HospitalInspections.org

Based on review of Governing Board meeting minutes, review of Quality Improvement meeting minutes, review of the hospital-wide Quality Indicators 2010, review of the hospital-wide Quality Improvement Plan and interviews with the Chief Executive Officer, the Chief Operating Office and the Director of Quality on January 3-6, 2011, it was determined that the hospital failed to have an effective governing body legally responsible for the conduct of the hospital as an institution as evidenced by:

1. The governing body failed to ensure that the Quality Improvement Plan followed its mission and objectives consistently (Tag A0083 and Tag A0338);

2. The governing body failed to be totally responsible for the operations of the hospital (Tag A0263, Tag A0297, Tag A0338, Tag A0657, and Tag A0724):

3. The governing body failed to ensure that the hospital identified project improvement projects in 2010 (Tags A0297);

4. The governing body failed to ensure that all medical staff requirements were met (Tag A0338);

5. The governing body failed to hold the medical staff accountable for the quality of care provided to patients (Tag A0338);

6. The governing body failed to take action through the hospital's quality program to identify quality and performance problems (Tag A0083, Tag A0297, Tag A0265, Tag A0724, and Tag A0338);

7. The governing body failed to ensure that the services provided under contracts were provided in a safe a effective manner (Tag A0083);

8. The governing body failed to ensure that the Emergency Service requirements were all met (Tag A0338); and

9. The governing body failed to ensure that the previous Plan of Correction issued after the June 2010 survey was followed (Tag A0083 and Tag A0338).



The cumulative effects of these deficient practices resulted in this Condition of Participation being out of compliance.

Based on review of clinical contracts and interviews with the Director of Quality on January 5, 2011, it was determined that the governing body failed to ensure that the quality program reflected the complexity of the hospital's organization and services; involved all hospital departments and services (including those furnished under contract or arrangement)

Findings include:

1. A review of five (5) clinical contracts on January 5, 2011, revealed that none of the five (5) contracts contained a written requirement that the contracted be involved in the hospital-wide quality assessment and performance improvement program,. This was verified during interviews with the Director of Quality on January 5, 2011.

2. This deficiency was a repeat from the June 7-10, 2010 Federal Validation survey conducted at the hospital. The Plan of Correction for this deficiency stated that the patient related contracts were to be reviewed and revised to ensure that all contracts would include the written requirement for participation in the hospital-wide quality assurance and performance improvement plan. The completion date was September 30, 2010 and the responsible individual was listed as the Director of Quality.

3. During an interview with the Director of Quality on January 5, 2011, she stated that this had been an "over sight " on her part.

Based on review of Northern Maine Medical Center's Quality Improvement Plan, review of Northern Maine Medical Center's Quality Indicators for 2010, review of Northern Maine Medical Center's Performance Improvement Committee meeting minutes from November 2010 thru December 2010 and interviews with the Director of Quality, the Emergency Department Medical Director, the Chief Executive Officer, the Chief Operating Officer and the President of the Medical Staff January 3-6, 2011, it was determined that the hospital failed to develop, implement and maintain an effective, ongoing hospital-wide, data driven quality assessment and performance improvement program that focused on indicators related to improving processes and systems as evidenced by:

1. The hospital failed to ensure that the scope of the hospital-wide Quality Improvement Program's requirements were met (Tag A0265 and Tag A0338);

2. The hospital failed to identify and develop quality indicators to measure and analyze aspects of performance that would improve care within the Emergency Department (Tag A0338);

3. The hospital failed to identify opportunities for improvement and changes that would lead to improvements within Respiratory Services based on data collected (Tag A0265);

4. The hospital failed to ensure that the hospital-wide Quality Improvement Plan's program activities were consistently met (Tag A0297 and Tag A0338);

5. The hospital failed to ensure that the hospital ' s governing body was responsible and accountable for ensuring full legal responsibility for the performance improvement program (Tag A0083 and Tag A0265);

7. The hospital failed to ensure that the governing body was responsible to see that an ongoing program for quality was implemented and maintained (Tag A0338);

8. The hospital failed to maintain a performance improvement program that addressed priorities for improvement and patient safety and that actions related to these were evaluated (Tag A0297 and Tag A0338);

9. The hospital failed to ensure that the Emergency Services requirements were met (Tag A0338); and

10. The hospital failed to ensure that a previous Plan of Correction dated June 2010 was followed related to contracts (Tag A0083).



The cumulative effects of these deficient practices resulted in this Condition of Participation being out of compliance.

Based on review of the Cardiopulmonary "Quality Review Form" and interviews with the Director of Respiratory Services on January 4, 2011, it was determined that there was no documentation of an ongoing program that showed measurable improvement in indicators for which there was evidence that it would improve health outcomes.

Findings include:

1. Review of the Cardiopulmonary Performance Improvement Plan for 2010 on January 4, 2011, contained only one (1) initiative pertaining to " patient no shows " for the Department. There was no initiative that evaluated the quality of care provided to patients.

2. In addition, there was no documentation of 3rd and 4 th quarter summary for that initiative. This was verified with an interview with the Director of Respiratory on January 4, 2010.

Based on review of information provided and interviews with the Director of Quality and the Chief Medical Officer on January 5 and 6, 2011, it was determined that the facility failed to identify any Performance Improvement projects that had been identified in 2010.

Findings include:

1. Quality Improvement data was reviewed January 4-5, 2011. Only Performance Improvement indicators were identified.

2. During an interview with the Director of Quality on January 5, 2011, she stated that she could not provide a list of Performance Improvement Projects for 2010, as none had been identified.

Based on a review of minutes including the meetings of the Medical Staff, the Medical Staff Peer Review and Quality Assurance Committee, the Clinical Services Committee, the ED Committee, Surgery Committee, and interviews with key staff January 3-6, 2011, it was determined that the medical staff at Northern Maine Medical Center failed to be responsible for the quality of care provided to patients as evidenced by:

1. During a previous survey, conducted in June 2010, the hospital received deficiencies which resulted in the Medical Staff Condition of Participation being out of compliance due to the Medical Staff failing to set measurable quality indicators for all services. The Plan of Correction accepted on August 31, 2010 stated that the plan was " all medical specialties will establish specific, evidenced based, measurable goals for their specialties to be established by August 17, 2010."

2. The Hospital ' s Plan of Correction dated June 10, 2010 stated, " The ED [Emergency Department]is in the process of selecting a high volume indicator ... " The top ten diagnosis reported will be reviewed bye [sic] the ED Director and the Director of Quality and an indicator selected by 8/13/10 " .

3. The Northern Maine Medical Center ' s Quality Indicators Tracking Log presented at the time of the survey lists the following indicators for the ED, Trauma cases transferred within 1 hour of ED arrival time, goal 80%; fibrinolytic therapy received within 30 minutes of ED arrival time for AMI patients, goal 80%; Activation of Life Flight or call for ground transfer within 1 hour of arrival for AMI patients, goal 80%; First antibiotic dose administered in patients with infections (pneumonia, sepsis, pyelonephritis, cellulitis and urosepsis) within 4 hours of arrival, goal 100%; within 3 hours, goal 80%; within 2 hours, goal 60%. The ED Director in an interview on January 5 stated that they were working to achieve the 3-hour administration goal.

4. The antibiotic administration results for the 3rd Quarter of 2010, which was retrospectively collected and analyzed show that this goal had already been achieved when the indicator was selected. There was no evidence that the department worked to achieve the 2-hour goal instead.

5. The Quality Indicators Tracking Log shows that there were no thrombolytic patients seen in the 3rd or 4 th quarters for analysis.

6. In the same interview with the Director of Emergency Medicine, he stated that there was no high volume indicator since there were few eligible infection cases, and that Northern Maine Medical Center sees few trauma cases and AMI [Acute Myocardial Infarction] cases. He stated that he had not selected another high volume indicator.

7. The ED Director also stated that he had not yet done anything to improve trauma transfer times, as he had not reviewed any of the trauma patient records as they had just been given to him.

8. The Quality Log lists " All C-sections will have appropriate DVT [Deep Vein Thrombosis] prophylaxis " and " Newborns receive bilirubin screening prior to discharge " as Process Improvement indicators. However, both these indicators were already at their designated thresholds during the 1st, 2nd, and 3rd quarters of 2010. The data for the 4 th quarter had not yet been reported. There were no indications in any minutes that the obstetrics service was in the process of selecting any process improvement indicators.

9. The Surgical Services quality measure for the physicians is listed as, " pre-operative screening compliance " . The Director of Quality described this as information gathered by anesthesia prior to surgery. There was no physician quality goal listed for surgeons.

10. The Organization Wide Quality Improvement goals include SCIP measures, to be accomplished 100% of the time. These were listed on the Quality Tracking Log as " Performance Monitoring " . When these measures did not achieve this target there was no indication as to the causes, nor any actions taken to achieve the stated goal.

11. In an interview with the President of the Medical Staff on January 5, he stated that he did not think that the Medical Staff was " on board with quality " , and " that was an obstacle " . He also stated that the Medical Staff had not worked with the Director of Quality, and " she was alone on that " . He also said that " they needed quality training and had a lot to learn and had not " adapted to the essence of quality."

The cumulative effects of these deficient practices resulted in this Condition of Participation being out of compliance.

Based on review of Utilization Review Committee Meeting Minutes, review of the Utilization Review Plan and interviews with the Director of Social Services/ Utilization Review, on January 05, 2011, it was determined that the Utilization Review Plan failed to contain all the necessary inclusions.

Findings include:

1. A review of the hospital Utilization Review Plan was conducted on January 4-5, 2011. The plan did not contain a definition of "extended stay." Additionally, the plan did not state the specified time by which the periodic review must be conducted.

2. These findings were verified by the Director of Social Services/ Utilization Review on January 5, 2011.

Based on tours of the hospital on January 4-6, 2011 and interviews with the Director of Facilities, it was determined that the facility failed to ensure that all equipment was maintained at an acceptable level of safety and quality.

Findings include:

1. It was observed during tours of the facility January 4-6, 2011, that all of the eye wash stations in the hospital lacked the appropriate signage.

2. OSHA [Occupational Safety & Health Administration] standard Z358.1-1900 regulation states: 3. Installation, B. The location of the eye wash unit shall be in a well-lit area and identified with a sign.

3. These findings were confirmed with the Director of Facilities on January 6, 2011.