HospitalInspections.org

Based on document review and staff interview, the critical access hospital (CAH) failed to ensure they had an effective quality assurance and performance improvement (QAPI) program which included performance improvement projects to improve patient care in the hospital. Evidence was lacking to indicate that QAPI activity was reported and documented on an ongoing basis in the following areas: radiology department, laboratory services, physical environment and contracted laundry services. This had the potential to affect all CAH patients.

Findings include:

Review of the radiology department QAPI program with the director of radiology on 10/29/13 at 9:00 a.m., revealed the department was working on a program, but "nothing formal." The director of radiology stated the department staff were monitoring turnaround times for STAT (immediate) reads on x-rays and computerized tomography (CT) exams. She stated this indicator had been implemented in February 2013. The director of radiology indicated the goal was 100% and had been met. The radiology director further revealed that this goal had not been revised since it had been implemented in 2011. No documentation was evident to indicate the goal had been tracked, monitored and/or revised.
During review of the QAPI program for laboratory services, the laboratory services manager was interviewed on 10/28/13 at 1:30 p.m.. The laboratory manager revealed the department currently did not have any formal QAPI program in place. The laboratory manager stated they had on-going audits in place for preventative measures, but documentation was lacking to show evidence that any indicators had been monitored and/or revised. No evidence was presented to confirm that indicators had been developed as a part of the QAPI program nor was documentation evident in QAPI meeting minutes. The laboratory director confirmed the lack of a current QAPI program and stated it would be beneficial.
The environmental services department did not have a current QAPI program in place. Review of the QAPI program with the environmental services/safety director on 10/29/13 at 1:00 p.m., indicated the department did not have any formal QAPI program currently in place to evaluate the contracted laundry and housekeeping services. In addition, the environmental services director stated she was not aware of what a QAPI program included. She stated that although concerns have been identified in each department, no objectives/goals, plans or evaluation had been implemented for the identified concerns.
Review of the 2013, organizational program improvement projects with the performance improvement director on 10/29/13 at 1:30 p.m., confirmed that reports, projects and/or activities were missing or did not include information about what these services were doing to evaluate and improve CAH services.
The Performance Improvement Plan/Quality Plan revised 9/11/13, identified the CAH as a continually evolving process and identified essential processes including: planning, process design, performance measurement, performance analysis, performance improvement, performance control/maintenance and shared learning. The plan identified a commitment to continually improve the methodologies and approaches employed in performance improvement. The above identified services were missing this information.