HospitalInspections.org

Based on review of facility documents and interview with staff (EMP), it was determined the Governing Body failed to ensure the Medical Staff discussed admissions, duration of stays and professional services furnished by the facility and failed to ensure there was an effective system for monitoring and evaluating the quality of patient care and services provided under contract.

Findings include:

Review on July 11, 2013, of the facility's "Medical Staff Bylaws," dated revised June 19, 2013, revealed "... 5.11. Other Committees Involving the Medical Staff ... 5.11.2 Utilization Review - The Medical Staff shall actively participate in the Hospital-wide utilization review program and plan. As such, the Staff shall be involved with determining the appropriateness of admissions, length of stay, discharge practices, utilization of medical and Hospital services, and all related facets which may contribute to effective utilization of Hospital and physician services. The Medical Staff shall be active in the formulation, implementation and periodic review of the written Utilization Review Plan. Such Utilization Review Plan must have the following features: (a) Organization and composition of the Utilization Review Committee: (b) Frequency of Meetings; (c) Types of records to be kept; (d) The method to be used in selecting cases on a sample or other basis; (e) Definition of what constitutes the period of extended duration, and; (f) The responsibilities of the Hospital's Administrative staff in support of the Utilization Review. Review and recommended actions shall be transmitted to the MEC."

Review on July 11, 2013, of the facility's "Utilization Review Plan," dated reviewed and revised June 2011, revealed "I. Authority ... The Utilization Review Process is a collaborative function of the medical staff of Wayne Memorial Hospital and is a standing committee of the Medical Staff. II. Purpose ... A. To recommend the appropriate allocation of the hospital's resources by striving to promote quality patient care in the most cost-effective manner. B. To assist in the promotion of effective health care by addressing the over utilization, under utilization, and inefficient scheduling of hospital's resources. ... IV. Meetings ... The Utilization Review Committee will meet monthly, or more frequently if deemed necessary by the Chairperson. ... V. Function ... The function of the Committee may be carried out by the whole committee, sub-committee, or by delegated agents, such as a physician advisor and/or review coordinator. A. To assure the proper utilization of hospital's resources while maintaining high quality patient care through admission review, timely concurrent review, and adequate discharge planning. B. To communicate the ongoing changes in Utilization Review function by governmental and private insurance carriers to all physicians, their office staff and involved hospital personnel. C. To recommend changes in hospital procedures or medical staff practices as a result of these changes. D. To develop a working mechanism to implement the improved changes. ..."

Review on July 11, 2013, of the Utilization Review meeting minutes revealed monthly meetings were held in 2012 and 2013.

Review on July 11, 2013, of the Medical Staff meeting minutes for 2012 and 2013 revealed no discussions determining the appropriateness of admissions, length of stay, discharge practices, utilization of medical and hospital services, and all related facets which may contribute to effective utilization of hospital and physician services.

Interview with EMP1 on July 11, 2013, at approximately 3:00 PM confirmed there was no documentation the Medical Staff discussed appropriate admissions, length of stay, discharge practices, utilization of medical and hospital services and all related facets, as required by the medical staff bylaws.

Based on review of facility documents and interview with staff (EMP), it was determined the Governing Body failed to ensure the contracted services provided to the hospital were assessed by the Quality Assessment and Performance Improvement Committee.

Findings include:

Review on July 11, 2013, of the facility policy and procedure "Quality Assessment And Performance Improvement Plan for Wayne Memorial Hospital," dated reviewed June 24, 2013, revealed "I. Purpose- The purpose of the Quality Assessment and Performance Improvement (QA-PI) Plan for Wayne Memorial Hospital is to insure the delivery of the best possible care for our patients. This is accomplished through an ongoing process of assessing patient care and other support processes in a systematic manner. The result will identify opportunities for improvement and a plan to act upon them. This plan integrates the pursuit of the mission of the Wayne Memorial Hospital with the understanding that excellence in clinical outcomes and patient safety must be achieved with appropriate allocation of resources. II. Mission- The mission of Wayne Memorial Hospital is to provide each patient the highest quality, compassionate and cost-effective care and treatment on every visit producing high levels of patient satisfaction. To that end the organization as a whole, participates in a systematic effort to improve performance. Core Values- Wayne Memorial Hospital's core values of compassion, advocacy, respect. education and safety are considered in all efforts to improve performance. III. Objectives- A. To promote National Patient Safety Goals through risk reduction in collaboration with the Patient Safety Committee. B. To increase patient satisfaction by assessing and improving those governance, administrative, clinical and support processes that most effect patient outcomes. C. To establish priorities for the investigation and resolution of issues and problems by focusing on those with the greatest impact on patient care outcomes, patient safety and patient satisfaction. D. To educate all employees about improving the processes they are involved in. E. To coordinate performance improvement activities of the medical staff with those of the organization and integrate efforts whenever possible. IV. Authority- The Board of Trustees of Wayne Memorial Hospital, in collaboration with the medical staff, professional and support staff and hospital leadership, bear the responsibility for assuring the quality and effectiveness of patient care services provided. The organization's leadership set expectations, develop plans and implement procedures to assess and improve the quality of the management, governance, clinical and support processes. The Board of Trustees holds the medical staff and hospital managers responsible for implementing performance improvement activities. The hospital leadership includes members of the Quality and Professional Affairs Committee, The Medical Staff Executive Committee, Directors and Departmental Manager. The Board of Trustees will review periodic reports of findings, actions and results from quality assessment and performance improvement activities to assess this program's efficiency and effectiveness."

Review on July 11, 2013, of the listing of "Wayne Memorial Hospital's Contract Directory," provided to the Department revealed the following services were provided thru contract: Laundry, Wound Expert, Sleep Lab equipment services, EMR [electronic medical record], Software Licensing Agreement, Trash Disposal, Elevators, Software, Copiers, Badges, Pyxis [a medication dispensing system], Telemedicine, Behavioral Health, Anesthesia Solutions, ePrescribing,Waste Management, Sani-Pac, Red Cross Blood Supply agreement, Contracted Laboratory Services, Hyperbaric Services, Temporary Nursing Staffing, and Communications.

Review on July 11, 2013, of the Quality Improvement/Infection Control Meeting Minutes for 2012 and 2013 revealed no documentation the contracted services provided to the hospital were included in the Quality Improvement Program.

Interview with EMP14 on July 11, 2013, at approximately 11:30 AM confirmed there was no documentation the contracted services provided to the hospital were included in the hospital Quality Improvement Program.

Interview with EMP1 on July 11, 2013, at approximately 11:00 AM confirmed there was no documentation the contracted services provided to the hospital were included in the Quality Improvement Program and brought forward to Utilization Review or the Board of Trustees for review.