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Based on a review of the Inland Hospital Quality Improvement Committee meeting minutes of May 2010 along with interviews with the Chief Medical Officer, Chair of the Medical Staff Quality Improvement Committee, and the Director of Quality, on May 24, 2010, it was determined that the Inland Hospital Medical Staff did not identify opportunities for improvement or make changes that would lead to improvement.

The findings include:

1. The Inland Hospital Plan of Correction, dated May 10, 2010 states: " the Medical Staff Quality Improvement Committee will conduct a quarterly analysis of the effectiveness of quality indicators. "

2. The May Plan of Correction states: " In an effort to increase our systemic focus on quality, the MSQI Committee will conduct a thorough analysis of its peer review process and of the effectiveness of its existing quality indicators at its next meeting of May 11, 2010. The ultimate goal is to devote greater focus to systemic quality issues while maintaining effective peer review. Analysis of current indicators is underway and will be substantially completed on May 11, 2010. An analysis of the effectiveness of quality indicators will now occur on a quarterly basis. "

3. The minutes of the May 11, 2010 Medical Staff Quality Committee state: "The Committee looked each peer review category. The Committee found the following peer review indicators worthwhile and will continue them as present: mortality, tissue review, and blood product review. The committee noted that the blood product review and the letters generated to the physician are part of the educational process that the committee believes is effective."

4. The minutes do not contain a data driven analysis to support the Committee ' s finding that mortality and tissue review were "worthwhile" . There was no analysis to demonstrate these reviews were effective in changing physician behavior, or improving the quality of care delivered to patients or in reducing medical errors.

5. The minutes did not contain a systemic analysis of the effectiveness of the medical staff peer review process as stated in the plan of correction.

6. The minutes do not contain a data-driven analysis to support the Committee ' s " finding " that the blood product review and letters to physicians were effective in decreasing the number of, or severity of, blood product " fall outs " . There was no analysis of whether the program had changed the behavior of individual physicians or the behavior of the medical staff.

7. The same meeting minutes also state: " The Committee reviewed the utility of the CMS indicators; this data is reported nationally and available to consumers on the web. These items are part of the zero defects program. Not all items are consistently at a 100% " and " It was Moved, Seconded and Voted to continue tracking the CMS indicators. "

8. While the Committee voted to " continue tracking the CMS indicators " , there was no discussion of the mechanisms the Committee would put in place to determine the reasons that these " CMS Indicators " were not at 100%, and the mechanisms that would be employed to achieve this goal.

9. When the Committee discussed peer review cases, there was no analysis of systemic causes which resulted in the case falling out for peer review. Nor was there discussion of systemic causes that would prevent future adverse patient events. Nor evidence of implementation of preventive actions to prevent any future adverse events.

10. In an interview with the Chief Medical Officer and the Chair of the Medical Staff Quality Committee on May 14, 2010, the Chair of the Quality Committee stated that they had reviewed their existing indicators and they were satisfied that they was no reason to change them.

11. The Chair of the Quality Committee stated that a blood transfusion protocol had been created that would prevent the transfusion of blood to patients who did not meet criteria, but no evidence of that discussion or protocol was found in the minutes. Furthermore, there was no evidence in the meeting minutes of the protocol ' s effectiveness in preventing transfusion " fall outs " .

12. There was no evidence in the May 11, 2010 minutes that the committee considered the effectiveness of the existing indicators at identifying opportunities for improvement and changes that will lead to improvement.