HospitalInspections.org

Based on interviews, the Hospital failed to ensure the Department of Surgery documented the context of the Surgical Services Mortality and Morbidity meetings and the Surgical Services Quality Assurance Committee meetings to provide evidence that: meetings were held as scheduled, tracking data was reviewed, concerning cases were reviewed and issues requiring follow-up were addressed.

Findings included:

The Surveyor interviewed the Vice President (VP) of Quality and the Chair of the Department of Surgery on 6/11/12 at 8:45 A.M.

The VP of Quality and Safety and the Chair of the Surgery Department said that the Department of Surgery's quality meetings included: Surgical Services M&M (held monthly), Patient Safety (held every 2 weeks) and Surgical Services Quality Assurance Committee (held monthly).

The Chair of the Department of Surgery said that the meetings were being held as scheduled.

The Surveyor asked to review the meeting minutes from Surgical Services M&M and Quality Assurance Committee for the period of 10/11 to 6/12.

The VP of Quality and Safety said that when she requested the Surgical M&M and Quality Assurance Committee meeting minutes, she was informed that the context of meetings (attendance and/or agenda) were not documented. The VP of Quality and Safety said that until now, she was not aware that the Department of Surgery was not documenting meeting minutes.