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Based on review of policies/procedures, documentation, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to include external peer review results during the credentialing process for all practitioners that provided care and services to the CAH patients for 2 of 2 practitioners reviewed. (Practitioners A, B) The CAH administrative staff reported a current census of 16 patients.

Failure to ensure an external entity evaluated the quality and appropriateness of the diagnosis and treatment furnished by doctors at the CAH could potentially result in medical staff members misdiagnosing patients and/or providing inappropriate or substandard patient care.

Findings include:

1. Review of documentation for the past credentialing period of 2 years revealed the CAH quality staff failed to include external peer review results during the credentialing process for all practitioners that provided care and services to the CAH patients (Practitioners A, B):
Practitioners A, B re-credentialed on 3/14/2011 by the Medical Staff and on 3/29/2011 by the Board of Directors revealed charts sent out on 3/24/2011 and results not available for review at the time of re-appointment.

2. Review of the CAH policy/procedure on 3/29/11 titled, "Quality Assessment/Performance Improvement (QA/PI) Peer Review", dated reviewed 11/18/10, revealed the following in part, ". . .[Network Hospital] will participate in our peer review process by conducting an annual review of a random sample of medical records, which include records of each member of our active medical staff. . . as well as specialty staff. . . ."

Review of the CAH Network agreement dated 10/26/2006 revealed the following in part, ". . . [Network Hospital] shall assist the hospital in reviewing the quality and appropriateness of the diagnoses and treatment furnished by hospital's physicians and other practitioners on an annual basis for purposes of assisting hospital in carrying out the requirements of its quality plan. . . ."

3. During an interview on 3/29/11 at 3:50 PM, the Director of Medical Records and the Chief Executive Officer stated the CAH administrative staff had sent records for Practitioners A, B external peer review. The Director of Medical Records further acknowledged the results of the external peer review for Practitioners A, B had not been returned and were not available for Medical Staff and Board of Trustees review during the re-appointment completed for Practitioners A, B on 3/29/2011. The Director of Medical Records confirmed Practitioners A, B had provided services to patients of the CAH during the last credentialing period.




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