HospitalInspections.org

Based on findings from document review and interview, the mechanisms in place to ensure the medical staff are accountable for the quality of medical care provided do not include maintenance of a complete quality file for each medical staff member as required by New York State Department of Health regulations. Also, not all peer reviews completed by the medical staff are documented.

Findings include:

-- Section 405.6(b)(7)(v) of Title 10 of the New York Codes Rules and Regulations requires hospitals to maintain a file on each physician granted privileges or otherwise associated with the hospital which contains credentialing and all other relevant information required to be gathered in accordance with the hospital's quality assurance program (e.g., reviews of medical records, complaints, incidents, and complications of care; profile analyses).

-- Physician "quality files" are maintained electronically at this hospital. Electronic quality information for 2 medical staff members was reviewed during interivew with the Director of Quality, Case Management on 4/10/14. Review and discussion revealed the files did not contain all quality information gathered by the hospital's quality assessment /performance improvement program, e.g., information from peer reviews of complications of care, reviews of complaints, etc. The Director of Quality, Case Management, explained that this information is acutally collected but acknowledged it is not maintained in one central repository for each physician and midlevel practitioner on the medical staff. Instead, some of this information is maintained electronically elsewhere (e.g., complaint information) or in a paper file in his/her office.

-- Also, per interview of the ED Medical Director at 8:00 am on 4/10/14, he / she reviews all returns to the ED within 72 hours but does not document these reviews.