HospitalInspections.org

Based on the review of eight credential files and interview, the governing body failed to discharge its responsibility in the appointment of members to the medical staff. Findings:

1. Credential file of MS5 showed that this staff who is a dentist was appointed as a temporary member of the Medical staff by the Acting Clinical Director on 04/22/2010. Furthermore, the appointment letter showed that this dentist willl be under the suprevision of the Acting Clincal Director who is an optometrist.

2. Review of the credential files of MS2, MS4, and MS7 as well as review of the Governing Body minutes isnce July 2009 showed that the Governing Body failed to conduct timely reappointments of these medical staff members.

These were discussed with the Acting CEO.

During the first day of the survey, there were only three inpatient. Review of one (Patient1) of the three medical records of the inpatients showed that he had a CT scan of the head and a CT scan of the cervical spine done on July 19, 2010. The CT scan reports showed that it was read by a medical resident at University Physicians Heathcare in Tucson, AZ on 07/19/2010. There was no document to review that the medical resident was licensed to practice in NM, nor were there documents offered to be reviewed that indicates that this medical resident is a radiologist.

The hospital staff was asked for the list of all contracted services, which include the scope and nature of services provided, for the three days of the survey but no list was ever provided to the surveyor.

Based on document reviews and interview, this hospital do not have an ongoing, hospital-wide quality assessment and performance improvement program in place at the time of the survey.

Interview with the Diretor of QAPI on 07/20/210 at 12:30 PM and on 07/21/2010 at 11:00 AM revealed that the last meeting of the hospital Quality Council was July 16, 2009. The hospital's "Quality Assurance Plan" have not been reviewed/revised since November 23, 2004.

Review of the hospital QAPI activities with the Director of QAPI showed that:

1. The activites failed to show measurable improvement in the indicators that showed evidence of improvement in patient's health outcomes, and identify and reduce medical errors.
2. The QAPI program failed to measure, analyze and track quality indicators including adverse patient events, and other aspects of performance that assess processes of care.
3. The QAPI program failed to identify the details of data collection and the frequency.
4. The hospital collects data but failed to analyze the data inorder to identify opportunities of improvement and formulate action plan that will lead to measurable improvement.
5. The governing body failed to discharge its responsibilities to ensure that the hospital has an effective, ongoing QAPI program.

Based on review on medical records and interview of staff, the medical staff failed to conduct appraisals of medical staff members in accordance with the provisions of its Medical Staff Bylaws. The Medical Staff Bylaw requires that it will be done every two years after a member is appointed as active staff, a minimum of six months but no more that eighteen months for provisional appointments. Three (MS2, MS4, MS7) of the eight credential files reviewed failed to meet the appraisal timeframe set forth under the Medical Staff Bylaws. Review of the Governing Body Minutes since July 2009 failed to show that the ceredentialing of these three medical staff members were brought up for discussion and review. The issue was discussed with the Acting CEO; no new information was provided.

Based on the review of medical staff organization, credential files and interviews, the medical staff organization was not under the direction of an individual who is a doctor of medicine or osteopathy. Review of the credential file of the hospital's Acting Clinical Director showed that he is a doctor of optometry. The Acting Clinical Director informed the surveyor that he has been in that position since September 2009. The Acting Clinical Director also stated that the hospital is recruiting a physician to assume the role. The issue was also discussed wiith the Acting CEO and the language of the regulation was showed and discussed.

The Medical Staff Bylaws requires the Cliical Director to be "a physician that demonstrates qualification on the basis of experience and ability." The definition of a physician set forth in Section 1861(r) of the Social Security Act does not include optometrist. The Medical Staff Bylaws list the responsibilities of the Clinical Director that incluldes: provide professional guidance to all clinical areas; reviews medical practices and procedures and referral policies of the Service Unit to assure they are appropriate, of high quality and consistent with Indian Health Service Policy; reviews the performance of all practitioners on the medical staff and assumes responsiility for continuing education and career development of the medical staff.

Review of the credential file of MS1 who is a physician assistant showed that he is under the supervision of a physician who is no longer affiliated with this hospital. This was brought to the attention of the Acting CEO.

Based on review of documents and interviews, the medical staff failed to enforce the provisions of its bylaws. Findings:

1. The Medical Staff Bylaw requires that appraisals of its members will be done every two years after a member is appointed as active staff, a minimum of six months but no more than eighteen months for provisional appointments. Three (MS2, MS4, MS7) of the eight credential files reviewed failed to meet the appraisal timeframe set forth under the Medical Staff Bylaws. Review of the Governing Body Minutes since July 2009 failed to show that the ceredentialing of these three medical staff members were brought up for discussion and review. The issue was discussed with the Acting CEO; no new information was provided.

2. The Medical Staff Bylaws requires the Clinical Director to be a physician. The Acting Clinical Director is an optomterist.

3. The Medical Staff Bylaws requires certain documents to be included in the appointment/reappointment application for medical staff membership which include: evidence of current licensure; peer review competence evaluation and both Clinical Director and Chief of Staff recommendation; evidence of satisfactory physical and mental condition. Review of eight credential files showed that six (MS1, MS2, MS3, MS4, MS6, MS7) credential files were deficient in one or more of the above requirements.