HospitalInspections.org

Based on document review and staff interview it was determined the hospital failed to ensure the professional group that develops and reviews facility policies includes a mid level Practitioner such as an Physician Assistant or Nurse Practitioner who is a member of the hospital staff. When a mid level Practitioner is not involved in policy development and review, it can result in missed opportunities for improvement in clinical services which can impact patient outcomes.

Findings include:

Review of the current medical staff roster revealed there is a Nurse Practitioner who is listed as an active medical staff member. Review of the hospital policy and procedure committee meeting minutes (dated 5/16/14) revealed the Nurse Practitioner was not a member of the committee.

The Performance Improvement Specialist reviewed the above documents on 8/19/14 at 1245 hours. She concurred they do have a Nurse Practitioner on active staff. Also, she agreed the Nurse Practitioner was not a member of the policy and procedure committee.