HospitalInspections.org

Based on a request for performance improvement documentation including root cause analysis (RCA) and Failure Mode Effects Analysis (FMEA), it was determined that the hospital failed to utilize these quality tools and failed to conduct a multidisciplinary process to monitor, analyze, and intervene in performance improvement and patient safety.

A request for three root cause analyses and the most recent FMEA revealed that the hospital does not utilize these performance improvement tools to identify and address adverse events occurring within the hospital. No documentation could be found during the survey evidencing a systematic approach that analyzed the frequency or severity of events or their root causes. There also was no evidence of actions aimed at performance improvement following events. Consequently, the hospital could not determine or ensure that the quality program adequately addressed outcomes and safety concerns.