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Based on interview and record review, the facility failed to include the scope and nature of services provided for 1 of 2 sampled vendors (Vendor K) on its list of contracts. The deficient practice eliminated a mechanism by which the facility could create an overview of its contracted services sufficient to target efforts monitoring vendor quality and compliance.

Findings:

Review of the facility's undated list of contracted services indicated Vendor K had a "Consulting Services Agreement" with the facility effective 7/1/11 through 6/30/12. The column of the list labeled "Description" was blank.

Review of an undated "AGREEMENT FOR SERVICES" between the facility and Vendor K indicated the services to be provided by Vendor K were delineated on an "attached Letter of Agreement". No "Letter of Agreement" was present, but an "Addendum to Letter of Agreement" signed by the vendor on 7/16/11 and by facility staff on 7/27/11 and 8/15/11 indicated Vendor K would provide "Two contemporaneous classes... in the Summer 2011... Class will be offered in the Fall, Winter/Spring and Summer sessions." The addendum did not describe the nature of the classes, though the name of the vendor implied that his services included martial arts instruction.

In an interview on 3/1/12 at 2:41 p.m., the Director of Accreditation stated there was no other letter of agreement between the facility and Vendor K. She stated Vendor K "teaches martial arts."

Based on interview and record review, the facility failed to consider the physician's individual performance on relevant indicators measured by the hospital's quality assessment and performance improvement (QAPI) program at the time of reappointment in 5 of 8 sampled credentials files (Practitioners 1, 4, 5, and 6). The deficient practice eliminated a mechanism of considering quality of work and patient outcomes as part of medical staff reappointments and had the potential to allow poor quality work to escape notice.

Findings:

Refer to A-945 regarding the facility's medical staff bylaws requirement to consider quality data at the time of reappointment and the absence of such data from the credentials files of Practitioners 1, 4, and 6.

Review of the statement of deficiencies from the hospital's survey completed 10/17/11 indicated that a Department of Anesthesiology Report to QIC (Quality Improvement Committee) dated 5/26/10 had revealed that the department had data on patient satisfaction but had not calculated physician individual performance regarding patient satisfaction. The statement of deficiencies also indicated the facility's "Acute Care Clinical Quality Statement Detail" (extracted 7/11/11) revealed the hospital had data on whether surgical patients received their antibiotics within one hour prior to incision, but had not calculated physician individual performance in this regard.

Review of the facility's plan of correction dated 1/30/12 indicated the facility would evaluate reintubation rates in the PACU (post-anesthesia care unit) and patient satisfaction scores as part of the credentialing process for anesthesiologists.

Review of the facility's credentials committee minutes dated 2/15/12 indicated the committee had recommended that Practitioner 5 be reappointed to the facility's medical staff. In an interview on 3/1/12 at 9:58 a.m., Staff J stated the chair of the credentials committee had just told her the governing body had approved the credentials committee recommendations from 2/15/12.

Review of Practitioner 5's credentials file indicated he was an anesthesiologist. The undated "ONGOING PHYSICIAN PEER EVALUATION" stated Practitioner 5 had not had "Quality Referrals", "Patient/staff complaints", "Disruptive behavior", or "Medical Record Suspension Days". No data was present which measured the quality of Practitioner 5's work or the outcomes experienced by his patients beyond documentation that the facility had not been alerted to problems. No patient satisfaction scores for Practitioner 5 were present.

In an interview on 3/1/12 at 1:04 p.m., Staff J stated the facility was still collecting data on PACU reintubation rates. Staff G added, "We don't have that yet."

Based on interview and record review, the facility failed to grant surgical privileges in accordance with each physician's current competence. Three of eight sampled credentials files (Practitioners 1, 4, and 6) did not have evidence of the physician's experience in procedures which a national guideline stated required a minimum number of cases each year to remain competent. The same three files also did not have data regarding the physician's practice from the hospital quality assessment and performance improvement (QAPI) program. The deficient practices eliminated mechanisms by which the facility could ensure that its medical staff performed only those procedures they had demonstrated they could do well, and had the potential to allow poor quality health care.

Findings:

Review of the facility's credentials committee minutes dated 2/15/12 indicated the committee had recommended reappointments for Practitioners 1, 4, and 6. In an interview on 3/1/12 at 9:58 a.m., Staff J stated the chair of the credentials committee had just told her the governing body had approved the credentials committee recommendations from 2/15/12.

Review of Practitioner 1's credentials file indicated he had requested and been approved for "Core Pulmonary Disease" privileges which included bronchoscopy (endoscopy of the respiratory tract) and pleural biopsy (sampling the membranes inside the chest wall). The delineation of privileges form (approved by the department chair 2/13/12) stated Practitioner 1's experience in the procedures consisted of over 100 "inpatient admissions or consultations with pulmonary care management during the past 2 years", but did not specify how many bronchoscopies and pleural biopsies Practitioner 1 had done. The delineation of privileges form also indicated Practitioner 1 had requested and been approved for "Core Critical Care Medicine" privileges which included "Chest tube placement (Tube thoracostomy)". The privileges form stated Practitioner 1's experience relevant to chest tube placement consisted of over 50 "inpatient admissions with critical care management during the past 2 years", but did not specify how many chest tube placements Practitioner 1 had done. A line listing of Practitioner 1's inpatient encounters at the facility for 12/1/09 through 12/15/11 was present which specified a code for the principal procedure performed on some of the patients, but other patients had no principal procedure, and there was no information specifying which procedures each code represented or summarizing how many of each procedure Practitioner 1 had performed. No other information was present in the credentials file indicating how many bronchoscopies, pleural biopsies, or chest tube placements Practitioner 1 had performed recently. Practitioner 1's file indicated the number of his medical record suspension days and that there had been "no reported professional liability cases, no adverse QI [quality improvement] reports and no recent NPDB [National Practitioner Data Bank] reports filed"; however, there was no data from the hospital QAPI program measuring the quality of Practitioner 1's work.

Review of Practitioner 4's credentials file indicated indicated he had also requested and been approved for "Core Pulmonary Disease" privileges which included bronchoscopy and pleural biopsy. The delineation of privileges form (approved by the department chair 2/13/12) stated Practitioner 4's experience in the procedures consisted of 50 "inpatient admissions or consultations with pulmonary care management during the past 2 years", but did not specify how many bronchoscopies and pleural biopsies Practitioner 4 had done. The delineation of privileges form also indicated Practitioner 4 had requested and been approved for "Core Critical Care Medicine" privileges which included "Chest tube placement (Tube thoracostomy)". The privileges form stated Practitioner 4's experience relevant to chest tube placement consisted of 100 "inpatient admissions with critical care management during the past 2 years", but did not specify how many chest tube placements Practitioner 4 had done. A line listing of Practitioner 4's inpatient encounters at the facility for 12/1/09 through 12/15/11 was present which specified a code for the principal procedure performed on each patient, but there was no information specifying which procedures each code represented or summarizing how many of each procedure Practitioner 4 had performed. No other information was present in the credentials file indicating how many bronchoscopies, pleural biopsies, or chest tube placements Practitioner 4 had performed recently. There was no data from the hospital QAPI program measuring the quality of Practitioner 4's work.

Review of Practitioner 6's credentials file indicated he had requested and been approved for "Core Pulmonary Disease" privileges which included pleural biopsy (sampling the membranes inside the chest wall). The delineation of privileges form (approved by the department chair 2/13/12) stated Practitioner 6's experience in the procedures consisted of over 12 "inpatient admissions or consultations with pulmonary care management during the past 2 years", but did not specify how many pleural biopsies Practitioner 6 had done. A line listing of Practitioner 6's inpatient encounters at the facility for 12/1/09 through 12/15/11 was present which specified a code for the principal procedure performed on each patient, but there was no information specifying which procedures each code represented or summarizing how many of each procedure Practitioner 6 had performed. No other information was present in the credentials file indicating how many pleural biopsies Practitioner 6 had performed recently. There was no data from the hospital QAPI program measuring the quality of Practitioner 6's work.

Review of the American College of Chest Physicians guideline titled "Interventional Pulmonary Procedures" (Chest 2003; 123:1693-1717) indicated physicians need to perform a minimum number of procedures each year to "maintain competency". The guideline stated a physician should perform at least 25 flexible bronchoscopies per year to remain competent in that procedure. The guideline stated a physician should perform 10 rigid bronchoscopies, 5 tube thoracostomies, or 5 percutaneous pleural biopsies each year to remain competent in each of those procedures.

In an interview on 3/1/12 at 9:58 a.m., Staff J confirmed that the pulmonary disease core privilege required admissions or consultations rather than experience in individual procedures. She acknowledged that the credentials files did not indicate experience in the procedures included in the critical care medicine core privilege, but stated that the information was present for those procedures listed separately as supplemental privileges. She stated the physicians were expected to cross out items in the core privileges they had not been doing.

In an interview on 3/1/12 at 11:07 a.m., the Director of Accreditation stated the facility had incorporated QAPI data into the credentials files for the three departments discussed in the facility's plan of correction after the last survey, but there had been no change in the other departments. Staff E stated the facility hoped to have a data system in place by fall that would capture individual medical staff QAPI data, but would have difficulty meeting that requirement if it needed to compute the data manually for other departments before then.

Review of the facility's "ICU [intensive care unit] Patient Quality of Care Committee Report to the Quality Improvement Committee (QIC)" dated 12/14/11 indicated the hospital collected data regarding ICU mortality, "VAP Bundle" (a group of performance indicators related to preventing ventilator-associated pneumonia or VAP), occurrences of VAP and CLBSI (central line blood stream infections), and post-operative glucose levels for cardiac patients. No information was present regarding how individual physicians performed on the data collected by the hospital.

Review of the facility's medical staff bylaws dated 10/6/11 indicated results of quality assurance activities were to be considered as part of the medical staff reappointment process.