HospitalInspections.org

Based on review of policy, document, and staff interviews, the Critical Access Hospital (CAH) failed to ensure 3 of 3 applicable consulting physicians and 1 of 1 applicable independent licensed practitioner selected for review, received an outside entity peer review prior to reappointment to the Medical Staff, to evaluate the appropriateness of diagnosis and treatment furnished to patients at the CAH. (Staff B, D, E and F). The CAH identified 3 active physicians, 114 consulting physicians, 1 courtesy physician, 1 licensed independent practice physician, 46 teleradiologist and 35 telemedicine physicians credentialed to provide services to CAH patients.

The CAH administrative staff identified the practitioners provided services to patients, from 12/1/13 to 11/30/15, as follows:

Staff B M.D. General Surgeon - 55 patients
Staff D D.P.M., Podiatrist - 35 patients
Staff E M.D., General Surgeon - 430 patients
Staff F, M.D., Orthopedics - 296 patients

Failure to ensure all medical staff members received an outside entity peer review could potentially affect the CAH's ability to assure physicians provided quality care to their patients.

Findings include:

1. Review of Sanford Health Services Division Administrative policy titled "Medical Staff Peer Review", revised 6/2013, revealed the policy failed to define the process for an outside entity peer review to ensure all of the physicians received evaluation of the quality and appropriateness of the diagnosis and treatment of the CAH's patients.

2. Review of CAH documentation on 12/3/15 revealed the facility failed to ensure the CAH completed outside entity peer reviews on the services provided to patients at the CAH for Physicians B, D, E and F, during their last credentialing cycle.

3. During an interview on 12/3/15, at 8:30 AM, Staff A, Sanford Health Systems Accreditation and Certification Coordinator and Staff C, Sanford Health Systems Director of Medical Staff Services reported the network hospital completed peer review on physicians based on pre-defined triggers and acknowledged peer review would not automatically be completed on all physicians providing care to the CAH patients, but would look to determine if the identified physicians had any peer review completed.

During a follow-up interview on 12/3/15, at 11:15 AM, Staff A confirmed the CAH failed to complete outside entity peer reviews for Staff B, D, E and F.