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Nashville General keeps Leapfrog A; sepsis bundle compliance rises to above 50% after chart reviews
Summary
Quality leaders reported the hospital maintained an A grade from Leapfrog, met multiple infection benchmarks, and improved severe sepsis bundle compliance to 72.7% for April after manual chart reviews; the board approved the quality report.
Christy Lewis, the hospital's chief compliance officer and interim quality lead, told the board that Nashville General Hospital maintained an A grade from Leapfrog and met several infection-prevention benchmarks.
Lewis reported that the hospital met benchmarks for central-line associated bloodstream infections, catheter-associated urinary tract infections, C. difficile and other measures, and that barcode medication administration reached 96% (above the 95% benchmark). She said hand-hygiene compliance was 94%, short of the 95% target, and the hospital plans increased coaching and observation to reach the goal.
On severe sepsis timeliness the hospital described a data lag in automated reporting and said manual chart reviews were used to measure compliance. Lewis provided monthly chart-review results showing improvement: January 16.7%, February 45%, March 50% and April 72.72% compliance for sepsis bundle adherence after manual review. She credited the quality department for the turnaround and said the team is working to reconcile those results with Cerner reporting.
Lewis also said Press Ganey patient-experience benchmark responses increased from 7 to 18 (month to month) and that staff-engagement surveys are scheduled for the summer; results are expected in October 2025. Dr. Elders added that the state conducted pediatric and other surveys and, while the state made recommendations, the hospital had no formal regulatory findings.
The board moved and approved the quality report.
Provenance: The quality report and related sepsis and infection metrics were presented during the quality agenda item and concluded with a board vote to approve the report.
