HospitalInspections.org

Based on a review of documents and interviews with key personnel on June 7 to 10, 2010, it was determined that the hospital failed to have an effective governing body responsible for the conduct of the institution.

Findings include:

1. The Hospital Performance Improvement Plan describes a " Plan, Do, Check, Act Model " of performance improvement. This includes "Establishing benchmarks. Identifying the most important aspects of care provided by the organization. Identifying dimensions of performance and indicators (and appropriate clinical criteria) for monitoring the important aspects of care. Establishing benchmarks for the indicators that trigger evaluation of the care or providing regional, state, or national benchmarks with which comparison can be made. Monitoring the important aspects of care by collecting and organizing the data for each indicator. Evaluating care to identify either opportunities to improve care or problems. Taking actions to improve care or to correct identified problems. Assessing the effectiveness or the actions and document the improvement in care. Communicating the results of the monitoring and evaluation process to relevant individuals, departments, or services and to the NMMC Performance Improvement Program."

2. The Performance Improvement Plan did not contain indicators or benchmarks (numeric goals) for performance improvement. This was confirmed by the Director of Quality.

3. The Northern Maine Medical Center Governing Body meeting minutes of May 2009 through May 2010 were reviewed. There was no evidence that the Performance Improvement Plan was reviewed, discussed, or approved. Nor was there evidence in the minutes that quality indicators were discussed. This finding was confirmed by the Director of Quality.

4. During a previous survey, conducted on May 8, 2009, the hospital received a deficiency related to the Medical Staff failing to set measurable quality indicators. The May 19, 2009 Governing Body meeting minutes state: " [CEO] reported the hospital received the written report from state surveyors highlighting the 4 deficiencies cited during the recent federal EMTALA Survey. Deficiencies cited were as follows: ... Quality-Medical Staff needs to have ongoing at any given time a number of continuous quality improvement projects along with quantifiable benchmarks " . During the current survey, there were no measurable, quantifiable benchmarks for the medical specialties of emergency medicine, anesthesia, or radiology in the May 2009 through May 2010 meeting minutes for the Medical Staff, the Medical Staff Peer Review and Quality Improvement Committee, or the Governing Body. Furthermore, there was no evidence in these meeting minutes that the Governing Body monitored or inquired as to the progress towards correcting the previously identified deficiency. This was confirmed by the Director of Quality and the President of the Medical Staff.

5. The Medical Staff Bylaws, Article XI, Section 14, 1, describing the Medical Staff Peer Review and Quality Improvement Committee states " To develop and maintain the Medical Staff Peer Review and Quality Assurance Plan. This Plan shall be presented annually for review by the Medical Staff and approved by the governing body. "

6. There was no evidence in the minutes of the Governing Body from May 2009 through May 2010 that the 2009/2010 medical staff quality plan was approved.

7. The Director of Quality and the Chief Operating Officer confirmed that the Hospital Quality Plan and the Medical Staff Quality Plan were not specifically approved by the governing body.

The cumulative affect of these deficient practices resulted in this Condition of Participation being out of compliance.

Based on a review of documents and interviews with key personnel on June 7 to 10, 2010, it was determined that the hospital failed to have an effective, ongoing, data driven quality improvement and performance improvement program that reflected the scope and complexity of medical services provided by the medical staff and contract services related to improving health outcomes and preventing medical errors.

Findings include:

1. The Hospital Performance Improvement Plan describes a " Plan, Do, Check, Act Model " of performance improvement. This includes "Establishing benchmarks. Identifying the most important aspects of care provided by the organization. Identifying dimensions of performance and indicators (and appropriate clinical criteria) for monitoring the important aspects of care. Establishing benchmarks for the indicators that trigger evaluation of the care or providing regional, state, or national benchmarks with which comparison can be made. Monitoring the important aspects of care by collecting and organizing the data for each indicator. Evaluating care to identify either opportunities to improve care or problems. Taking actions to improve care or to correct identified problems. Assessing the effectiveness or the actions and document the improvement in care. Communicating the results of the monitoring and evaluation process to relevant individuals, departments, or services and to the NMMC Performance Improvement Program."

2. The Performance Improvement Plan did not contain indicators or benchmarks (numeric goals) for performance improvement. This was confirmed by the Director of Quality.

3. The Northern Maine Medical Center Governing Body meeting minutes of May 2009 through May 2010 were reviewed. There was no evidence that the Performance Improvement Plan was reviewed, discussed, or approved. Nor was there evidence in the minutes that quality indicators were discussed. This finding was confirmed by the Director of Quality.

4. During a previous survey, conducted on May 8, 2009, the hospital received a deficiency related to the Medical Staff failing to set measurable quality indicators. The May 19, 2009 Governing Body meeting minutes state: " [CEO] reported the hospital received the written report from state surveyors highlighting the 4 deficiencies cited during the recent federal EMTALA Survey. Deficiencies cited were as follows: ... Quality-Medical Staff needs to have ongoing at any given time a number of continuous quality improvement projects along with quantifiable benchmarks " . During the current survey, there were no measurable, quantifiable benchmarks for the medical specialties of emergency medicine, anesthesia, or radiology in the May 2009 through May 2010 meeting minutes for the Medical Staff, the Medical Staff Peer Review and Quality Improvement Committee, or the Governing Body. Furthermore, there was no evidence in these meeting minutes that the Governing Body monitored or inquired as to the progress towards correcting the previously identified deficiency. This was confirmed by the Director of Quality and the President of the Medical Staff.


5. The medical staff quality plan contained no evidence that the medical staff established measurable quality indicators for anesthesia, emergency medicine, and radiology. In an interview with the President of the Medical Staff and the Director of Quality at the time of the survey, the President of the Medical Staff confirmed that there were no measurable physician quality goals in the specialties of anesthesia, emergency medicine, radiology, and surgical practice.

6. The Medical Staff Bylaws, Article XI, Section 14, 1, describing the Medical Staff Peer Review and Quality Improvement Committee states " To develop and maintain the Medical Staff Peer Review and Quality Assurance Plan. This Plan shall be presented annually for review by the Medical Staff and approved by the governing body. "

7. There was no evidence in the minutes of the Medical Staff meeting minutes that the 2009/2010 medical staff quality plan was presented to the medical staff for review.

8. The minutes of the Governing Body do not contain evidence that the 2009/2010 medical staff quality plan was approved. This was confirmed by the Director of Quality.

9. Additionally, the Medical Staff Quality Plan did not contain specific, measurable targets for systemic performance improvement. The Director of Quality confirmed at the time of the survey that the medical staff did not have measurable performance improvement indicators in the medical staff quality plan. The Director of Quality further confirmed that the hospital did not have measurable goals for all aspects of care in the hospital ' s Performance Improvement Plan.

10. The lead Certified Registered Nurse Anesthetist (CRNA), who collects the anesthesia performance improvement data, said in a meeting at the time of the survey, that he does not have performance improvement indicator data. He stated that he believed that intra-operative normothermia is an important indicator, but he does not collect, monitor or engage in performance improvement activities in anesthesia.

11. The Chief Operating Officer identified a member of the surgery department as performing the duties of the Chief of Anesthesia, but in an interview with this surgeon, he reported that he was not collecting, analyzing or performing performance improvement data, but his role was to co-sign orders for sedative agents for outpatients who were having imaging procedures whose ordering physician was not on the medical staff. He reported that the lead CRNA was responsible for collecting anesthesia quality information.

12. The Chief of Radiology reported that he had requested outside review of his radiology cases, but the hospital did not come to an agreement on specifics and the review has not taken place.

13. A review of five (5) patient related contracts on June 10, 2010, revealed that three (3) of the five (5) contracts were not included in the hospital-wide quality assessment and performance improvement program. This was verified during interviews with the Director of Nursing and the Quality Director on June 10, 2010.

14. A review of five (5) patient related contracts on June 10, 2010, revealed that none of the five (5) contracts contained a written requirement that the contracted be involved in the hospital-wide quality assessment and performance improvement program. This was verified during interviews with the Quality Director on June 10, 2010.

15. During interviews with the Quality Director on June 10, 2010, she stated that hospital complaints were not presented to the Governing Body. She continued, "The hospital was not sorting out complaints due to not knowing how exactly it would be handled with the Governing Board." The Quality Director also stated that at this time, the complaints were not included in the quality assurance and performance improvement program.

The cumulative effect of these deficient practices resulted in this Condition of Participation being out of compliance.




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Based on a review of documents and interviews with key personnel from June 7 to 10, 2010, it was determined that the hospital Medical Staff failed to take responsibility for the quality of medical care provided to patients.

Findings include:

1. The Hospital Performance Improvement Plan describes a " Plan, Do, Check, Act Model " of performance improvement. This includes "Establishing benchmarks. Identifying the most important aspects of care provided by the organization. Identifying dimensions of performance and indicators (and appropriate clinical criteria) for monitoring the important aspects of care. Establishing benchmarks for the indicators that trigger evaluation of the care or providing regional, state, or national benchmarks with which comparison can be made. Monitoring the important aspects of care by collecting and organizing the data for each indicator. Evaluating care to identify either opportunities to improve care or problems. Taking actions to improve care or to correct identified problems. Assessing the effectiveness or the actions and document the improvement in care. Communicating the results of the monitoring and evaluation process to relevant individuals, departments, or services and to the NMMC Performance Improvement Program."

2. The Medical Staff Bylaws, Article XI, Section 14, 1, describing the Medical Staff Peer Review and Quality Improvement Committee states " To develop and maintain the Medical Staff Peer Review and Quality Assurance Plan. This Plan shall be presented annually for review by the Medical Staff and approved by the governing body. "

3. There was no evidence in the minutes of the Medical Staff meeting minutes that the 2009/2010 medical staff quality plan was presented to the medical staff for review.

4. The minutes of the Governing Body do not contain evidence that the 2009/2010 medical staff quality plan was approved. This was confirmed by the Director of Quality.

5. The Medical Staff Quality Plan did not contain specific, measurable targets for systemic performance improvement. The Director of Quality confirmed at the time of the survey that the medical staff did not have measurable performance improvement indicators in the medical staff quality plan. The Director of Quality further confirmed that the hospital did not have measurable goals for all aspects of care in the hospital ' s Performance Improvement Plan.

6. In an interview with the President of the Medical Staff and the Director of Quality at the time of the survey, the President of the Medical Staff confirmed that there were no measurable physician quality goals in the specialties of anesthesia, emergency medicine, and radiology. Also, the President of the Medical Staff confirmed that the Medical Staff had not set measurable quantitative goals for any medical staff quality indicators. Lastly, the President of the Medical Staff confirmed that the Medical Staff had not discussed a mechanism to address one of the surgeons who was not complying with the indicator relating to the discontinuation of antibiotics after surgery.

7. The medical staff quality plan contained no evidence that the medical staff established measurable quality indicators for anesthesia, emergency medicine, and radiology. In an interview with the President of the Medical Staff and the Director of Quality at the time of the survey, the President of the Medical Staff confirmed that there were no measurable physician quality goals in the specialties of anesthesia, emergency medicine, radiology, and surgical practice.

8. The lead Certified Registered Nurse Anesthetist (CRNA), who collects the anesthesia performance improvement data, said in a meeting at the time of the survey, that he does not have performance improvement indicator data. He stated that he believed that intra-operative normothermia is an important indicator, but he does not collect, monitor or engage in performance improvement activities in anesthesia.

9. The Chief Operating Officer identified a member of the surgery department as performing the duties of the Chief of Anesthesia, but in an interview with this surgeon, he reported that he was not collecting, analyzing or performing performance improvement data, but his role was to co-sign orders for sedative agents for outpatients who were having imaging procedures whose ordering physician was not on the medical staff. He reported that the lead CRNA was responsible for collecting anesthesia quality information.

10. The Chief of Radiology reported that he had requested outside review of his radiology cases, but the hospital did not come to an agreement on specifics and the review has not taken place.

11. During a previous survey, conducted on May 8, 2009, the hospital received a deficiency related to the Medical Staff failing to set measurable quality indicators. The May 19, 2009 Governing Body meeting minutes state: " [CEO] reported the hospital received the written report from state surveyors highlighting the 4 deficiencies cited during the recent federal EMTALA Survey. Deficiencies cited were as follows: ... Quality-Medical Staff needs to have ongoing at any given time a number of continuous quality improvement projects along with quantifiable benchmarks " . During the current survey, there were no measurable, quantifiable benchmarks for the medical specialties of emergency medicine, anesthesia, or radiology in the May 2009 through May 2010 meeting minutes for the Medical Staff, the Medical Staff Peer Review and Quality Improvement Committee, or the Governing Body. Furthermore, there was no evidence in these meeting minutes that the Governing Body monitored or inquired as to the progress towards correcting the previously identified deficiency. This was confirmed by the Director of Quality and the President of the Medical Staff.


The cumulative effect of these deficient practices resulted in this Condition of Participation being out of compliance.

Based on a review of the meeting minutes of the Medical Staff, the Medical Staff Peer Review and Quality Improvement Committee, the Medical Staff Quality Plan and in interviews with the physician identified as the Chief of Anesthesia, the Director of Quality, and the President of the Medical Staff between June 8 to June 10, 2010, it was determined that the Hospital failed assure that anesthesia services are being provided in a safe or appropriate manner.

Findings include:

1. The medical staff quality plan contained no evidence that the medical staff established measurable quality indicators for anesthesia. In an interview with the President of the Medical Staff and the Director of Quality at the time of the survey, the President of the Medical Staff confirmed that there were no measurable physician quality goals in the specialty of anesthesia.

2. The Chief Operating Officer identified a member of the surgery department as performing the duties of the Chief of Anesthesia, but in an interview with this surgeon, he reported that he was not collecting, analyzing or performing performance improvement data, but his role was to co-sign orders for sedative agents for outpatients who were having imaging procedures whose ordering physician was not on the medical staff. He reported that the lead CRNA was responsible for collecting anesthesia quality information.

3. The lead Certified Registered Nurse Anesthetist (CRNA), who collects the anesthesia performance improvement data, said in a meeting at the time of the survey, that he does not have performance improvement indicator data. He stated that he believed that intra-operative normothermia is an important indicator, but he does not collect, monitor or engage in performance improvement activities in anesthesia.

The cumulative effect of these deficient practices resulted in this Condition of Participation being out of compliance.