1. Aim: Advance the adoption of proven strategies to improve the reliability, safety and quality of care received by patients in Tennessee hospitals

2. Tennessee Center for Patient Safety Objectives 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

3. 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

4. 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

5. 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

6. 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

7. Collaborative on Reducing Infections Leading Change What 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

8. How can we improve “Every system is perfectly designed to achieve the results it gets” Caregivers are not to blame

9. 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

10. 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,

11. 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