Get Full Government Meeting Transcripts, Videos, & Alerts Forever!
Get email alerts on the Quality Of Care topic
No spam. Unsubscribe anytime.
Quality report: hospital meets some targets, vows fixes on hand hygiene and consent form; Joint Commission findings accepted
Summary
Quality staff reported met targets in several clinical measures but flagged hand-hygiene compliance and transfusion consent form issues; the hospital reported one superficial surgical-site infection and said the Joint Commission accepted corrective evidence submitted in June.
Chief compliance officer Christy Lewis presented the quality scorecard, noting wins in inpatient falls, hand-hygiene observations (on trend), language-line usage and barcode medication administration. She outlined targeted improvement work for hand-hygiene compliance, bedside shift-report documentation and the redesign and reeducation of the blood-transfusion consent form after Tennessee Department of Health surveys found the form confusing.
Lewis reported that a new infection preventionist, Dr. Fabiola Danuth, led a manual review of hospital-acquired infections from January through March; the hospital recorded one superficial surgical-site infection identified 30 days after a procedure and plans an actual-cause analysis rather than a more detailed corrective action. Lewis also said the Joint Commission conducted an unannounced visit on April 17, 2026, found complaint allegations unsubstantiated, and accepted the hospital's evidence submission on June 23, 2026, so no further corrective actions are anticipated at this time.
