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OCHSNER CHOCTAW GENERAL
QUALITY ASSURANCE
Tag No.: C0336
Based on review of the Quality Assessment and Process Improvement Plan and interviews with staff, it was determined the facility failed to monitor quality indicators and other aspects of patient care services and operations for each department. This had the potential to negatively affect all patients served by the hospital.
Findings include:
Review of the Quality Assessment and Process Improvement (QAPI) Plan and interviews with department supervisors, revealed all departments of the facility failed to track, monitor, and submit quality assurance and performance improvement (QAPI) activities to be included in the hospital-wide QAPI program.
An interview was conducted 6/4/15 at 10:35 AM with Employee Identifier (EI) # 1 , Assistant Administrator, who confirmed the QAPI program did not encompass every department in the hospital.