HospitalInspections.org

Based on document review and interview it was revealed the governing body failed to ensure the medical staff by-laws were updated and correct for the description of one (1) of three (3) medical staff officers and the Chief Medical Officer. This failure has the potential to cause confusion for all hospital staff when they need to invoke the medical staff chain of command.

Findings:

1. A review of the document entitled 'Thomas Memorial Hospital MEDICAL STAFF BYLAWS' last revised 8/11/15 and last reviewed 4/2021 revealed in part: "The President shall: acts as the chief medical officer of the Hospital, in coordination and cooperation with the Chief Executive Officer and/or designee and the Medical Director, in matters of mutual concern involving the hospital ..."

2. A review of the document entitled 'Thomas Memorial Hospital MEDICAL STAFF BYLAWS' last revised 8/11/15 and last reviewed 4/2021 revealed in part: "To be adopted, an amendment must receive a majority of the votes cast by the voting staff. Amendments so adopted shall be effective when approved by the Board ..."

3. An interview with the Chief Operating Officer (COO) on 8/11/21 at approximately 9:30 a.m. revealed she/he is a member of the governing body and the officers section of the medical staff by-laws had not been amended or updated since the Chief Medical Officer (CMO) became a separate position.

4. The COO concurred with the above findings during the interview on 8/11/21 at approximately 9:30 a.m.

Based on document review and interview it was revealed the medical staff failed to correct and up-date the officers section of the medical staff by-laws for one (1) of three (3) officers when a new Chief Medical Officer (CMO) was named. This failure has the potential to cause confusion for all hospital staff when they need to invoke the medical staff chain of command.

Findings:

1. A review of the document entitled 'Thomas Memorial Hospital MEDICAL STAFF BYLAWS' last revised 8/11/15 and last reviewed 4/2021 revealed in part: "The President shall: acts as the chief medical officer of the Hospital, in coordination and cooperation with the Chief Executive Officer and/or designee and the Medical Director, in matters of mutual concern involving the hospital ..."

2. An interview with the Chief Operating Officer (COO) on 8/11/21 at approximately 9:30 a.m. revealed the CMO was not the president of the medical staff. The officers section of the medical staff by-laws had not been updated since the CMO became a separate position.

3. An interview with the CMO on 8/11/21 at 2:00 p.m. revealed she/he had been the CMO for 6 years, since 2015, and she/he concurred with the above findings.