HospitalInspections.org

Based on review of documents and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure the quality improvement committee evaluated 6 of 9 contracted patient care services for effectiveness and quality of care provided. (Nuclear Medicine, Magnetic Resonance Imaging (MRI), Physical Therapy, Occupational Therapy, Speech Therapy, and Anesthesia.)

Failure to ensure the quality improvement committee evaluated all contracted patient care services provided at the CAH could potentially result in the failure to identify problems that could impact patient care.

Findings include:

1. Review of document titled, "Quality Improvement Plan", revised 10/2015, included in part, "...Purpose: A formal program designed to evaluate the quality of health care against pre-established indicators for the purpose of improvement and/or maintenance of patient care...Objectives: Establish a mechanism to identify and solve problems that impact directly and indirectly on patient care...Each non-clinical and patient related service is responsible for identifying and resolving problems for the purpose of improvement and/or maintenance of patient care...."

2. Review of documents titled, "Quality Committee Meeting Minutes" dated January 22, 2015 through December 29, 2015 revealed the CAH quality committee did not evaluate the quality of treatments and services furnished by Nuclear Medicine, MRI, Physical Therapy, Occupational Therapy, Speech Therapy, and Anesthesia.

3. During an interview on 1/14/2016 at 7:55 AM, Staff A, Quality Assurance Leader agreed the quality improvement committee did not evaluate the identified contracted patient services.