation from the American Academy of Sleep Medicine (AASM)
• Magnet Recognized Organization
• National Surgical Quality Improvement Program
• American College of Surgeons Bariatric Quality Improvement Program
• American College of Cardiology PCI Database
• Association of Thoracic Surgeons Surgical Database

The University of Tennessee Medical Center participates in measuring and publicly reporting clinical data. We monitor our surgical care and are involved in the Surgical Care Improvement Project (SCIP). We also monitor and measure inpatient medical conditions such as Acute Myocardial Infarction (AMI), Heart Failure, and Pneumonia and outpatient conditions like chest patients and surgical procedures. Within these categories there are 25 core components such as: antibiotic administration, influenza vacations and smoking cessation counseling. This data is publicly reported online and updated regularly.

What are Core Measures?

UT Medical Center delivers quality patient centered care using proven and quantitative medical treatments. By doing this, we adhere to a set of care processes called Core Measures developed by The Joint Commission, the nation’s prominent standards-setting and accrediting body in health care, to improve the quality of health care by implementing a national, standardized performance system. The Core Measures are derived from a set of quality indicators defined by the Centers for Medicare and Medicaid Services (CMS). These quality indicators have been shown to reduce the risk of complications and prevent readmissions of patients who come to a hospital to receive treatment of a condition or illness. We proudly stand by our Core Measures as they help us continuously improve quality patient care, safety and outcomes.

To see how we are doing go to the Hospital Compare website.

LEAN is about improving quality and productivity.

According to author Mark Graban (LEAN Hospitals, 2009), “LEAN is about looking at how we do our work and figuring out ways to improve how that work is done. LEAN is about improving quality and productivity. LEAN is about learning to fix problems permanently instead of hiding them or working around them.”

LEAN has its roots in the automotive industry, with Henry Ford’s moving assembly line, implemented to eliminate wasted motion. Even during this time, Mr. Ford noted that hospitals could learn from his principals, noting in 1922, “In the ordinary hospital the nurses must make useless steps. More of their time is spent in walking than in caring for the patient.”

After World War II, Toyota developed their “Toyota Production System” (TPS) to improve quality, while increasing productivity and reducing costs. While Toyota did not call this system LEAN, it is widely agreed to be the precursor of current LEAN efforts, demonstrating less use of space, less labor effort, less capital, less inventory, less defects and less safety incidents.

History of LEAN at UT Medical Center

In 2006 the hospital’s senior management was approached by a graduate of the Physician Executive MBA program at the University of Tennessee College of Business Administration (CBA) suggesting collaboration between the College of Business Administration and the Medical Center that would further the organization’s mission through LEAN principles. The management team embraced the concept and proceeded to work with the CBA to strengthen operational processes through the application of LEAN concepts, tools and management prescriptions.

A key part of this LEAN journey was the appointment of the Chief Nursing Officer and Chief Operating Officer serve as executive champions. In conjunction with the CBA, 120 vice-presidents, directors, managers and physicians have been formally educated regarding LEAN. As a condition to training, the individuals signed an agreement to conduct improvement events.

In addition, staff have been realigned to provide for coordination. A process engineer was hired out of a manufacturing setting to provide experience in practical use of LEAN. A LEAN Toolkit has been developed and posted on the medical center’s intranet site to provide tools for use by staff. LEAN teams provide progress reports regularly to management and the Board of Directors.

The following are important principles that are integral to the success of LEAN:

• How can we simplify, combine and/or eliminate processes or steps in the process to improve flow?
• Value-added is always determined from the patient’s perspective.
• Every process should be focused on adding value to the patient. Processes should flow for the patient.
• Standardize work and processes.
• Anything that does not add value is WASTE! Eliminate waste.
• Aim for perfection; don’t settle for benchmarks. We should always strive to improve.

Goal of LEAN at UT Medical Center

The goal of LEAN implementation at UT Medical Center is to improve processes and outcomes, increase capacity, reduce costs, and increase satisfaction among our patients, providers and staff.

At the University of Tennessee Medical Center, safety is first. Our safety culture is shaped using a methodology known as a “Just Culture.” We continuously monitor processes, procedures and systems to ensure quality and safety for all of our patients, families and staff. Another crucial element is to ensure our staff has access to continuing education and training. Our safety culture creates an environment where errors can be reported without the apprehension of disciplinary action. Our goal and responsibility is to identify the root cause of a situation and be able to correct it, preventing recurrence. By implementing Just Culture, we focus on what happened, how it happened and why it happened, rather than who did it. This approach enables staff to report a situation immediately so the proper attention is given in a timely manner.

We operate using many systems and processes requiring staff to have education and training. With change being constant, we strive to keep the systems and processes current, efficient and productive. Using Just Culture as our model, we can identify and pinpoint where to focus efforts. We can determine if there is a break in process or if education/training is needed for our staff. This model is beneficial for everyone and allows us to constantly improve our patient care.

The University of Tennessee Medical Center is committed to providing excellent care through a series of checks and balances to assure the safety of our patients in all aspects of their care. The medical center has a designated patient safety officer who provides training to staff and oversees implementation of policies. In addition, a culture of safety is practiced by enabling staff to openly voice concern about safety issues to senior management.

Each year, national goals are established to address specific areas of concern in regards to patient safety by The Joint Commission, a not-for-profit organization that accredits more than 17,000 health care organizations and programs in the United States. The University of Tennessee Medical Center takes these National Safety Goals seriously and works to ensure a safe environment throughout your hospital stay and for all aspects of your care.

You will find a detailed description of each of the National Patient Safety Goals on The Joint Commission Website.

We are committed to the safest and best quality patient care experience from admission to discharge based on the highest health care standards. To help improve your care and experience, we have several processes and systems in place to protect you while you are with us.

• We abide by the National Patient Safety Goals
• We incorporate the TeamSTEPPS patient safety program into our culture
• We educate our patients about patient safety and their risk
• We partner with you and your family so you can make the best and most informative decisions regarding your health care

We believe in continually improving our medical center and the service and care we provide our patients. Please let our team members know if you have any questions or concerns.

The University of Tennessee Medical Center takes a special interest in providing continuing education for team members on the subjects of safety, quality and service. All clinical employees and new physician residents participate in TeamSTEPPS safety training.

In addition to the structured education, we also focus on patient safety during National Patient Safety Awareness week focusing on specific topics identified nationally.

We have teams in place to assess quality and safety. Our Performance Improvement efforts evaluate current processes and determine educational needs, process redesign, and efficiency.

Projects focused on topics such as fall prevention and and infection prevention have proved to benefit our patients.

Safety teams also are in place to monitor areas such as medical equipment use, hazardous materials, fire prevention, emergency management, community disasters and security. All these teams are focused on the safety of our patients, their families and team members.

Teamwork is of the utmost importance for a meaningful patient experience. We provide team training to educate all our staff on the significance and impact of communication, coordination, and collaboration of patient care. This training incorporates case studies, activities, and real examples in health care.

Each year, national goals are established to address specific areas of concern in regard to patient safety by The Joint Commission, a not-for-profit organization that accredits more than 17,000 health care organizations and programs in the United States. The University of Tennessee Medical Center incorporates these goals into process improvement,  ensuring a safe environment throughout your hospital stay for all aspects of your care.

You will find a detailed description of the National Patient Safety Goals on The Joint Commission Website.

UT Medical Center offers experts in a variety of specialties in order to provide the most comprehensive care for making you healthy. We take your care very seriously, and so should you. While doctors, nurses and the entire team of caregivers at the medical center work together to get you the best treatment, we expect you to ask questions and be involved in your care. We want to make sure you understand what’s happening from your initial checkup through diagnosis and treatment.

Here are some things you can do to be an active participant in your care.

• SPEAK UP! A program sponsored by The Joint Commission that urges patients to take an active role in preventing health care errors by becoming involved and informed participants on the health care team. Learn more about the Speak Up! Program.
• Ask questions – Make a list of questions prior to your appointment and don’t be afraid to ask them. Visit AHRQ for more information.
• Take a family member or friend with you to your appointments.
• Take pen and paper with you to your appointments.
• Write all of your medications down and have them with you. If receiving medications, ask questions regarding medications you already are taking and speak with both your doctor and pharmacist for instructions.
• Write in a journal in between checkups and appointments so you can describe your experiences to your physician.

Here are some easy things that you can do to protect yourself and fight the spread of infection.

• Clean your hands. Use a 15-second scrub with water and soap or clean them with an alcohol-based sanitizer.
• Expect health care providers to clean their hands. Don’t be afraid to ask providers if they have cleaned their hands or if they should wear gloves.
• Cover your mouth and nose. When coughing or sneezing, cover your mouth or nose with a tissue, or the bend of your elbow. Be sure and clean your hands right away.
• Get shots to avoid disease. Make sure that your vaccinations are current — even for adults.
• If visitors or family members are sick, ask them not to visit. Try to maintain contact through phone calls or e-mail.

The staff at UT Medical Center invite you to actively participate in your care by asking questions and discussing concerns.

Our service quality and your safety are our biggest initiative. We are continually improving our processes to better serve the needs of you, your family and the community. Below are some of the safety and quality initiatives at the medical center.

Current Improvement Projects

Central Line Bloodstream Infection

• Reduce central line blood tream infection (CLABSI) rates to be better than the National Healthcare Safety network (NHSN) benchmark.

Catheter-Associated Urinary Tract Infections

• Reduce catheter associated urinary tract infections (CAUTI) to be better than the NHSN benchmark rates.

Surgical Site Infection

• Reduce surgical site infection (SSI) rates to be better than the NHSN benchmark rates.

Patient Falls

• Reduce the number of patient falls.

TeamSTEPPS Program

• Apply team training program to improve communication and teamwork skills among health care professionals to improve patient safety.

Past Improvement Projects

Hospital Beds Needs Analysis

• Determined the optimal number of Acute Care and Critical Care Beds at UT Medical Center by using a queuing calculation analysis.

Decubitus Ulcer Team

• Prevent the occurrence of bed sores and pressure ulcers among patients.

Transporter/Housekeeping Staffing Analysis 

• Determine optimal staff scheduling necessary to meet demands using queuing calculation analysis.

Heart Failure Patient Education

• Provide education to patients with heart failure in a timely matter.

Hand washing is one of the most important ways to avoid getting sick and to prevent spreading germs. It is very important both at home and in the hospital. Millions of microbes are on hands and can cause colds, the flu or diarrhea. These disease causing microbes can be picked up by touching doorknobs, stair railings, telephones and any other surfaces that multiple people touch.

Because proper hand hygiene is one of the primary responsibilities of your healthcare team, feel free to ask any member of your healthcare team if they have washed their hands before they have any direct contact with you.

You may see your healthcare workers using a quick drying, alcohol based, waterless hand gel or foam. These gels are fast acting and are a highly effective in killing hospital germs. Waterless gels are an acceptable alternative to washing your hands with soap and water when your hands are not visibly dirty.

You may also see your healthcare workers wearing a small white badge in addition to their regular badge. Because we are all invested in keeping you safe, we have installed a hand hygiene reminder system that helps our hard-working team members remember to perform hand hygiene when appropriate.

Also, remind your visitors to clean their hands with soap and water or an alcohol-based hand rub before they enter and leave your room.

How to Properly Wash Your Hands

• Wet your hands with clean and preferably warm running water.
• Apply soap and rub your hands together creating lather.
• Scrub all surfaces on your hands for 10 – 15 seconds including under your fingernails and the back of your hands.
• Rinse hands well.
• Dry your hands and if possible use a paper towel and then use your paper towel to turn off the faucet.

When to Wash Your Hands with Soap and Water

• Hands are visibly soiled (dirty)
• Hands are visibly contaminated with blood or body fluids
• Before eating
• After using the restroom
• After changing diapers or cleaning up a child who has gone to the bathroom
• Before and after touching someone who is sick
• Before and after caring for a wound
• After coughing, sneezing or blowing your nose
• After handling an animal or animal waste
• After handling garbage

How to Use an Alcohol-Based Hand Sanitizer

• Apply product to the palm of one hand.
• Rub hands together.
• Rub the product over all surfaces of hands and fingers until hands are dry.