HospitalInspections.org

Based on a review of facility documents and interview with facility staff (EMP), it was determined that the facility failed to include Surgical Services data into the Quality Assurance Program and failed to follow their adopted Quality Improvement Plan.

Findings Include:

Review of "Fulton County Medical Center Medical Staff Bylaws: dated June 25, 2013, revealed, " ... Article II. Purposes and Responsibilities 2.1 Purpose: The Medical Staff's purposes are: ... (b) To account for the ethical and professional appropriateness of its Medical Staff Members (each a 'Medical Staff Member' and collectively the 'Medical Staff Members') performance and to strive toward continually improving the Hospital's patient care quality and efficiency, consistent with the local state of healing arts and resources; ... 2.2 Medical Staff Responsibilities: ... (a) To account to the Board for the quality and efficiency of patient care provided by all Medical Staff Members through the following measures: (i) review and evaluate the quality of patient care provided by the Medical Staff Members through valid and reliable concurrent and retrospective patient care monitoring, (ii) an organizational structure and mechanisms that allow ongoing monitoring of patient care practices, ... (d) To account to the Board for the quality and efficiency of patient care through regular reports and recommendations ... ."

Review of "FCMC Quality Improvement Plan Management" policy and procedure dated May 10, 2010, revealed, " ... Policy: It is the policy of the Fulton County Medical Center that all Hospital Departments have an ongoing Improvement Plan within their individual departments; to have an ongoing effort to provide patient/employee safety and to meet the health care standards outlined by the Department of Health as well as manage risk in order to 'continuously improve the health care in our community'." Procedure: ... Departmental Quality Improvement: a. All hospital departments. b. All clinical departments submit data into RPM (Rural Quality Management) on a monthly basis and monitor their balanced scorecards. c. Will look at changes within the department: 1. Those include: Acute/Emergency Room/Operating Room ... ."

1) Review of "Risk Management Committee Meeting Minutes" dated June 2013, through February 2014, revealed no documented evidence of Surgical quality data being discussed.

2) Review of "Interdisciplinary Event Review Committee Meeting Minutes" dated April 2013, through March 2014, revealed no documented evidence of Surgical quality data being discussed.

3) Review of "Performance Improvement/Peer Review/Medical Record/Tissue and Transfusion Committee" meeting minutes dated December 2013, through March 2014, revealed no documented evidence of Surgical quality data being discussed.

4) Review of "Medical Staff Committee Meeting Minutes" dated January 2013, through March 2014, revealed no documented evidence of Surgical quality data being reported to the Board.

5) Review of "Board of Directors Quality Improvement Committee Meeting Minutes" dated January 2013, through March 2014, revealed no documented evidence of Surgical quality data being reported to the Board.

Interview with EMP1 on April 9, 2014, at 1:30 PM confirmed the above findings and revealed, "We discuss things but not in committee format. Nothing except infections and complications would be reported to the Board."