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Based on interview and record review, the facility failed to demonstrate how the blood utilization study affected health outcome, patient safety, or quality of care. The blood utilization study did not provide quality indicators that measured patient health outcome. There was no data available in tracking and trending patients that received blood. There was no starting hemoglobin for the patients in the transfusion study, or how this study improved the patients utilization of blood transfusion. No report was provided that demonstrated how an ongoing, hospital wide utilization of Blood products.

Findings:

During an interview on 6/3/15 at 2:10 p.m., Administrator 1 was asked to review a hospital wide ongoing QAPI projects. Administrator 1 stated the blood product utilization review study was hospital wide and involved mostly dialysis patients.

When asked to provide patient quality indicators, and how they were tracked for performance improvement over the study, no data was available to demonstrate improved patient outcome and sustained improvement. Administrator 1 was not able to provide transfusion criteria that were tracked in the study. There were no blood transfusion guidelines used to track patient improvement or response to blood transfusion. There was no data evaluating patient health care outcome, patient safety and quality of care.

During an interview on 6/3/15 at 2:30 p.m., Laboratory Coordinator 1, stated for two years, he collected data for Blood Products Utilization improvement study. The study tracked physicians ordering one or two red blood cell units for patients. When asked for the study, he stated he collected the study and compared blood usage by physicians that ordered either one or two unit of blood. There was no data for health outcome of patients that received one or two units of blood transfusion.

A review of the facility policy and procedure titled " Lakewood Regional Medical Center Medical General Rules and Regulations " dated March 17,2015, indicated the performance improvement committee,.. " ...shall identify and appraise all hospital performance improvement annually. The committee shall provide summary documenting activity and demonstrating relevant findings, actions taken and evidence of the program's impact on clinical performance, patient care, and patient safety, on a bimonthly basis. This report shall be presented to the Executive Committee, Governing Body, and Administration ".

Based on interview and record review, the facility failed to follow its own policy and procedure on physician immunization at time of credentialing. The medical staff credentialing files did not have documentation of physician immunization at the time of credentialing. This failure had a potential for harm to patients from the potential transmission of infections and communicable disease to patients.

Findings:

On 6/3/15 at 13:15 p.m., during a review of the medical staff credentialing file, ten of ten physician files reviewed did not have documentation of current immunization status for influenza or Hepatitis B.

On 6/3/15 at 2:10 p.m., during an interview with Medical Staff Coordinator 1, she stated the physician immunization information is being compiled and followed by Medical Executive Committee (MEC), and the Infection Control Preventionist. When Medical Staff Coordinator 1 was asked if she could show where the immunization status was one of the requirement for credentialing a physician, she stated the credentialing of a physician has not been denied based on immunization status.

On 6/3/15 at 14:35 p.m., the director of Clinical Quality Improvement (Administrator 1) stated there are many physician with privileges at the facility who might not meet the criteria for the immunization requirement. Administrator 1 was not able to show in the Medical Staff bylaws where some medical staff could be excluded from immunization.

A review of a document titled Influenza vaccination 2013-2014 indicated, the total number of Medical staff for 2013 to 2014 was 382 of which 35% received influenza vaccine. For the Influenza vaccination year 2014 to 2015, the total number of Medical Staff for 2014 to 2015 was 410 of which 25% received influenza vaccination. There was no information available on Hepatitis B status for any of the medical staff.

The Facility policy and procedure titled, "Clinical Safety policy: Immunization of Physicians...to prevent Transmission of Infectious Disease", dated 8/1/2007, indicated the purpose is to provide "the following immunizations free of charge: Hepatitis B; Influenza; MMR(measles, mumps and rubella);Tdap; Varicella. The policy indicated ".... draft a provision in the medical staff policies and procedures and/or rules and regulations to include the need for adherence to the Center for Disease Control and Prevention recommendations for immunizations." The Procedure indicated "... the Chief of staff and the Director of Medical Staff Office to include medical staff vaccination in the credentialing and re credentialing packets..."

A review of the facility policy and procedure titled, "Lakewood Regional Medical Center Medical Staff Bylaws", dated 1/15/2013, indicated medical staff..." abide by the medical staff bylaws, Rules and Regulations, and all other lawful standards, policies(procedures) of the medical staff and such hospital policies and procedures as have been approved by the MEC.