HospitalInspections.org

Based on document review and staff interview, it was determined the facility did not ensure that the Surgical Department measured, analyzed and tracked quality indicators that assess performance of clinical services. This is evident for the NeuroInterventional Surgery Program.


Findings include:

The NeuroInterventional Surgery Program was started in February of 2015.
The program treats patients with aneurysms and blood clots in the brain; using various neurointerventional techniques for revascularization and thrombectomy of ischemic stroke and coil embolization of hemorrhagic aneurysmal stroke.
Since the beginning of the program, there has been no documented evidence of submission of quality improvement data to the hospital's Quality Assurance Program.

During interview on 1/8/16 at 1:30 PM, witnessed by Employee #1, of QA department, the physician stated that her experience in the coiling procedures prior to this facility was limited to 2 procedures performed during her fellowship. She also stated that she has attempted to remove clots from patients up to 24 hours after a stroke depending on whether the patient could tolerate the procedure and benefit from it.
The physician was asked to share the data of the morbidity and mortality within the program since its inception. The physician stated that she could by the following day.
The physician and the facility did not submit any quality improvement data while surveyors were at the facility.

There was no documented evidence that the facility's Quality Assurance Program ensured that the NeuroInterventional Surgery Program had quality indicators, including adverse events, that were analyzed and tracked to assess patient care service and identify areas for improvement for this new and innovative method of treatment.