Nashville General's quality leaders reported to the Hospital Authority Board that the hospital has sustained multiple infection‑prevention wins while continuing targeted work on hand hygiene and safety processes.

Felicia (quality lead) told the board that barcode medication administration (BCMA) adherence has exceeded the 95% goal for five consecutive months, with August at 98%. Severe sepsis bundle adherence exceeded the national benchmark (58%) for two consecutive months and reached 70.6% in July. The hospital has had four months without a reported health care‑associated infection (HAI) event and more than a year without central line‑associated bloodstream infection (CLABSI), catheter‑associated urinary tract infection (CAUTI), MRSA bacteremia or surgical site infections tied to specified procedures.

Nut graf: Quality leaders said those outcomes reflect focused operational improvements but also warned of an important weakness: hand hygiene adherence has declined and requires renewed coaching and education.

What the board heard
- Wins: BCMA adherence >95% for five months; August: 98%. Severe sepsis bundle adherence in July: 70.6% (above 58% benchmark). Four consecutive months without an HAI event; >1 year without CLABSI, CAUTI, MRSA bacteremia or certain surgical site infections.
- Concern: Hand hygiene adherence fell to a low of 87% in the most recent month. Leadership said observations are collected by unit leaders and directors through direct observation; leaders are assigned minimum monthly observation counts.
- Actions planned: leaders will coach in the moment on missed hand hygiene; partnership with Meharry Medical College to include residents in training; multidisciplinary peer review for medical staff is moving through legal review after Medical Staff Bylaws Committee approval; rapid hospital‑wide training on consent processes for forensic (inmate) patients was rolled out within seven days and will be followed by expanded training slots and chart audits to ensure advanced care plans are placed in the record.

Officials said the peer review process and forensic consent training are intended to close gaps identified by staff and to make documentation available across teams. The quality presenter noted that the hospital will present safety‑culture survey results at the next reporting period.

Ending: The board accepted the quality report and approved it by motion.