HospitalInspections.org

Based on a review of the appointment and reappointment process of the medical Staff by the Governing Body, as compared with the Medical Staff By-Laws, Rules and Regulations and staff interview, the Critical Access Hospital (CAH) failed to follow the by laws in the reappointment process.

This failed practice had the potential to affect all patients receiving services at the hospital.

The CAH reported a total of 355 acute inpatients for the most recent fiscal year.

Findings include:

1. The Medical Staff By-Laws Rules and Regulations Clinical Privileges Sections 2 Qualifications b. Competence, stated that practitioners must, 'Possess and maintain demonstrated clinical competence, including current knowledge, judgement and technique, in his or her specialty area and for all privileges held or applied for'.
In addition, the quality assurance requirements specified on page 44, " a systematic process for monitoring and evaluating the quality and appropriateness of the care and treatment of patients served by the Hospital and the clinical performance of all individuals with clinical privileges.

2. A review of the reappointment files of five (5) Active Medical Staff members and two (2) Courtesy Staff members lacked evidence of any specific data, numbers of procedures performed, quality of diagnosis and treatment or an assessment of clinical performance based on any of the quality systems currently in place in the CAH. (Members A,B,C,D,E,FG)

3. An interview conducted with the Director of Nursing, who oversaw the reappointment process, on 1/24/17 at 2:30 PM, confirmed that medical staff privileges were not tied to quality performance, as specified in the by-laws.