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Based on policy/procedure review, document review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the evaluation of the quality and appropriateness of the diagnosis and treatment furnished by physicians by an appropriate entity as required by the regulation for the contracted radiologist service. Concerns for 19 of 20 contracted radiology practitioners.

Failure to ensure the evaluation of the quality and appropriateness of the diagnosis and treatment furnished by Physicians at the CAH could potentially lead to medical staff providing
substandard patient care.

Findings include:

Review of CAH policy/procedure titled "Medical Staff Bylaws" dated March 2007 revealed the following in part "SCOPE OF PEER REVIEW: Each other practitioner or officer or employee of the Hospital, and each other committee of the Medical Staff, shall furnish such investigating body or committee with any requested information which is in their possession and which may bear on the matter under investigation. Hospital as a member of a rural health network has an agreement with respect to peer review (quality assurance) with at least: a) one hospital that is a member of the network; b) one Peer Review Organization (PRO) or equivalent; or c) one other appropriate and qualified entity identified in the state rural health care plan.

A review External Peer Review documentation for 20 contracted radiologist's revealed that 19 contracted radiologists lacked an external peer review (a Medical Record selected for an evaluation of the quality and appropriateness of the diagnosis and treatment furnished by Physicians at the CAH).

During an interview on 7/6/2010 at 2:10 PM, the Director of Reimbursement Services acknowledged 19 of the 20 contracted radiologists lacked an external peer review. The Director of Reimbursement reported he/she wasn't clear how many of the contracted tele-radiologists were to have an external peer review, so at this time only one external peer review had been completed. The Director of Reimbursement Services reported the 19 contracted tele-radiologist will be scheduled to have a medical record selected for an external peer review.




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