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Based on review of facility documents and staff interview (EMP), it was determined the Performance Improvement Plan did not provide an ongoing program that showed measurable improvement in indicators for which there was evidence that it improved health outcomes for one of three indicator studies as demonstrated by lack of collection of measurable data for Indicator #3 on three separate monitoring periods.

Findings include:

Review of the 2011 Performance Improvement Plan reviewed and revised January 28, 2011, revealed, "Plan: ... -Document the desired outcome of the study (specifically state the measurable outcome and time frame in which the outcome will be reached; e.g. to go from 80-95% compliance in 6 months) ..."

1. Review of Indicator #3 revealed a study regarding the Adolescent Behavioral Health unit. The study was chosen to improve patient safety and orderliness of the unit. The initial data was collected November 11, 2011, to December 18, 2012, with monitoring sheets to be completed daily. Staff did not complete data collection according to the study specifications and there was not measurable data provided. Staff were re-educated on completion of the data collection. A follow-up data collection period from December 19, 2011, through February 14, 2012, revealed no measurable amount for part of the information collected, but again noted that the data was not collected as specified and that there could be days when some of the specific data being collected was missed. Staff assigned to collect data on days when data was not collected were to receive verbal reminders of accountability. An additional data collection period of from February 23-March 11, 2012, revealed 100% compliance with collection of data, but did not provide additional patient safety data in a measurable form that led to improved health outcomes for patients.

2. Interview on August 22, 2012, at 3:45 PM with EMP3 confirmed the indicator information was not provided in a measurable form.

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to measure, analyze, and track quality indicators and other aspects of performance that assess processes of care, hospital services and operations for one as evidenced by the lack of specific measurement of patient safety data and tracking of the data for one of three indicator studies (Indicator #3).

Findings include:

Review of the 2011 Performance Improvement Plan reviewed and revised January 28, 2011, revealed, "Document the reason why the study was chosen ...Document the desired outcome of the study (specifically state the measurable outcome and time frame in which the outcome will be reached... -Determine the length of the data collection period ... Develop criteria for determining which population will be the pilot group for the testing of changes ... Determine the sample size ... -Develop a review form/tracking sheet -Implement the change ... Perform review on the pilot group for the selected amount of time using the provided review form/tracking sheet Study: -After completion of the review, tally the results - Determine if the desire results were achieved -If yes-the study is complete ... -If no-proceed to the ACT step ... ACT: -After reviewing, determine other actions ... -Implement the fix ... Repeat the above cycle until desired results are achieved. ..."

Review of the 2012 Performance Improvement Plan reviewed and revised March 16, 2012, revealed, "Document the reason why the study was chosen ...Document the desired outcome of the study (specifically state the measurable outcome and time frame in which the outcome will be reached ... -Determine the length of the data collection period ... Develop criteria for determining which population will be the pilot group for the testing of changes ... Determine the sample size ... -Develop a review form/tracking sheet -Implement the change ... Perform review on the pilot group for the selected amount of time using the provided review form/tracking sheet Study: -After completion of the review, tally the results - Determine if the desired results were achieved -If yes-the study is complete ... -If no-proceed to the ACT step ...ACT: -After reviewing, determine other actions ... -Implement the fix ... Repeat the above cycle until desired results are achieved ..."

1. Review of Indicator #3 revealed the study was initiated on November 11, 2011, and continued through March 11, 2012. The reason the study was chosen was based on a need identified by the adolescent Behavioral Health Unit. Documentation revealed that February 14, 2012, data was still not being collected as desired and specified in the indicator. It also noted that the desired patient related outcomes had not been met. Additional data was collected from February 23-March 11, 2012, which showed staff were 100% compliant with collecting data, and that a new policy was "effective" without specifying a measurable outcome and tracking to see if the results could be maintained. The study was discontinued as the goal was met.

2. Interview on August 22, 2012, at approximately 3:45 PM with EMP3 and EMP18 confirmed that the study was complete and did not continue to determine if results were sustained.

Based on review of facility documents and staff interviews (EMP), it was determined the QA program failed to incorporate patient care data and other relevant data in the information submitted by report to the PI/UR/MR committee and board of trustees as evidenced by incomplete data, data that was not measurable, and/or not included in the report for Indicator #3.

Review of the 2011 Performance Improvement Plan, reviewed and revised January 28, 2011, revealed, "The ultimate responsibility and authority for quality care and patient, staff and visitors safety lies with the Board of Trustees. The Board has delegated this task to the PI/UR/MR Committee, to coordinate and carry out the functions, which includes medical staff, in accordance with HFAP Accreditation Standards, medical staff bylaws rules and regulations, and all other hospital policies ... It is the department representative responsibility to report this study to the PI/UR/MR committee. A signed copy of the study will be forwarded to the PI/A Coordinator for distribution to the PI/UR/MR committee and electronic version sent to PI/A Coordinator for submission to the Board of Trustees for review and approval"


Review of the 2012 Performance Improvement Plan, reviewed and revised March 16, 2012, revealed, "The ultimate responsibility and authority for quality care and patient, staff and visitors safety lies with the Board of Trustees. The Board has delegated this task to the PI/UR/MR Committee, to coordinate and carry out the functions, which includes medical staff, in accordance with HFAP Accreditation Standards, medical staff bylaws rules and regulations, and all other hospital policies ... It is the department representative responsibility to report this study to the PI/UR/MR committee. A signed copy of the study will be forwarded to the PI/A Coordinator for distribution to the PI/UR/MR committee and electronic version sent to PI/A Coordinator for submission to the Board of Trustees for review and approval."

1. Review of the 2011 and 2012 Performance Improvement Plans revealed a list of indicator studies required of the hospital by various organizations and a reporting calendar of indicator studies chosen by individual units and the date of the report is/was due. Data included in the report for Indicator #3 failed to incorporate specific, measurable data relating to each of the sections of the indicator study.

2. Interview on August 22, 2012, at approximately 3:00 PM with EMP3 confirmed there was data in the computer system, as well as information on individual monitoring tools that were incomplete and/or that was not included in the report.

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to identify opportunities for improvement and changes that would lead to improvement as evidenced by the failure to fax records to a patient's Primary Care Physician (PCP) who was not on staff at this facility in one of three indicator studies (Indicator #2).

Findings include:

Review of the 2011 Performance Improvement Plan reviewed and revised January 28, 2011, revealed, "Determination of Studies Studies are chosen by any Committee or Department (hospital or medical staff) that believes there are areas that need improvement..."

1. Review of Indicator #2 revealed the indicator study was chosen to measure the consistency of medical information of Emergency Department patients being shared with the patient's primary care physicians. Findings of the study revealed that information was shared consistently with physicians on staff, but not shared with primary care physicians that were not members of the hospital staff.

2. Interview with EMP3 on August 22, 2012, at 3:10 PM confirmed that the study only addressed physicians on staff at the hospital and revealed, "We don't have those physicians' [not on staff] numbers."

Based on review of facility documents and staff interviews (EMP), it was determined the facility failed to include frequency and/or details of data collection for two of three indicator studies as demonstrated by lack of frequency requirements for Indicators #1 and #2, and lack of specifics for data collection for Indicator #1.

Findings include:

Review of the 2011 Performance Improvement Plan revealed, "Plan: ... Document the desired outcome of the study (specifically state the measurable outcome and time frame in which the outcome will be reached ... Determine the length of the data collection period (one week, one month, etc.) ... -Determine the sample size of data collection (should be at least 10% of the population if doing a study over an extended period of time or 100% if doing the study over a short time period) All of these items are to be presented in a 1-2 sentence AIM statement (goal) ..."

Review of the 2012 Performance Improvement Plan revealed, "-Document the desired outcome of the study (specifically state the measurable outcome and time frame in which the outcome will be reached ... Determine the length of the data collection period (one week, one month, etc.) ... -Determine the sample size of data collection (should be at least 10% of the population if doing a study over an extended period of time or 100% if doing the study over a short time period) All of these items are to be presented in a 1-2 sentence AIM statement (goal) ..."

1. Further review of the 2011 and 2012 Performance Improvement Plans failed to reveal the requirement for a frequency and/or detail of data collection.

2. Review of Indicator #1 revealed the study was a three month observational medication monitoring study to assess the need for a pharmacy driven medication dosing program. The data collection period was listed as August 2011-October 2011. There was no specification for the frequency or specifics of the data collection listed on the study.

3. Interview on August 22, 2012, at 2:55 PM with EMP3 confirmed the lack of documentation regarding the frequency of the data collection and revealed, "It was done on a daily basis, but it was not specified. We were looking to see if the INRs were in the therapeutic range."

4. Review of Indicator #2 revealed the data collection period was listed from January 16, 2012 to April 30, 2012. There was no specification for the frequency of data collection.

5. Interview on August 22, 2012, at 3:25 PM with EMP18 confirmed it was not specifics of the data collection were not included and revealed, "The information is collected each shift."

Based on review of facility documents and staff interview (EMP), it was determined the facility did not focus on high-risk, high-volume, or problem prone areas for it's performance activities as evidenced by a study that was initiated in August 2011, with the resultant policy not yet implemented as of August 22, 2012, in one of three studies (Indicator #1).

Findings include:

Review of the 2011 Performance Improvement Plan reviewed and revised January 28, 2011, revealed, "Determination of Studies Studies are chosen by any Committee or Department (hospital or medical staff) that believes there are areas that need improvement. This can include (but not limited to): ... high-risk procedures and patients, high-volume patients and procedures ... Departments providing direct patient care should focus on PI studies that will minimize patient risk, improve patient outcomes, reduce errors and process improvements ..."

Review of the 2012 Performance Improvement Plan reviewed and revised March 16, 2012, revealed, "Determination of Studies Studies are chosen by any Committee or Department (hospital or medical staff) that believes there are areas that need improvement. This can include (but not limited to): ... high-risk procedures and patients, high-volume patients and procedures ... Departments providing direct patient care should focus on PI studies that will minimize patient risk, improve patient outcomes, reduce errors and process improvements ..."

1. Review of Indicator #1 revealed the study was chosen to assess the need for a pharmacy dosing program. The initial study included data from August 2011 through October 2011. A new policy was developed for the implementation of the dosing program. There was no documentation identifying the need for improvement, but noted only that there was a need to increase awareness.

2. Interview on August 25, 2012, at 3:05 PM with EMP3 revealed, "The followup has not yet been completed. P&T [Pharmacy and Therapeutics committee] tabled the policy until the next meeting. The house staff do have a pocket guide that was developed since July 2012."

Based on review of facility documents and staff interview (EMP), it was determined that the facility failed to track performance to ensure that improvements are sustained for one of three indicator studies (Indicator #3).

Findings include:

1. Review of Indicator #3 revealed the reason for the study was because contraband was found on the adolescent Behavioral Health unit as well as patient belongings being disorganized/lost. The initial study was completed between November 11, 2011, and December 18, 2011. The results of the initial study addressed the items in the indicator but noted that staff were not completing the monitoring tools. Reeducation of staff was provided. The follow-up study conducted between December 19, 2011, and February 14, 2012, revealed an improvement in the results but again noted the goals of the study were only partially met. The data collection was not performed as designated on the indicator study, therefore the results of the study may not have been accurate. "We will continue to follow, educate, and monitor ..." The follow-up study conducted between February 23, 2012, and March 11, 2012, noted, "The second followup study showed 100% compliance by staff [collecting data] ... Were the goals of the study met: Yes." There was no documentation that all areas of the indicator study were followed to ensure that the previously reported improvements were sustained.

2. Interview on August 22, 2012, at 3:50 PM with EMP3 confirmed that the entire desired outcome was not completely addressed and the study was completed when goals met.