HospitalInspections.org

Based on document review and interview, the facility did not appoint a Director/Chairman of Radiology from 06/01/22 to 10/12/22, to provide oversight of Radiology Services, including staffing supervision, training/education, quality assurance activities, and the development/implementation policy & procedures. Lack of oversight has the potential for an adverse event.

Findings Include:

Review on 10/19/22 of the credential file for Staff (O), MD, Radiologist, revealed a contract dated 03/18/15 for his appointment as the Director/Chairman of Radiology Services. Review of the Medical Staff Termination/Resignation Checklist indicates Staff (O)'s resignation effective 05/31/22. Interview on 10/17/22 at 01:00 PM with Staff (B), RN, Chief Nursing and Operations Officer confirmed this finding.

Review of the facility Medical, Dental, and Podiatric Staff Bylaws amended 02/27/18 revealed staff shall be organized in the following Clinical Care Service: Medicine, Surgery, Pathology, Psychiatry, Radiology, Radiation Oncology, Emergency Medicine and Women and Children. Qualifications for each clinical service shall be directed by a chairperson who shall be a member of the active staff qualified by training, experience, and demonstrated ability for the position. Functions of the Clinical Care Service chairperson include being a member of the Medical Executive Committee (MEC), providing guidance on medical policies and making recommendations/suggestions regarding policies & procedures for their own Clinical Care Service to assure quality patient care. They will maintain continuing review of the professional performance of all practitioners with clinical Privileges in their own Clinical Care Service and report to the MEC, as necessary. They will perform continuous assessment and improvement of the quality of care, treatment and services provided by the Clinical Care Service and maintain such quality control programs. They will assist in the preparation of reports, including budgetary planning, pertaining to their own Clinical Care Service as may be requested. Each Clinical Care Service will use quality assurance and accountability functions to conduct studies to evaluate clinical work performed, establish minimum requirements for privileges, monitor performance with adherence to policies, principles of clinical practice, for unexpected clinical outcomes, and for patient safety. Attendance requirements include that each member shall be required to attend not less than fifty percent (50%) of the meetings of committees to which they are assigned in each year.

Review of the policy "Purpose of the Radiology Department," last revised 11/03/20 revealed the department is responsible for planning and carrying out policies and procedures; for providing consultation and advice to the medical staff in interpreting diagnostic radiographic findings and in planning diagnostic x-ray procedures. The authority for radiological services of the hospital rests with the Director of Radiology who reports to the hospital administrator on matters of departmental administration and who, together with all other radiologists in the department, is responsible to the medical staff for his professional services. The director is delegated authority for organization, operation and training of personnel which shall under routine circumstances be carried out by the administrative technologist. The Director of radiology shall be a physician licensed in the State of New York and certified by the American board of Radiology. He shall be a member of the medical staff of the hospital.

Review of the policy "Quality Assurance," last revised 11/03/20 revealed that the Department of Radiology follows a formal quality assurance program including procedures and monitoring, X-ray/ER variance, X-ray/pathology, identified cases, special review/correlation of any case identified by the facility staff member, technical review, double readings, monthly double readings for interpretative observer consistency and diagnostic analysis, and cases that are cited/reviewed are to be addressed in the monthly Department of Radiology minutes and/or logged accordingly.

Review of the policy "Training and Education of Radiology Department, last revised 11/03/2020 revealed the Director of Radiology is responsible to ensure: all radiology personnel are properly trained and educated; radiology personnel are responsible for generating, collecting, and analyzing data/information; and to provide the necessary tools and training and to educate to improve the processes to generate, collect and analyze data/ information.

Review on 10/19/22 of the Radiology Clinical Care Meeting Minutes revealed the committee meets bi-monthly to review incidents, complaints, double readings, contrast reactions, referred cases, Emergency Department X-Rays, and delinquent reports. The last meeting was 03/23/22.

Review on 10/19/22 of the Radiation Safety Committee meeting minutes the committee meets quarterly to review topics such as clinical reports for nuclear medicine statistics, apron safety checks and the nuclear medicine reconstitution monthly audit. The last meeting was 03/23/22.

Review on 10/19/22 of the QIPS meeting minutes dated 02/24/22 to 09/22/22 and the MEC meeting minutes from 03/14/22 to 09/14/22 revealed that there was no Radiologist in attendance.

Review on 10/19/22 of the adverse events and complaint log dated from 04/18/22 to 09/30/22 revealed no radiologist review.

Interview on 10/19/22 at 12:40 PM with Staff (A), President/CEO, revealed Staff (O), MD, Radiologist, agreed upon 6-month termination timeframe per his contract and ended his employment at the facility on 05/31/22. The facility does not have a designated Radiology Director. Directorial duties are performed by Staff (A), President/CEO, and Staff (D), MD, CMO. The facility was never without a Radiologist to perform services.

Interview on 10/19/22 at 01:00 PM with Staff (D), Chief Medical Officer revealed that since 06/01/22, she has overseen the clinical/medical issues, policy reviews, adverse events, staff issues, and supply issues for Radiology. However, Staff (D), does not have radiology privileges at the facility.