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WAYNE MEMORIAL HOSPITAL
REASSESSMENT OF DISCHARGE PLANNING PROCESS
Tag No.: A0843
Based on review of the facility's performance plan, quality documentation and staff interviews, it was determined that the facility failed to reassess its discharge planning process on an on-going basis.
Findings were:
A review of the facility's Performance Improvement Plan, Section 12. Title "Annual Appraisal", revealed that quality assessment forms were submitted to each department director annually for completion by year's end. The purpose of the form was for the evaluation of the department's improvement activities for the previous year. In addition a Performance Improvement Summary report was to be completed summarizing the year's accomplishments. The department directors were responsible for identifying, and documenting opportunities for improvement for the coming year. The department directors were also responsible for submitting the data to the Quality Management Director who reported to the leadership council so organization-wide strategies for improvement could be determined. The accomplishments and strategies were to be sent to the Medical Executive Committee and Governing Authority for review and recommendations.
A review of the facility's Performance Improvement Activity Report for 2011 and 2012 revealed no documented evidence of review of the discharge planning process. There was also no documented evidence that the quality assessment form and performance summary for the Discharge Planning Department had been completed and submitted as required by the Performance Improvement Plan.
An interview was conducted with the facility's Quality/Risk Management Coordinator and the Case Management/Discharge Planning Nurse Manager, on 08/16/12, at 10:00 a.m., in the Administrative Conference room. Both interviewees confirmed that the facility's discharge planning process had not been reviewed in an ongoing manner. They also confirmed that the quality assessment form and performance summary for the Discharge Planning Department had not been completed and submitted as required by the Performance Improvement Plan.