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Based on review of the hospital organization chart, the Joint Operating Board (JOB) Bylaws, the proposed fiscal year (FY) 2023 budget, review of policies and procedures, and interviews, the hospital failed to ensure the Governing Body was effective and legally responsible for the conduct of the hospital. This deficient practice had the potential to affect all patients receiving services in the hospital, clinics, and all hospital employees.

Findings include:

1. The hospital failed to ensure one individual was responsible for the medical staff of the hospital (Refer to A0053).

2. The hospital failed to ensure one Administrator had the authority to manage the entire hospital (Refer to A0057).

3. The hospital failed to ensure the Governing Body had the overall authority to develop and implement the hospital budget (Refer to A0077).

4. The hospital failed to ensure policies and procedures were developed for the Fast Track area of the Emergency Department. (Refer to A1104)

Based on review of the hospital organization chart and interviews, the hospital failed to ensure one individual was responsible for the medical staff of the hospital and locations operating under the hospital Centers for Medicare and Medicaid Services Certification Number (CCN). This deficient practice had the potential to affect all patients receiving services in the hospital, clinics, and all employees.

Findings include:

Review of the hospital's organizational chart dated 02/15/21 revealed Organization (ORG)1 and ORG2 oversee the hospital Governing Body (Joint Operating Board). The organizational chart revealed a Chief Medical Information Officer (CMIO), and a Chief Medical Officer (CMO) were under the direction of the hospital Administrator and were responsible for ORG1's medical staff. The organizational chart did not identify a CMO position for responsibility of ORG2's medical staff.

During an interview on 06/21/23 at 12:05 PM, the Administrator, employed by ORG1, stated when he assumed the title of Administrator, the hospital had two CMOs. One CMO was responsible for ORG1's medical staff and one CMO was responsible for ORG2's medical staff. The Administrator stated the hospital organizational chart last revised in 2021, did not identify ORG2's CMO position. The Administrator stated the hospital and other locations owned by ORG1 and ORG2 operate under the hospital's CCN. The Administrator stated when ORG1's CMO position became vacant, he decided to split the CMO full time position into two one half time positions. The Administrator stated CMO1 was responsible for medical staff under all hospital-based practices and CMO2 was responsible for medical staff at the specialty clinics.

During an interview on 06/21/23 at 3:25 PM, Medical Director (MD)1, employed by ORG1 as CMO, stated he was appointed to the position approximately three weeks ago and works one-half of his time as CMO. MD1 stated he was responsible for ORG1's inpatient services on the hospital campus that include medical staff of the hospitalist group, Pediatric Intensive Care Unit (PICU) group, radiology, and anesthesia. MD1 confirmed he has oversight for only part of the hospital medical staff.

During an interview on 06/21/23 at 3:35 PM, MD2, employed by ORG1 as CMO, stated he was appointed to the CMO position about three weeks ago. MD2 stated he was responsible for medical staff at ORG1's subspecialty locations that have clinics including the internal medicine clinic, the pulmonology clinic, cardiology clinic, general surgery clinic, orthopedics, and urology clinics. MD2 stated he works one-half time as CMO and one-half time as an infection control provider at the hospital. MD2 confirmed he does not provide oversight to the ORG2's clinic providers. MD2 stated the Quality Assurance Medical Director (QAMD) of ORG2 was "viewed as" the CMO of the ORG2's providers.

During an interview on 06/22/23 at 10:00 AM, QAMD, employed by ORG2, stated she was listed on the hospital organizational chart as the Quality Assurance Medical Director, but she actually was the CMO equivalent for ORG2. QAMD stated she was responsible for the medical staff who work in ORG2's locations.

Based on review of the hospital organization chart and interviews, the hospital failed to ensure the hospital and locations operating under the hospital Centers for Medicare and Medicaid Services Certification Number (CCN) were under the authority and direction of one Administrator. This deficient practice had the potential to affect all patients receiving services in the hospital, clinics, and all employees.

Findings include:

Review of the hospital organizational chart dated 02/15/21 revealed Organization (ORG)1 and ORG2 have oversight of the hospital Joint Operating Board (JOB), the hospital Governing Body. The Administrator, who was employed by ORG1, was under the direction of the JOB. The organizational chart revealed the Emergency Department Fast Track, Anchorage Native Primary Care Clinic, the Gottlieb Building Obstetrical/Gynecology, Gottlieb Building Maternal Fetal Medicine, Outpatient Physical Therapy, Complementary Medicine, Health Education, Audiology, Specialty Pediatrics Clinic, Gottlieb Building Family and Development Services, and the Sleep Laboratory were under the direction of Vice President of Medical Services (VPMS), who was employed by ORG2.

During an interview on 06/21/23 at 11:00 AM, the Governing Body Chairperson (GBC), an employee of ORG1, stated ORG1 and ORG2 created the JOB to be the Governing Body of the hospital. The Administrator was responsible for providing oversight to the hospital and other ORG1 locations where services are provided. VPMS was ORG2's administrator and has responsibility and oversight for locations owned by ORG2. The GBC stated all locations operate under the hospital's CCN.

During an interview on 06/21/23 at 12:05 PM, the Administrator stated he was an employee of ORG1 and is the Administrator for the hospital. The Administrator stated he reports directly to ORG1's Chief Operating Officer (CEO). As the Administrator, he has responsibility and oversight for most areas and locations of the hospital operating under the hospital's CCN. The Administrator stated he does not have responsibility or oversight for locations under the hospital CCN that include, the Emergency Department Fast Track, Anchorage Native Care Clinic, the Gottlieb Building Obstetrical/Gynecology, Maternal Fetal Medicine, Outpatient Physical Therapy, Complementary Medicine, Health Education, Audiology, and Child Family and Development Services. The Administrator stated the VPMS at ORG2 has responsibility for ORG2's outpatient clinics. The Administrator confirmed only the acute care hospital and clinics that are owned by ORG1 report to him.

During an interview on 06/21/23 at 1:30 PM, CEO1, employed by ORG2, stated she was the CEO of ORG2 and has supervisor oversight of ORG2's VPMS Administrator. CEO2 stated her responsibilities as President/CEO include co-managing the hospital with ORG2. CEO2 stated the Administrator has ultimate responsibility for ORG1, but ORG2 has not granted the Administrator authority to "be the boss of their [ORG2] employees."

Based on review of the Joint Operating Board (JOB) Bylaws, proposed fiscal year (FY) 2023 budget, and interviews, the hospital failed to ensure the Governing Body had the overall authority to develop and implement the hospital budget. This deficient practice had the potential to affect all patients receiving services in the hospital, clinics, and all employees.

Findings include:

Review of the hospital document dated 12/02/98 and revised on 02/19/20 titled, "Joint Operating Board Bylaws Alaska Native Medical Center" revealed, " ...The Alaska Native Tribal Health Consortium (ANTHC) and the Southcentral Foundation (SCF) adopt the following Bylaws for the shared and unified Operation of Alaska Native Medical Center (ANMC), defined here as both the hospital and the Anchorage Native Primary Care Center. These Bylaws are intended to guide the Joint Operating Board (as defined in Section 1.2 hereof) and the ANMC, and its interactions with the ANTHC and SCF executive management. In the event of conflict between The Joint Operating Board Bylaws and the Articles of Corporation or Bylaws of either the ANTHC or SCF, the Articles and Bylaws of the individual corporations shall prevail ...The Joint Operating Board will oversee and emphasize the development of an effective, appropriate ANMC planning process, and shall recommend an overall plan and annual budget that reflects the annual operating budget prepared by management. The Joint Operating Board will accomplish this work using its standing committee process, and in direct consultation with the ANMC Administrator ...The ANTHC Board of Directors is ultimately responsible for the elements of ANMC operations and related resources identified in its compact and/or contracts with the Federal Government. The SCF Board of Directors is ultimately responsible for the elements of the ANMC operations and related resources identified in its compact and/or contracts with the Federal Government ...Each Board of Directors must authorize a level of funding for the ANMC operations in their respective compacts and/or contracts, which will be used to construct the ANMC operating budget. The Joint Operating Board will review the operating budget constructed by ANMC management. Upon approval of the Joint Operating Board, the proposed operating budget is forwarded to the respective Board of Directors for approval ...It shall be the responsibility of the Chairperson of the ANMC Joint Operating Board to obtain the approval required by the Boards of Directors of the ANTHC and SCF, in accordance with policy, procedure and protocol negotiated incidental to these Bylaws ..."

Review of the undated "Joint Operating Board Reporting Form" revealed the Chief Financial Officer (CFO), employed by Organization (ORG)2 submitted ORG2's proposed FY 2023 budget for review and approval by the JOB.

Review of the undated "Joint Operating Board Reporting Form" revealed the Vice President of Finance (VPF), employed by ORG1 submitted ORG1's proposed FY 2023 budget for review and approval by the JOB.

During an interview on 06/21/23 at 11:00 AM, the Governing Body Chairperson (GBC), employed by ORG1, stated the JOB was the Governing Body for the hospital and has members from both ORG1 and ORG2. The GBC stated ORG1 and ORG2 oversee certain hospital locations and services that make up the hospital. The boards of ORG1 and ORG2 retain ultimate authority of the hospital. The GBC stated ORG1 submits a budget for the locations they oversee, and ORG2 submits a budget for the locations they oversee. The GBC stated the JOB has a budget committee and two budgets and two capital funds are presented separately by ORG1 and ORG2 to the JOB. The GBC stated, "they [ORG2 sites] are not approved by the JOB. We don't approve the primary care budget which is under [ORG2]. We approve the [ORG1] budget but not the [ORG2] budget."

During an interview on 06/23/23 at 9:00 AM the VPF, employed by ORG1, stated he was responsible for the budget process for ORG1. The majority of the hospital falls within the division of ORG1 with the exception of certain ORG2 locations. The VPF stated ORG1 and ORG2 each develop a budget and the two separate budgets are presented to the JOB and are never consolidated into one budget. If the JOB denies the proposed ORG1 budget, the budget would be brought back to the ORG1 board to consider amending. The VPF stated if the ORG1 board doesn't agree with the JOB recommendations, ORG1 board could override the JOB. The VPF stated the JOB does not have control over the budget submitted by ORG1, because once the JOB approves the budget it must go back to the ORG1 board for final approval.

During an interview on 06/23/23 at 9:30 AM, the CFO, employed by ORG2, stated ORG2 has a portion of the hospital budget. The CFO stated both ORG2 and ORG 1 submit budgets that make up the hospital budget. The CFO stated he presents ORG2's hospital budget that is reviewed by ORG2 management group, then the Executive Management Team (EMT), the Joint Operating Finance committee, and then to the JOB for acceptance. If the JOB doesn't accept the budget, it would go back to EMT. The CFO stated the JOB cannot make the decision to reject ORG2's budget. If the budget is not accepted, it is sent back to ORG2's board for review and if changes are made, the budget is resubmitted to JOB. The CFO stated if JOB and ORG2's boards can't reach a decision on the budget, ORG2's board has the final authority. The CFO stated, "one budget isn't created; when the JOB approves the budget, they approve each budget separately."

Based on organizational chart review and interviews, the hospital failed to ensure the nursing service was under the authority and direction of one registered nurse (RN). This deficient practice had the potential to affect all patients receiving services in the emergency department (ED) and Fast Track areas of the ED and all ED and Fast Track employees.

Findings include:

Review of the hospital's organizational chart dated 02/15/21 indicated the main ED was under the direction of Medical Director2, who was under the direction of Administrator who was employed by Organization1 (ORG1). The Fast Track, a separate section of the ED where low acuity patients was seen after being triaged by the ED nurse, was under the direction of an administrator employed by Organization2 (ORG2) who was under the direction of the Vice President of Medical Services (VPMS) for ORG2. The main ED nursing staff was under the direction of Chief Nursing Officer (CNO), an employee of ORG1. The Fast Track area of the ED was under the direction of Administrator of Specialty Services (SSA), who was not a nurse.

During an interview on 06/20/23 at 11:10 AM, Fast Track Manager (FTM), an employee of ORG2, stated Fast Track and ED don't share staff. FTM stated ED and Fast Track are two different entities. FTM stated ORG1 has responsibility for the ED, and ORG2 has responsibility for Fast Track. FTM stated Fast Track and ED are two different departments owned by two different organizations but work as one emergency department. FTM stated the nursing staff hired for Fast Track was done by ORG2. FTM stated full-time nursing staff of the Fast Track were not under the direction of CNO.

During an interview on 06/21/23 at 10:00 AM, CNO stated the CNO oversees the training and competency with the manager of education for the hospital side (ORG1). CNO stated ORG2 has their own side of education, and CNO was not involved in the education of ORG2's Fast Track nursing staff. CNO stated he/she was responsible for staffing ratios in the main ED but has not been involved with Fast Track staffing ratios. CNO confirmed the Fast Track nursing staff training and competency evaluation was under ORG2, and CNO had no responsibility for the training and competency of the Fast Track nurses.

During an interview on 06/21/23 at 11:30 AM, Emergency Department Medical Director (EDMD), employed by ORG1, stated the ED was made up of two divisions, "the sicker side and the Fast Track side." EDMD stated EDMD manages the physicians and four physician assistants hired by EDMD. EDMD stated Fast Track was run by ORG2, and ORG2 was responsible for hiring their physician assistants and nurses. EDMD stated the two divisions function as one department.

During an interview on 06/21/23 at 2:50 PM, Director of Emergency Services (ESD) stated ESD was employed by ORG1. ESD stated the education and competencies of nurses in the Fast Track was not his/ her responsibility. ESD stated a physician assistant and FTM in Fast Track were responsible for the education and competencies of the Fast Track nursing staff. ESD confirmed Fast Track was part of ED, but the main ED had no authority over the education, training, and competency of the staff providing care to patients in the Fast Track.

During an interview on 06/22/23 at 3:52 PM, FTM stated Fast Track doesn't have nurse managers. FTM stated Fast Track has four nurse shift supervisors who report to FTM (who was not a nurse). FTM stated the nurse shift supervisors provide orientation, training, and onboarding for Fast Track nurses. FTM stated the nurse shift supervisors evaluate annual competencies, and FTM oversees that the evaluations were done. FTM stated the nurses report to FTM as the Manager, and FTM reports to SSA (who was not a nurse).

Based on review of the hospital's organizational chart, policy review, and interviews, the hospital failed to meet the emergency needs of patients. This deficient practice had the potential to affect all patients receiving services in the emergency department (ED) and Fast Track areas of the ED and all ED and Fast Track employees.

Findings include:

1. The hospital failed to ensure emergency services were organized under the direction of a qualified member of the medical staff. (Refer to A1102)

2. The hospital failed to ensure policies and procedures were developed for the Fast Track area of the ED. (Refer to A1104)

Based on review of the hospital's organizational chart and interviews, the hospital failed to ensure emergency services were organized under the direction of a qualified member of the medical staff. This deficient practice had the potential to affect all patients receiving services in the emergency department (ED) and Fast Track areas of the ED and all ED and Fast Track employees.

Findings include:

Review of the hospital's "organizational chart" dated 02/15/21 indicated the ED was under the direction of Medical Director2, who was under the direction of Administrator who was employed by Organization1 (ORG1). The Fast Track, a separate section of the ED where low acuity patients was seen after being triaged by the ED nurse, was under the direction of an Administrator employed by Organization2 (ORG2) who was under the direction of the Vice President of Medical Services (VPMS) for ORG2.

During an interview on 06/20/23 at 11:10 AM, Fast Track Manager (FTM), an employee of ORG2, stated Fast Track and ED don't share staff. FTM stated ED and Fast Track were two different entities. FTM stated ORG1 has responsibility for the ED, and ORG2 has responsibility for Fast Track. FTM stated Fast Track and ED are two different departments owned by two different organizations but work as one emergency department.

During an interview on 06/21/23 at 11:30 AM, Emergency Department Medical Director (EDMD), employed by ORG1, stated the ED was made up of two divisions, "the sicker side and the Fast Track side." EDMD stated EDMD manages the physicians and four physician assistants hired by EDMD. EDMD stated Fast Track was run by ORG2, and ORG2 was responsible for hiring their physician assistants and nurses. EDMD stated the two divisions function as one department.

During an interview on 06/21/23 at 12:05 PM, the Administrator stated that the Medical Director1 and Medical Director2 worked directly for Administrator. The Administrator stated Medical Director1 and Medical Director2 are not responsible for Fast Track.

During an interview on 06/21/23 at 3:25 PM, the Medical Director1 stated he/she was appointed as Chief Medical Officer. Medical Director1 stated anything to do with an inpatient goes through Medical Director1 but not Fast Track. Medical Director1 confirmed Medical Director1 has oversight over part of the hospital. Medical Director1 stated Medical Director1 doesn't have great clarity over who was over the Fast Track providers.

During an interview on 06/21/23 at 3:35 PM, Medical Director2 confirmed he/she doesn't have authority over the Fast Track providers.

Based on policy review, organizational chart review, and interviews, the hospital failed to ensure policies and procedures were developed for the Fast Track area of the emergency department (ED). This deficient practice had the potential to affect all patients receiving services in the emergency department (ED) and Fast Track areas of the ED and all ED and Fast Track employees.

Findings include:

Review of the hospital's "organizational chart" dated 02/15/21 indicated the ED was under the direction of Medical Director2, who was under the direction of the Administrator who was employed by Organization1 (ORG1). The Fast Track, a separate section of the ED where low acuity patients was seen after being triaged by the ED nurse, was under the direction of an Administrator employed by Organization2 (ORG2) who was under the direction of the Vice President of Medical Services (VPMS) for ORG2.

Review of the hospital policy titled " Emergency Medical Services and Emergency
Medical Treatment and Labor Act (EMS/EMTALA) General Procedure," reviewed 05/01/17, indicated ". . . [name of hospital] staff will provide an appropriate Medical Screening Examination and necessary stabilizing treatment and/or an appropriate transfer to all individuals at [name of hospital] in accordance with the EMS/EMTALA Policy and related procedures. . . Triage: The Emergency Department and Labor and Delivery will triage all individuals in accordance with established protocols. Medical Screening Examination: A physician or qualified medical personnel will provide an appropriate Medical Screening Examination to an individual to determine within reasonable clinical confidence whether the individual has an
Emergency Medical Condition. . . The Medical Screening Examination will be provided as soon as possible according to the individual's relative urgency of need for medical care as determined in triage. Emergency Screening Examinations will be appropriate to the individual's condition, including reported and observed signs and symptoms. . ." Review of the policy indicated the Fast Track area was not addressed in the policy, specifically the process for transferring patients in the Fast Track who had a change in condition that warranted the patient being transferred back to the main ED.

No policy and procedure related to the Fast Track area of the ED was presented prior to survey exit.

During an interview on 06/21/23 at 12:05 PM, the Administrator stated he/she hasn't done any policy reviews for Fast Track. The Administrator stated since October 2022 when he/she became Interim Administrator, he/she hasn't seen any Fast Track policies.

During an interview on 06/22/23 at 11:55 AM, the Fast Track Manager (FTM) confirmed there were no specific Fast Track policies. FTM stated there was a triage guideline for Fast Track to determine ESI (Emergency Severity Index) levels for patients to be sent to Fast Track. FTM stated they follow the hospital's EMTALA policies and procedures. FTM stated the ESI guidelines do not address the process to be followed when the patient has to be sent back to ED from Fast Track due to a change in the patient's condition. FTM confirmed the EMTALA policies don't include any information or guidance related to Fast Track.