Four Big Wins for Nashville General Hospital

Achieving Success In Times Of Adversity

Nashville General Hospital, Nashville, TN (Photo:
Nashville General Hospital, Nashville, TN (Photo:

NGH has faced unprecedented challenges over the past two years, from the COVID-19 pandemic and the funding struggle faced by all public safety hospitals. Yet, throughout it all, Nashville General Hospital (NGH) has continued to grow and achieve multiple milestones and awards. The following are just four of its top achievements.

Provisional Level III Trauma Designation

After a state trauma visit on March 21, 2022, NGH was granted a provisional designation as a Level III Trauma Center. This means the health system has demonstrated the ability to provide “prompt assessment, resuscitation, surgery, intensive care, and stabilization of injured patients and emergency operations.”1 The designation process, which includes both an assessment and validation, affirms the health system meets national quality standards based on resources available and the number of patients admitted each year.

According to the American Trauma Society, Level III elements include:

  • 24-hour immediate coverage by emergency medicine physicians and the prompt availability of general surgeons and anesthesiologists.
  • Incorporates a comprehensive quality assessment
  • Has developed transfer agreements for patients requiring more comprehensive care at a Level I or Level II Trauma Center.
  • Provides backup care for rural and community
  • Offers continued education of the nursing and allied health personnel or the trauma team.
  • Involved with prevention efforts and must have an active outreach program for its referring

The provisional designation is good for one year and will include another visit where the health system hopes to be granted an official Level III Trauma Designation. While a Level III is an appropriate designation for tertiary hospitals like NGH, the health system has a plan to achieve Level II in the future.

Joint Commission Accreditation

The Joint Commission arrived at NGH on Tuesday, March 22 for their three-day, triennial accreditation survey, followed by a 2-day Environment of Care Survey which started on March 31, 2022. The Summary of Survey Findings Report identified 28 findings which is a downward trend from the past 2 surveys. To be accredited means an organization has proven it has a “commitment to continuous improvement in patient care.”2

The Joint Commission is an independent organization and the nation’s largest standards-setting and accrediting organization in healthcare. The Commission’s objective evaluation process helps healthcare organizations measure, assess, and improve processes for patient care and organizational functions that impact safety and care quality.

This is the third time NGH has been accredited since 2015. While the organization has always had a number of findings that align with the national average, that number has dramatically decreased with each subsequent survey. This most recent survey found minimal deficiencies and produced the best results yet.

Joseph Webb, DSc, FACHE, CEO of NGH, puts the utmost importance on achieving and maintaining an audit-ready status. “We’ve created a culture of safety at Nashville General,” Webb says.

Management throughout the health system encourages individuals to report issues so they can be proactively addressed. “Our primary focus is on patient safety and care quality,” Webb says. “The entire team at NGH understands their role in continuous improvement.”

Certification of Need (CON) for Diagnostic Imaging

Expanding facilities or services requires healthcare organizations to demonstrate community need through the state-regulated certification of need (CON) program. The purpose is to control costs by reducing duplicative services in a given area. On

On March 23, 2022, a hearing was held where NGH was awarded CON approval to provide diagnostic imaging services at its Charlotte Clinic, located in mid-town Nashville. The new imaging services, which are projected to begin in October 2022, will be the only imaging services north of Charlotte.

The clinic, which is owned by NGH, was established as a separate business so that providers outside of the NGH network can refer patients. This helps the community meet capacity and need while also being a more affordable option than some of the larger clinics like Premier and Vanderbilt.

“Our goal is to bring high-quality imaging services to areas that have previously lacked that type of access,” says Webb. “It’s part of our mission to improve health equity and the health status of the populations we serve.” Webb says the CON board gave a unanimous “thumbs up” for its CON request.

The new imaging services will include:

  • Advanced MR scanner that is more open and includes technology that reduces sound for a better patient experience
  • Mammography
  • 64-slide CT
  • Digital radiology
  • Ultrasound/ECHO
  • Diagnostic CT and MR

The clinic also offers after-hours urgent care, so imaging will be available around the clock.

Level 3 TNCPE

On March 23, 2022, NGH was awarded the 2021 TNCPE (Tennessee Center for Performance Excellence) Achievement Award. The Achievement Award recognizes health systems that demonstrate “high-performance levels of organizational results” and the “commitment and practice of performance improvement principles outlined in the Baldrige Framework for Excellence, fact-based evaluation and improvement.” NGH is the only hospital in the Middle Tennessee region to be recognized with the 2021 TNCPE Achievement Award.

In 2015, NGH began planning around the TNCPE Framework and eventual application for the national Malcolm Baldrige award. This was all a part of its strategic goals for achieving the Triple Aim: Improving the care experience, improving the health of populations, and reducing per capita costs of care.3

Receipt of the TNCPE Achievement Award is the result of everyone’s hard work. “We made sure we were focusing on all aspects of the

framework,” says Webb. From strategic planning, patient care, operations, measurements, and analysis—everyone was trained on the framework. “Everything we are doing—from Baldridge to the Triple Aim to our chronic care model and patient-centered medical home—all work in collaboration to support our overall system of care delivery here at Nashville General.”

Stronger Than Ever

The past two years have been challenging for hospitals and health systems across the country and NGH is no exception. But with a great team effort and the organization’s approach to evidence-based healthcare delivery and clinical integration models, NGH has been able to grow and thrive.

These significant achievements are examples of strong leadership, a culture of continuous improvement, and a commitment to health equity.

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