HospitalInspections.org

Based on interview and review of the hospital's quality improvement plan and governing body meeting minutes, the hospital's governing body failed to specify the frequency of data collection performed by hospital staff members.

Findings:

1. The hospital's policy and procedure entitled "Quality Improvement and Safety Plan (QISP)" (Policy 395.00; Reviewed 10/18/2011) stated that the hospital's quality committees and groups, including the Board of Directors, would determine the frequency of data aggregation and analysis.

2. Review of the governing body meeting minutes for 9/29/2011 and 1/26/2012 revealed that results of quality metrics were presented to the Board of Directors by the Vice President of Quality. There was no evidence in the minutes that board members provided feedback regarding data collection frequency.

3. On 7/11/2012 at 9:40 AM, Surveyor #1 conducted a telephone interview with the Director of Quality and Clinical Support (Staff Member #1) and a nurse representative of the healthcare system's Safety and Regulatory Compliance unit (Staff Member #2). During this interview, these hospital staff members stated that the frequency and detail of data collection regarding quality indicators was not specified by the Board of Directors. This was done by hospital leaders.
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