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ASCENSION ST JOHN MEDICAL CENTER
INTEGRATION OF OUTPATIENT SERVICES
Tag No.: A1077
Based on a review of policies and procedures, quality assurance/performance (QAPI) improvement meeting minutes and staff interviews, the facility failed to ensure the QAPI reviews were implemented into the housewide QAPI program.
Findings:
1. In the review of the QAPI meeting minutes for the last six months there was no evidence the Department (The Breast Care Center) participated in the hospital"s (St. John Medical Center) house wide QAPI, process, or findings.
2. During an interview with the Radiology Director on 03/01/11 at approximately 1125, the director confirmed that the Breast Care Center is not included in the hospital's QAPI process.