HospitalInspections.org
Bringing transparency to federal inspections
WHITE ROCK MEDICAL CENTER
DATA COLLECTION & ANALYSIS
Tag No.: A0273
Based on interview and record review the hospital failed to ensure the Quality Improvement Committee met at least quarterly during the year 2018. The committee met 2 (1st & 4th quarters) out of 4 quarters.
Findings included:
During an interview with Personnel #1 she was asked by the surveyor to provide Quality Improvement comittee meeting minutes for the year 2018. Personnel #1 stated the committee only formally met the 1st and 4th quarters of 2018. She said with the recent sale of the hospital, things had been very busy. There had been informal discussions regarding QI concerns with other staff members and those concerns had been addressed, but there were no formal meeting minutes for the 2nd and 3rd quarters.
A review of the hospital's Organization Performance Improvement Plan with a revised date of 09/2018 reflected on page 3, "...The QIC [Quality Improvement Committee) meets at least quarterly..."