HospitalInspections.org

Based on document review and interviews with key staff members from March 1 through March 3, 2010 and April 21, 2010, it was determined that the failure of the governing body to enforce its Medical Staff bylaws, the failure of the governing body to ensure medical staff perform an analysis of the quality of care and determine opportunities to improve patient care by analyzing the effectiveness of its existing indicators, and the failure of the governing body to ensure that all members of the Outpatient Medicine department participate in quality improvement activities, indicates a serious deficiency in the scope and complexity of medical quality assurance and performance improvement activities.

Findings include:

The Medical Staff failed to enforce its bylaws, failed to perform an analysis of the quality of care and determine opportunities to improve patient care by analyzing the effectiveness of its existing indicators, and failed to enforce their bylaws and to ensure that all members of the Outpatient Medicine department participated in quality improvement activities related to improving health outcomes and preventing medical errors (For further information see Tags A0263 and A0338).

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

Based on document review and interviews with key staff members from March 1 through March 3, 2010 and April 21, 2010, it was determined that the failure of the Medical Staff to enforce its bylaws, the failure of the medical staff to perform an analysis of the quality of care and determine opportunities to improve patient care by analyzing the effectiveness of its existing indicators, the failure of the medical staff to enforce its bylaws and to ensure that all members of the Outpatient Medicine department participate in quality improvement activities, and the assertion by the Chief Executive Officer and the Chief Nursing Officer that a physician ' s employment status would be the determining factor of their compliance with the requirements to participate in departmental quality programs indicates a serious deficiency in the scope and complexity of medical quality assurance and performance improvement activities provided by the medical staff related to improving health outcomes and preventing medical errors.

Findings include:

1. 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 March 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. (For further information see CMS Form 2567 dated March 4, 2010.)

2. A Plan of Correction dated March 31, 2010, stated that the Medical Staff Quality Improvement Plan "was approved by the full Medical Staff on March 24, 2010 and by the Board of Trustees on March 25, 2010." The attached Medical Staff Quality Improvement Plan stated under 'Scope' that "the scope of this Plan is to include all Physicians, Dentists, Podiatrists, Allied health Practitioners, Contracted Physician Services, and Telemedicine Services of Inland Hospital."

3. The Inland Hospital Medical Staff Bylaws, Article X, Section 1, A defined Outpatient Medicine as a Department.

4. The Inland Hospital Medical Staff Bylaws, Article X, Section 3, K, describing duties of Chiefs, " Insure the Department's participation in the Hospital and Medical Staff Quality Improvement Plans ."

5. 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.

6. During a meeting with the Chief Nursing Officer and the Director of Quality on April 21, 2010, the Chief Nursing Officer contacted the Chair of Outpatient Medicine and was told that only members of the Department who were employed by the hospital were participating in the newly established quality measures. Those members of the department who were not employees, but who were members of the Medical Staff, were not currently participating.

7. In spite of the Medical Staff Quality Plan, the Medical Staff Bylaws, and the Conditions of Participation not limiting participation in the Medical Staff quality activities to employed physicians, ten (10) of thirty-one (31) members of the Outpatient Department were not expected by Inland Hospital to participate in the Medical Staff Quality Plan. The Chief Nursing Officer and the Quality Coordinator confirmed that there were thirty-one (31) members of the Outpatient Department, and, of these, ten (10) were not employed by the hospital and were not participating in the quality improvement initiative for their department. When asked about this, the Chief Nursing Officer and Quality Coordinator said that these practitioners were not currently participating.

8. The Chief Nursing Officer told the survey team that there were no plans to initiate corrective actions for those members of the medical staff who were not currently participating in the hospital ' s quality improvement activities.

9. The Medical Staff Bylaws, Article II, Section 2, A, I " I. maintain an organizational structure and mechanisms that allow continuous systematic monitoring and evaluation of patient care practices and provide opportunity to improve patient care and resolve identified problems.

10. Additionally, the Medical Staff Bylaws, Article XI, Section 7 describe the QIC duties: " The Q.I.C., acting pursuant to the Quality Improvement Plan, shall be the mechanism for disseminating information on the quality of patient care, as well as identifying opportunities for improvement by using a systematic process to measure patient care, and by offering alternatives to improve upon the patient care delivery process. "

11. The Medical Staff Quality Plan describes: " The Q.I.C. receives the indicators, guidelines and threshold from the Department Chairman. The Q.I.C. develops indicators and thresholds to study special areas of concern ... "

12. The minutes of the QIC for the thirteen months from January 2009 through January 2010 were reviewed. Thirty-six transfusions were reviewed, sixty (60) " quality " cases were reviewed, and fifty-six (56) surgical cases were reviewed. Of these, only one (1) transfusion case, three (3) " quality " case and zero (0) surgical cases resulted in a letter to the physician or other comment on the quality of care.

13. In a discussion with the Chief Medical Officer on April 21, 2010, he was asked if the Medical Staff QIC had done any analysis of its review process, or review indicators to determine if they were effective in identifying opportunities for improvement, he responded that the hospital was obligated to do peer review by the AOA (American Osteopathic Association), " there is no requirement that we have to find anything, what is wrong with a negative review? " and " Where does it say that we have to find problems ?"

14. At the same interview, when asked if there had been any discussion about the Inland Hospital Quality indicators by the Medical Staff QIC to determine if they were effective in improving patient care, he responded that " we are quite satisfied with our indicators and see no reason to change them. "

15. In a teleconference with the Chief Executive Officer, the Chief Nursing Officer, the Director of Quality, the Chief Medical Officer, and members of the Survey Team on April 13, 2010, the Chief Medical Officer stated that the discussions at the Medical Staff QIC were used to identify opportunities for systemic improvement. When asked on April 21, 2010 to give examples of case reviews in the previous year that had identified any opportunities for systemic improvement, he responded that he could not and, " I don ' t know why you are critical of peer review, but there is nothing wrong with our review process " .


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

Based on document review and interviews with key staff members from March 1 through March 3, 2010 and April 21, 2010, it was determined that the failure of the Medical Staff to enforce its bylaws, the failure of the medical staff to perform an analysis of the quality of care and determine opportunities to improve patient care by analyzing the effectiveness of its existing indicators, the failure of the medical staff to enforce its bylaws and to ensure that all members of the Outpatient Medicine department participate in quality improvement activities, and the assertion by the Chief Executive Officer and the Chief Nursing Officer that a physician ' s employment status would be the determining factor of their compliance with the requirements to participate in departmental quality programs indicates a serious deficiency in the duties of the Inland Hospital Medical Staff.

Findings include:

1. 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 March 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. (For further information see CMS Form 2567 dated March 4, 2010.)

2. A Plan of Correction dated March 31, 2010, stated that the Medical Staff Quality Improvement Plan "was approved by the full Medical Staff on March 24, 2010 and by the Board of Trustees on March 25, 2010." The attached Medical Staff Quality Improvement Plan stated under 'Scope' that "the scope of this Plan is to include all Physicians, Dentists, Podiatrists, Allied health Practitioners, Contracted Physician Services, and Telemedicine Services of Inland Hospital."

3. The Inland Hospital Medical Staff Bylaws, Article X, Section 1, A defined Outpatient Medicine as a Department.

4. The Inland Hospital Medical Staff Bylaws, Article X, Section 3, K, describing duties of Chiefs, " Insure the Department's participation in the Hospital and Medical Staff Quality Improvement Plans ."

5. 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.

6. During a meeting with the Chief Nursing Officer and the Director of Quality on April 21, 2010, the Chief Nursing Officer contacted the Chair of Outpatient Medicine and was told that only members of the Department who were employed by the hospital were participating in the newly established quality measures. Those members of the department who were not employees, but who were members of the Medical Staff, were not currently participating.

7. In spite of the Medical Staff Quality Plan, the Medical Staff Bylaws, and the Conditions of Participation not limiting participation in the Medical Staff quality activities to employed physicians, ten (10) of thirty-one (31) members of the Outpatient Department were not expected by Inland Hospital to participate in the Medical Staff Quality Plan. The Chief Nursing Officer and the Quality Coordinator confirmed that there were thirty-one (31) members of the Outpatient Department, and, of these, ten (10) were not employed by the hospital and were not participating in the quality improvement initiative for their department. When asked about this, the Chief Nursing Officer and Quality Coordinator said that these practitioners were not currently participating.

8. The Chief Nursing Officer told the survey team that there were no plans to initiate corrective actions for those members of the medical staff who were not currently participating in the hospital ' s quality improvement activities.

9. The Medical Staff Bylaws, Article II, Section 2, A, I " I. maintain an organizational structure and mechanisms that allow continuous systematic monitoring and evaluation of patient care practices and provide opportunity to improve patient care and resolve identified problems.

10. Additionally, the Medical Staff Bylaws, Article XI, Section 7 describe the QIC duties: " The Q.I.C., acting pursuant to the Quality Improvement Plan, shall be the mechanism for disseminating information on the quality of patient care, as well as identifying opportunities for improvement by using a systematic process to measure patient care, and by offering alternatives to improve upon the patient care delivery process. "

11. The Medical Staff Quality Plan describes: " The Q.I.C. receives the indicators, guidelines and threshold from the Department Chairman. The Q.I.C. develops indicators and thresholds to study special areas of concern ... "

12. The minutes of the QIC for the thirteen months from January 2009 through January 2010 were reviewed. Thirty-six transfusions were reviewed, sixty (60) " quality " cases were reviewed, and fifty-six (56) surgical cases were reviewed. Of these, only one (1) transfusion case, three (3) " quality " case and zero (0) surgical cases resulted in a letter to the physician or other comment on the quality of care.

13. In a discussion with the Chief Medical Officer on April 21, 2010, he was asked if the Medical Staff QIC had done any analysis of its review process, or review indicators to determine if they were effective in identifying opportunities for improvement, he responded that the hospital was obligated to do peer review by the AOA (American Osteopathic Association), " there is no requirement that we have to find anything, what is wrong with a negative review? " and " Where does it say that we have to find problems ?"

14. At the same interview, when asked if there had been any discussion about the Inland Hospital Quality indicators by the Medical Staff QIC to determine if they were effective in improving patient care, he responded that " we are quite satisfied with our indicators and see no reason to change them. "

15. In a teleconference with the Chief Executive Officer, the Chief Nursing Officer, the Director of Quality, the Chief Medical Officer, and members of the Survey Team on April 13, 2010, the Chief Medical Officer stated that the discussions at the Medical Staff QIC were used to identify opportunities for systemic improvement. When asked on April 21, 2010 to give examples of case reviews in the previous year that had identified any opportunities for systemic improvement, he responded that he could not and, " I don ' t know why you are critical of peer review, but there is nothing wrong with our review process " .


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