HospitalInspections.org

Based on document review and interview with key personnel on September 5 and 6, and September 20, 2012, it was determined that the medical staff and the governing body failed to be responsible for assessing the quality and competence of members of the medical staff during the recredentialing and reprivileging process.

The evidence follows:

Despite requests for governing body meeting minutes, no meeting minutes or alternative documentation of the medical staff reappointment process were provided. The surveyors were unable to determine that the governing body was accountable for the quality and competence of members of the medical staff during the recredentialing and reprivileging process. Additionally, the hospital failed to ensure that the medical staff was responsible for the policies and procedures governing emergency medical care.

For further information regarding the medical staff reappointment process, and the policies and procedures governing emergency medical care, please refer to Tag A-0338 and Tag A-1104.

The cumulative effect of these deficient practices is that this Condition of Participation is out of compliance.

Based on document review and interview with key personnel on September 5-6 and September 20, 2012, it was determined that the medical staff and the governing body failed to be responsible for assessing the quality and competence of members of the medical staff during the recredentialing and reprivileging process. Additionally, the medical staff failed to take responsiblity for the policies and procedures governing emergency medical care.

The evidence follows:

1. The SMMC "Medical Staff &Allied Health Staff Quality Assessment & Improvement Plan 2012-2013" stated: "K. To ensure that when the findings of assessment are relevant to individuals' performance, the Medical Staff determine their use in peer review or ongoing evaluation of practitioners competence in accordance with standards related to renewing and/or revising clinical privileges. VIII. Documentation/ Communication Reporting ...F. Peer Review and case review findings shall be documented and maintained in quality files ...IX. Confidentiality/ Conflict of Interest ...A. Data collected through Quality Improvement activities is confidential and shall be accessible only to those individuals who are responsible for Quality Improvement programs and those individuals responsible for surveying hospitals ..."

2. On September 20, 2012 the credentialing files of four (4) emergency physicians were reviewed. None of the files contained information on individual physician quality and competence.

3. During and interview on September 20, 2012, the Director of Quality and the Coordinator of Quality were asked to provide evidence that quality data was available and reviewed by the Medical Staff at the time of recredentialing of emergency physicians.

4. The additional documents were provided by the hospital on September 24, 2012. The documents provided by the hospital did not include physician identifiers. The Hospital did not provide evidence of review of physician quality data at the time of recredentialing.

5. Additionally, the hospital failed to provide the quality data to the survey team as stated in the SMMC "Medical Staff & Allied Health Staff Quality Assessment & Improvement Plan 2012-2013."

6. For further information on medical staff policies and procedures in the Emergency Department, please refer to Tag A-1104.

The cumulative effect of these deficient practices is that this Condition of Participation is out of compliance.

Based on document review and interview with key personnel on September 5 - 6, and September 20, 2012, it was determined that the hospital failed to ensure that the medical staff was responsible for the policies and procedures governing emergency medical care.
The evidence follows:

1. The SMMC physician bylaws for the Department of Emergency Medicine stated: "the department of Emergency Medicine functions in accordance with policies and protocols developed by the Chief of the Department of Emergency Medicine. Theses policies are consistent with rules, regulations and bylaws of the Medical Staff ..."

2. The SMMC physician bylaws for the Department of Pathology and Clinical laboratories stated: "C. Anatomical Specimens .... The following is a list of specimens that need not be submitted to pathology as long as they are documented in the patient ' s chart by the physicians: teeth, lens of the eye, incidental pieces of bone, orthopedic hardware unless it is defective and foreign bodies."

3. Review of the physician's documentation on the Emergency Physician Record Form of Record A indicated that he failed to send the products of conception for pathology.

4. An interview was conducted with the emergency department physician on September 6, 2012. When asked about protocols for sending products of conception to pathology, he stated: "There are no set protocols for handling products of conception or standards of practice."

5. During an interview on September 5, 2012 with the Emergency Director, she stated: "We don't have written policies for physicians to follow ...there is no policy on what is/isn't sent for pathology."

6. In spite of the statements made by the Emergency Director, the 'Medical Staff Rules & Regulations' 2.2 Department of Emergency Medicine stated: "The Department of Emergency Medicine functions in accordance with policies and protocols developed by the Chief of the Department of Emergency Medicine."