HospitalInspections.org

Based on a review of facility documentation and interview with facility staff (EMP), it was determined that the facility failed to provide documented evidence that the Governing Body Bylaws delegate, in writing, the responsibility to review and resolve complaints/grievances.

Findings Include:

Conemaugh Memorial Medical Center ... PolicyStat ID: 1574470 ... Last Reviewed: October 2015 ... Policy Area: Risk Management ... Patient/Customer Complaint/Grievance ... revealed, "Statement of Policy: To ensure patients/families/customers the right to present complaints and grievances and in order to identify opportunities to improve in service excellence and promote positive outcomes, it is the policy of Memorial Medical Center to provide a prompt and appropriate response to any complaints or grievances voiced by its customers. Customers include patients, families, physicians, etc. At no time shall a complaint or grievance be used to deny a patient current or future access to services provided by Memorial Medical Center. ... Requirements: ... D. Patient Relations Department Responsibilities ... 10. Data of the type of complaints/grievances and other pertinent information will be provided to the Ideal Patient Experience Committee Steering Committee for use in identifying opportunities for improvement. 11. The Patient Relations Department will perform organizational tracking and trending of complaints and grievances as needed. ... Responsibility: The Patient Relations Department is responsible for implementation of this policy. Department managers are responsible for implementation in their areas of responsibility. ... ."

Review of Conemaugh Memorial Medical Center ... PolicyStat ID: 1574403 ... Last Reviewed: December 2015 ... Policy Area: Organization-General ... Performance Excellence Plan ... revealed, "... Strategic Plan Deployment/Journey of Excellence and Planning Process ... Memorial Medical Center's strategic planning and deployment focuses on specific challenges derived from an assessment or our organization's strength's, weaknesses, opportunities and threats (SWOT) and an environmental scan. These opportunities are then formulated under the Key Strategies as critical success factors (CSF) and are monitored as key performance indicators (KPI) monthly. The product of this work is housed electronically by 'On Focus' a transparent web based tool integrated into our management structure for reporting of our critical success factors. This same tool is also used to depict the Opportunities for Excellence for PE Steering and PEC. In order to maintain an organizational focus on our deployment of our strategic planning, 'On Focus' and dashboards are used. MMC's dashboards are used as a systematic evaluation of our organizational performance. Our strategic plan deployment permeates through our organization as depicted in the following schematic. ... Journey of Excellence and Planning Process ... Department or Service Line ... A. Board of Trustees The Board is responsible to set the direction for performance excellence in collaboration with the Medical Staff and senior management. Leadership, inclusive of the Medical Staff Leadership, actively plans and prioritizes quality and patietn [sic] safety activities of the organization. This plan and any changes will become effective after review and approval of the Board of Trustees. B. DLP Quality Oversight Committee The DLP Quality Oversight Committee is consultative and advises the Leadership Team and the Hospital Patient Safety and Performance Excellence Committee. C. Performance Excellence Committee of the Board: Although the ultimate responsibility and authority for organization-wide performance excellence rests with the Board of Trustees, the Board delegates oversight responsibility and authority to the Performance Excellence Committee (PEC) of the Board. This Committee is composed of members of the Board of Trustees, Medical Staff Leadership, GME Resident delegates, Administration, and Community Representatives. PEC shall serve as the Board's working committee on all matters pertaining to performance excellence. It will be the vehicle to enhance trust and communication among the Board, corporate officer team, Medical Staff, Allied Health Staff and employees on quality related-matters by providing candid and confidential forum for discussion. The performance Excellence Committee's key responsibilities are to review and make appropriate recommendations on the following: Top-level, corporate commitment to the performance excellence. Information flow throughout the organization. ... Objective measures to gauge the quality of care and services being provided such that all patients with the same health problems and care needs are receiving the same quality of care; Quality management programs and quality related policies; The degree to which the organization meets patients' expectations; ... Patient Safety/Risk Management ... E. Performance Excellence Steering Committee The PE Steering Committee provides operational oversight for the Performance Excellence activities to include Performance Excellence activities to include clinical and service excellence objectives according to our strategic plan. The committee coordinates activities of the numerous PE operating units, including prioritizing PE objectives, assessing the need for cross-departmental Limited Purpose Teams, and establishing parameters for surveillance measures. This committee also serves as the focus for organizational quality oversight, gathering and assessing measures of quality, service, and cost-effectiveness. Data is used to identify and improve care and services. Performance Excellence will be monitored and reported through the PE Steering Committee to PEC utilizing clinical and service dashboards. ... Excellence Process ... G. Operating Units Operating Units for purposes of performance excellence and service excellence are defined as Departments, Divisions, Service Lines or other functional business units. Such Operating Units are subject to change from time to time. Operating Unit Leaders, whether they be Department Directors and Chairpersons or others, are responsible for continuous monitoring of activities that support the organization's vision and appropriate metric development for services that are provided at MMC. ... Measurement of both process and outcome for high volume, high risk, high cost, and/or problem prone processes or populations is required. Data is collected then trended, analyzed and prioritized. Department managers report the results of their performance excellence activity to their senior leader and these unit specific results are discussed at staff meetings and displayed on unit Quality Boards. Based on magnitude of issue, it may be resolved at the departmental level and/or be channeled to PEC. ... O. Knowledge Management Data is systematically collected in order to design new processes, assess dimensions of performance relevant to processes, outcomes and functions, determines level of stability of important processes, identify possible opportunities for Excellence, and determine if excellence efforts have resulted in desired changes. The detail and frequency of data collected will be determined based on the impact of the process or activity being measured. Perceptual data that would reflect the needs and expectations of patients, medical staff, community and employees is measured periodically. The hospital through various vehicles collects data on: Service Excellence (Customer Satisfaction) ... A process for management of patient complaints/grievances will assure appropriate contact with patients and that issues identified are addressed ... Clinical Excellence (Quality) A clinical dashboard has been created and is reported monthly to the Steering Committee (as well as to the PEC) ... Regulatory Requirements ... Growth Opportunities. The assessment process is systematic, interdisciplinary and interdepartmental. Analysis involves comparing your performance with: ... consideration of legal or regulatory requirements for process design or redesign; ... best practices within healthcare or in other service areas. ... Performance Excellence Process Performance Excellence is an integrated approach to organizational performance management and is linked by the Journey of Excellence model to the Strategic Plan. However, the current Performance Excellence Teams (PET) have been selected by each operating unit, and are inclusive of all levels of staff within those operating units. Operating units may be service lines, departments, divisions, administrative units, or simply functionally related services. Overall direction to the PET teams and CPE will be provided by the Performance Excellence Steering Committee, following the same process principles as described for the individual operating units. ... Each operating unit is responsible to review relevant input to determine opportunities for Excellence. Such review will include a balance of elements including People, Service Excellence, Clinical Excellence (including regulatory requirements), Fiscal Soundness, and Growth opportunities. Additional input shall be obtained when appropriate from the PE Steering Committee. ... C. Opportunities for Excellence ... The Compliance Hot Line and SRM near miss/incident reporting are additional vehicles that can be used to vet an issue or concern in person or anonymously. Identified issues are referred by the PE Steering Committee to the appropriate person or team for evaluation or action. Referrals are also tracked to and from PE Steering to Medical Staff PE/Peer Review/to Nursing Peer Review/to CME Steering. Innovation is often highlighted in Lean Six Sigma Project reporting at Council of Performance Excellence. Outcomes of PE initiatives shall be reported to the CPE, The Steering Committee and the PEC Committee. ... ."

1. A request was made for a copy of the facility's most current set of Bylaws. The Bylaws failed to reveal documented evidence that the Governing Body had delegated a committee as the responsible party for the review and resolution of complaints/grievances.

2. Review of PE [Performance Excellence] Steering Committee meeting minutes dated January 11, 2017, February 8, 2017, March 8, 2017, April 12, 2017, and May 10, 2017, was conducted.

An interview was conducted with EMP1 on May 9, 2017, at approximately 1:30 PM. EMP1 revealed that they take the minutes for that Committee and that there would be no discussion or report of complaints or grievances in the meeting minutes.

An interview was conducted with EMP2 on May 9, 2017, at approximately 9:30 AM. EMP2 revealed that complaints are reviewed at PEC [Performance Excellence Committee] but not on any routine basis.

Based on a review of the patient's medical record (MR), facility documentation and interview with staff (EMP), it was determined that the facility failed to follow their adopted policy to report the occurrence of an unusual incident in one of one medical record (MR3).

Findings Include:

Review of Conemaugh Memorial Medical Center ... PolicyStat ID: 1574433 ... Last Reviewed: December 2015 ... Policy Area: Organization-General ... Patient Safety Plan ... revealed, "Statement of Policy Memorial Medical Center is committed to providing a safe environment for its patients, employees , physicians, students, volunteers, and visitors. It is the responsibility of each employee, physician, student, and volunteer to promote safety and prevent injury. Commitment of the Board and leadership to fostering a culture in which patient safety is paramount and all individuals (employees, physicians, volunteers, and students) work diligently to ensure safe patient care. Non-punitive process for reporting adverse patient events, errors (weather of commission or omission), sentinel events, near misses, and incidents to permit investigation of process failures and process improvement to prevent future occurrences. Establishment of a Patient Safety Committee, which is a subcommittee of the Performance Excellence Steering Committee of the Trustees. Appointment of a Patient Safety Officer to oversee the Patient Safety Program. Trending of events to identify opportunities for improvement and to assess compliance with existing processes. Continuation of existing processes for categorizing events and harm to patients to allow for appropriate response to errors. Continuation of existing processes for disclosing unexpected outcomes to patients and families. ... ."

Conemaugh Memorial Medical Center ... PolicyStat ID: 161804 ... Reviewed March 2015 ... Policy Area: Risk Management ... Event/Incident Reports ... revealed, "Statement of Policy: It is the policy of Memorial Medical Center that all events/incidents be reported promptly. Prompt reporting of events/incidents is necessary to protect patients, visitors, employees and students against hazards as well as to provide a complete and accurate record of the event/incident. ... Specific Examples of Patient Events/Incidents Following are examples of patients events/incidents which must be reported. It is not intended to be inclusive. For events/incidents which do not fall under these examples, please refer to the general definition to determine reportability. A. Treatment/Procedure Events/Incidents Treatment, procedure or test that was delayed or omitted. Delayed or incorrect result of test. Adverse reaction to medication, contrast media, etc. Problem with informed consent. Patient misidentification. Other events/incidents involving treatment or procedure that should be reported. ... D. Miscellaneous Events/Incidents ... Patient trauma, miscellaneous, including self-inflicting injury ... Other miscellaneous events/incidents ... H. Surgery Events/Incidents ... Patient or site misidentification ... Other reportable surgical complications and/or events/incidents ... ."

1. Review of MR3 dated March 2, 2017, revealed, "... Progress Notes: Recent Labs: ... Hemoglobin ... Hematocrit ... BUN ... Creatinine ... eGFR ... Plan: 1. ... Will schedule for renal biopsy. ... 03/03/17 ... Hemoglobin ... 03/04/17 ... Hemoglobin ... Impression: ... 5. Anemia, worsening. ... Plan: ... 4. Am labs, Hb dropping: may need CT abdom non-contrast to r/o RP bleed. ... 03/05/17 ... Impression: ... 2. Anemia, worsening, r/o RP bleed post renal biopsy ... Plan: ... 2. Stat CT to r/o RP bleed. 3. Transfuse 2 units prbc today with IV Lasix between units; consent obtained. ... Hemoglobin ... Hematocrit ... Addendum: ... Discussed CT findings: acute subscapular hematoma around left kidney. Discussed plan of prbc transfusion, monitoring, will decrease norvasc to 5mg qam as b/p lower. ... 03/06/17 0827 ... Interventional Radiology Progress Note : The patient ... underwent successful left renal biopsy on 3/3/2017. The patient was noted to have a steady decrease in his H&H post procedure. On the morning of 3/5/2017 it was noted be .... a CT abdomen and pelvis was performed later that morning revealing a left renal sub-capsular hematoma. Patient was then brought to Interventional Radiology where a left renal angiogram and embolization was performed. The patient was transfused 2 units packed red blood cells yesterday. ... ."

A telephone interview was conducted with EMP6 on May 26, 2017, at approximately 11:30 AM. EMP6 was queried as to whether the patient returning to Interventional Radiology on March 5, 2017, for the renal angiogram and embolization following the CT guided renal biopsy on March 3, 2017, which resulted in a hematoma, was reported as an incident according to their policy. EMP6 stated that this event was not entered into SRM and that it should have been because the patient required two units of blood and was taken back to IR for an additional procedure.