Tennessee Hospital Association Uses AHRQ Tools To Boost Patient Safety, Saving $17 Million

Patient Safety
March 2017

AHRQ resources used by the Tennessee Center for Patient Safety—the quality and safety unit of the Tennessee Hospital Association (THA)—helped 120 member hospitals reduce safety events by more than 1,000 and readmissions by more than 1,500 between 2012 and 2014. The efforts saved the hospitals $17 million.

The THA relied upon several AHRQ tools, particularly the Comprehensive Unit-based Safety Program (CUSP) and Re-Engineered Discharge (RED) toolkits to prevent numerous safety challenges. Among others, these safety challenges included:

  • Adverse drug events.
  • Catheter-associated urinary tract infection (CAUTI).
  • Central line-associated blood stream infection (CLABSI).
  • Injuries from falls and immobility.
  • Obstetrical adverse events.
  • Pressure ulcers.
  • Surgical site infections.
  • Venous thromboembolism (VTE).
  • Ventilator-associated pneumonia.

"We used a variety of AHRQ resources and relied heavily on AHRQ," said Chris Clarke, R.N., B.S.N., senior vice president at the THA. The Tennessee Center for Patient Safety trains hospitals in the effective use of AHRQ's evidence-based clinical resources and tools to change practice. "AHRQ is one of the top places we go for resources, and the resources are available without a charge," she noted.

"Tennessee hospitals have changed practices significantly," noted Ms. Clarke. Improvements in 2014 resulted in an estimated 45 percent reduction in pressure ulcers, 24 percent reduction in falls, 5 percent reduction in VTEs, and 2 percent reduction in readmissions.

The RED toolkit, developed by AHRQ-funded researchers, provides evidence-based strategies to help hospitals re-engineer their patient discharge processes. RED interventions focus on comprehensive discharge planning, patient education, and post-discharge patient followup.

The CUSP toolkit, meanwhile, helped the hospitals prevent infections that can lengthen hospital stays and increase costs, intensify patient suffering, and even lead to death. CUSP combines improvement in safety culture, teamwork, and communication with a checklist of evidence-based practices to reduce healthcare-associated infections and other patient harms.

CUSP helped Tennessee hospitals decrease neonatal CLABSI rates by 47 percent and overall CLABSI rates by 37 percent. Data from 2014 indicated CLABSI rates in ICUs fell by 15 percent, while ICU CAUTI rates dropped 14 percent, compared to the 2012 baseline year.

Impact Case Study Identifier: 
AHRQ Product(s): Comprehensive Unit-based Safety Program (CUSP), Patient Safety Organization (PSO), Re-Engineered Discharge (RED)
Topics(s): Adverse Drug Events (ADE), Healthcare Costs, Healthcare-Associated Infections (HAIs), Quality of Care, Hospital Readmissions, Patient Safety, Prevention, Patient Safety Organizations
Geographic Location: Tennessee
Implementer: Tennessee Hospital Association
Date: 03/09/2017
Page last reviewed March 2017
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