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Nashville General board adopts 2026 quality plan and creates compliance-and-quality committee charter
Summary
The board approved the hospitalwide Quality Assessment and Performance Improvement plan (citing 42 CFR 482.221) and adopted a new compliance-and-quality committee charter plus the 2026–2027 compliance work plan to formalize oversight and reporting.
The Nashville General Hospital Authority approved its 2026 Quality Assessment and Performance Improvement (QAPI) plan and adopted a new compliance-and-quality committee charter and the 2026–2027 compliance work plan during its June meeting.
Christie Lewis, the hospital’s chief compliance officer, presented the QAPI plan as the hospitalwide framework to reduce patient harm, strengthen a culture of safety and accountability, improve reliability of clinical and operational processes, and enhance patient experience and equity. Lewis cited a condition of participation in federal rulemaking—42 CFR section 482.221—as the mandate requiring hospitals to maintain a data-driven quality assessment and performance improvement program.
Board members noted the Joint Commission Resource team’s prior feedback that the hospital lacked a sufficiently robust policy; Lewis and others said the new plan addresses those concerns. Dr. Martin and others praised the compliance and quality team, and the board moved and approved adoption of the plan.
Separately, the compliance committee reported year-end progress (completion of work-plan items rose from roughly 24% to 75% year to date) and presented a compliance-and-quality committee charter intended to define committee authority, responsibilities and membership. The board approved the charter and also unanimously approved the 2026–2027 compliance work plan.
Board members said the approvals are an important step toward the hospital’s stated goal of becoming a high reliability organization and cited ongoing Joint Commission engagement and future phase visits. The board directed staff to report back on deliverables and Joint Commission findings as phase two and subsequent reviews are completed.
What happens next: Staff said Joint Commission Resource will complete on-site review work tied to the plan and return deliverables; the board will receive subsequent reports on compliance metrics and improvement initiatives.
