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Based on review of the Governing Board Meeting Minutes for November 2009, review of Departmental Quality data, and interview with the Chief Medical Officer, the Chief Nursing Officer, the Chief Executive Officer, the Chief of Anesthesia Services and the Director of Performance Improvement from March 1 through March 3, 2010, it was determined that the Governing body failed to assure that all areas of the hospital participated in the Hospital Quality Plan for 2010.

Findings include:

1. The Inland Hospital Medical Staff Quality Plan approved December 18, 2008 stated: " The Quality Improvement Plan will be updated annually. "

2. The November 2009 Inland Board meeting minutes stated that the 2010 Hospital Quality Plan was approved; however, this plan did not contain an updated Medical Staff Quality Plan. Therefore, at the time of the survey, the Medical Staff Quality Plan was over fourteen months old, and the Governing Body had adopted a hospital-wide plan without any medical staff indicators.

3. There was no documentation of Anesthesia quality improvement indicators or activities. This was confirmed by a review of meeting minutes of the Department of Surgery and in an interview with the Chief of Anesthesia.

4. There was no documentation that seven departments of the hospital (Laboratory, Rehab Works, Cardiopulmonary, Materials Management, Safety Engineering, Environmental Services and HIMS) reported to the Governing Board on Quality Improvement Initiatives for the year 2009.

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

Based on a review of the minutes of the Inland Hospital Medical Staff Quality Improvement Committee, the minutes of the Departments of Inpatient Medicine, Outpatient Medicine, Surgery, and Emergency Medicine, as well as interviews with the Chief Medical Officer, the Chief Nursing Officer, and the Chief Executive Officer from March 1, through March 3, 2010, it was determined that Inland Hospital did not have an effective, ongoing, data driven quality improvement and performance improvement program that reflected the scope and complexity of medical services provided by the medical staff related to improving health outcomes and preventing medical errors.
Findings include:

1. The Inland Hospital Medical Staff Quality Plan approved December 18, 2008 stated: "The Quality Improvement Plan will be updated annually. "

2. The November 2009 Inland Board meeting minutes stated that the 2010 Hospital Quality Plan was approved, however, this plan did not contain an updated Medical Staff Quality Plan. Therefore, at the time of the survey, the Medical Staff Quality Plan was over fourteen months old, and the Governing Body had adopted a hospital-wide plan without any medical staff indicators.

3. At the time of the survey, there was no evidence in the minutes of the Medical Staff Quality Improvement Committee that a draft 2010 Quality Improvement Plan had been written or discuessed, nor had the Committee or Medical Staff re-approved the 2009 Medical Staff Quality Plan. This was confirmed by the Chief Medical Officer.

4. The Inland Hospital Medical Staff Bylaws, Article X, Section 1, A defined Outpatient Medicine as a Department. There was also a Service of Women and Children ' s Health.

5. The April 2009 minutes of the Medical Staff Quality Improvement Committee stated, " Birthing center had 2 fetal events and 1 maternal event. Our C-section rate the AOA has asked where we stand. We are tracking this rate but are not requiring reporting quality of care. Currently we are tracking data within the birthing center that we have not set up goals for. Department of Surgery tracks OB statistics. "

6. The Chief Medical Officer and the Chief Nursing Officer confirmed in meetings on March 3rd 2010 that there were no Obstetrical quality improvement indicators for 2009 through the time of the survey.

7. There were no Outpatient Medicine quality improvement indicators. This was confirmed in a review of the 2009 Medical Staff Quality Plan, the minutes of the Outpatient Department, the Medical Staff Quality Improvement Committee, and further confirmed in an interview with the Chief Medical Officer on March 2nd and 3rd. In the same interview, he confirmed that there were no Outpatient Medicine quality improvement indicators in development by the Outpatient Medicine Chief as stipulated in the Medical Staff Bylaws, Article X, Section 3.

8. The Chief Medical Officer stated in a meeting on March 2, 2009 that he knew prior to our survey, that there were no Outpatient Medicine indicators, and that these needed to be developed.

9. The Chief Executive Officer, in a meeting on March 3, 2009, said that the Governing Body was aware that there were no Anesthesia quality indicators.

10. Both the Chief Executive Officer and the Chief Medical Officer expressed concern, in meetings on March 3rd, 2010, that members of the Outpatient Medicine Department who were not employees of the Hospital might not participate in quality improvement activities once indicators were developed.

11. The Medical Staff Quality Improvement Committee meeting minutes were reviewed from January 2009 through January 2010. Of the sixty (60) cases reviewed in this period, all but three, (3) were considered " appropriate " . Of the three that were not " appropriate " , the final results were not complete in two (2) cases at the time of the survey. Only one (1) case resulted in a letter being sent to the provider. While the Medical Staff Quality Improvement Committee reviewed cases for over a year, there was no tabulation of the results of the reviews, no trending of the data, nor any reassessment of this process to determine if they were identifying opportunities for improvement. There was no reassessment of the effectiveness of the review process, and no discussion of mechanisms to identify or prevent or reduce medical errors.

12. According to a document titled " Med-Surg Scope of Care 2010" given to the survey team by the Chief Nursing Officer on March 3rd, the Hospital ' s Scope of Services includes high volume services such as endoscopy. In a review of the Medical Staff Quality Plan and a review of the meeting minutes of the Departments of Inpatient Medicine and Surgery, and confirmed by the Chief Medical Officer, no quality indicators have been created for endoscopic services. The Chief Medical Officer stated that he did not believe that the medical staff quality improvement activities need include these high risk, high volume or problem prone services.

13. Additionally, there were no anesthesia indicators or process improvement activities (for further information see Tag A-1000).

14. The hospital failed to assure that all outpatient departments participated in the hospital-wide quality assurance program and reported to the governing body (for further information see Tags A-267 and A-277).
The cumulative effect of these deficient practices resulted in this Condition of Participation being out of compliance.

Based on document review and interview with key staff on March 3, 2010, it was determined that the hospital failed to ensure that all out patient departments participated in measuring, analyzing, and tracking quality indicators.

The evidence is as follows:

1. During a review of ten (10) outpatient areas on March 3, 2010, it was noted that three (3) of the departments (IMS Internists, Inland Orthopedists, and Heart First Cardiology Associates) did not participate in the hospital wide Quality Assurance program.

2. This was confirmed during interviews with the respective practice managers and the Specialty Practice Administrator on March 3, 2010.

Based on interview with the Director of Performance Improvement and review of Departmental Quality data on March 3, 2010, it was determined that the hospital failed to have all services reported to the hospital governing body on an annual basis.

The findings are as follows:

1 There was no documentation that seven departments of the hospital (Laboratory, Rehab Works, Cardiopulmonary, Materials Management, Safety Engineering , Environmental Services and HIMS) reported to the Governing Board on Quality Improvement Initiatives for the year 2009.

2. This was confirmed with and interview with the Director of Performance Improvement on March 3, 2010.

Based on a review of the minutes of the Inland Hospital Medical Staff Quality Improvement Committee, the minutes of the Departments of Inpatient Medicine, Outpatient Medicine, Surgery, and Emergency Medicine, as well as interviews with the Chief Medical Officer, the Chief Nursing Officer, and the Chief Executive Officer from March 1 through March 3, 2010, it was determined that the Inland Hospital Medical Staff was not responsible for the quality of care provided to patients at Inland Hospital.

Findings include:

1. The Inland Hospital Medical Staff Quality Plan approved December 18, 2008 stated: "The Quality Improvement Plan will be updated annually. "

2. The November 2009 Inland Board meeting minutes stated that the 2010 Hospital Quality Plan was approved; however, this plan did not contain an updated Medical Staff Quality Plan. Therefore, at the time of the survey, the Medical Staff Quality Plan was over fourteen months old, and the Governing Body had adopted a hospital-wide plan without any medical staff indicators.

3. At the time of the survey, there was no evidence in the minutes of the Medical Staff Quality Improvement Committee that a draft 2010 Quality Improvement Plan had been written or discussed, nor had the Committee or Medical Staff re-approved the 2009 Medical Staff Quality Plan, This was confirmed by the Chief Medical Officer.

4. The Inland Hospital Medical Staff Bylaws, Article X, Section 1, A defined Outpatient Medicine as a Department. There was also a Service of Women and Children ' s Health.

5. The April 2009 minutes of the Medical Staff Quality Improvement Committee stated, " Birthing center had 2 fetal events and 1 maternal event. Our C-section rate the AOA has asked where we stand. We are tracking this rate but are not requiring reporting quality of care. Currently we are tracking data within the birthing center that we have not set up goals for. Department of Surgery tracks OB statistics. "

6. The Chief Medical Officer and the Chief Nursing Officer confirmed in meetings on March 3rd 2010 that there were no Obstetrical quality improvement indicators for 2009 through the time of the survey.

7. There were no Outpatient Medicine quality improvement indicators. This was confirmed in a review of the 2009 Medical Staff Quality Plan, the minutes of the Outpatient Department, the Medical Staff Quality Improvement Committee, and further confirmed in an interview with the Chief Medical Officer on March 2nd and 3rd, In the same interview, he confirmed that there were no Outpatient Medicine quality improvement indicators in development by the Outpatient Medicine Chief as stipulated in the Medical Staff Bylaws, Article X, Section 3.

8. The Chief Medical Officer stated in a meeting on March 2, 2009 that he knew prior to our survey, that there were no Outpatient Medicine indicators, and that these needed to be developed.

9. The Chief Executive Officer, in a meeting on March 3, 2009, said that the Governing Body was aware that there were no Anesthesia quality indicators.

10. Both the Chief Executive Officer, and the Chief Medical Officer, expressed concern, in meetings on March 3rd, 2010, that members of the Outpatient Medicine Department who were not employees of the Hospital might not participate in quality improvement activities once indicators were developed.

11. The Medical Staff Quality Improvement Committee meeting minutes were reviewed from January 2009 through January 2010. Of the sixty (60) cases reviewed in this period, all but three, (3) were considered " appropriate " . Of the three that were not " appropriate " , the final results were not complete in two (2) cases at the time of the survey. Only one (1) case resulted in a letter being sent to the provider. While the Medical Staff Quality Improvement Committee reviewed cases for over a year, there was no tabulation of the results of the reviews, no trending of the data, nor any reassessment of this process to determine if they were identifying opportunities for improvement. There was no reassessment of the effectiveness of the review process, and no discussion of mechanisms to identify or prevent or reduce medical errors.

12. According to a document titled " Med-Surg Scope of Care 2010" given to the survey team by the Chief Nursing Officer on March 3rd, the Hospital ' s Scope of Services includes high volume services such as endoscopy. In a review of the Medical Staff Quality Plan and a review of the meeting minutes of the Departments of Inpatient Medicine and Surgery, and confirmed by the Chief Medical Officer, no quality indicators have been created for endoscopic services. The Chief Medical Officer stated that he did not believe that the medical staff quality improvement activities need include these high risk, high volume or problem prone services.

13. Additionally, there were no anesthesia indicators or process improvement activities, (for further information see Tag A-1000).

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

Based on a review of the meeting minutes of the Surgical Department, the Medical Staff Quality Plan and in interviews with the Chief of Anesthesia and the Chief Medical Officer on March 3, 2010, it was determined that the Hospital cannot assure that anesthesia services are being provided in a safe or appropriate manner.
Findings include:

1. At the time of the Survey, there were no Anesthesia quality improvement indicators. This was confirmed by a review of meeting minutes of the Department of Surgery and in an interview with the Chief of Anesthesia.

2. There were no quality improvement activities being performed by the anesthesia service at the time of the survey. This was confirmed by a review of meeting minutes of the Department of Surgery and in an interview with the Chief of Anesthesia

3. The minutes of the August 2009 Medical Staff Quality Improvement Committee stated: " The hospital had AOA deficiencies regarding Anesthesia QI. Dr. (Chief of Anesthesia) presented a review of what Anesthesia plans for quality improvement indicators. They plan to do 100% chart review for " time of post op visit " which will include a post op note "

4. An interview with the Chief of Anesthesia on March 3, 2010 confirmed that anesthesia quality improvement indicators including targets for process improvement were not in place or being performed.

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

Based on review of Emergency Department medical records, Hospital policies and procedures, the Hospital-wide Quality Plan for 2010, the Hospital Medical Staff Rules and Regulations, the hospital 's Plan of Correction dated February 18, 2010, and interviews with the Director of Emergency Services and the VP of Medical Affairs on March 1 through March 3, 2010, it was determined that as of March 3, 2010 the hospital failed to complete or initiate the intense analysis of the care and transfer of Patient A.

Findings include:

1. The Hospital Quality Plan, that was adopted November 2009, states that the Medical Staff will, " ....Participate in conducting root cause analysis of sentinel events and intense analysis of clinical functions when undesirable patterns or trends are identified through risk management reporting or patient complaints. "

2. An interview conducted with the Director of Emergency Services indicated that the intense analysis of the care and transfer of Patient A had not been initiated or completed at the time of survey on March 3, 2010. Therefore, without the intense review as required by the Hospital Quality Plan, the causes of the event had not been fully determined and could not be remedied.

3. The hospital had not fully implemented their Plan of Correction submitted on February 26, 2010. Please see Tag A-1104 for further information.

The cumulative effect of these deficient practices resulted in this Condition of Participation continuing to be out of compliance.

Based on review of emergency department medical records, hospital policies and procedures, the hospital-wide quality plan for 2010, the hospital's medical staff rules and regulations, the hospital's Plan of Correction dated February 18, 2010 and interviews with the Director of Emergency Services and the VP of Medical Affairs on March 1-3, 2010, it was determined as of February 26, 2010, the hospital medical staff had failed to fully implement their Plan of Correction.

Findings include:

1. A review of Inland Hospital's Plan of Correction dated February 18, 2010 indicated that a letter was sent to the Chief of Staff requesting that the Medical Executive Committee consider corrective action concerning the performance of the physicians involved in the care of the patient.

2. A review of the Medical Executive Committee meeting minutes dated February 24, 2010, indicated that an Ad Hoc Committee was established to review the incident and make recommendations to the Medical Executive Committee for corrective action on April 14, 2010.

3. During an interview with the VP of Medical Affairs on March 2, 2010, it was confirmed that a committee had been formed to review the incident. However, the review had not been completed as of March 3, 2010.

4. Inland Hospital's Emergency Department Scope of Care policy dated January 2010 indicated, under Performance Improvement, "...issues of an immediate nature are investigated by the ED Director or designee. Issues requiring immediate action will be addressed using the mechanism specified in the hospital's Unresolved Patient Care Issues procedure..."

5. Inland Hospital's Performance Improvement Plan for FY 2010, approved by the Board of Trustees in November 2009, indicated, "...The Medical Staff at Inland Hospital participates in organizational performance improvement...Participate in conducting...intense analysis of clinical functions when undesirable patterns or trends are identified through risk management reporting or patient complaints..."

6. As of March 3, 2010, there has been no intense analysis of the incident as identified in the Hospital's Quality Plan. This was confirmed during interviews on March 1-3, 2010 with the VP of Medical Affairs and the President of Inland Hospital.