HospitalInspections.org

Based on review of hospital documents, meeting minutes, and staff interviews, it was determined the governing body failed to oversee hospital functions independently as one distinct entity.

This deficient practice does NOT rise to Condition Level.

Findings include:

The Chief Operating Officer (COO), Director of Quality, and Director of Medical Staff Services all confirmed the following during interviews conducted on 11/02/11:

Yavapai Regional Medical Center (East Campus) located at 7700 E. Florentine, Prescott Arizona, and Yavapai Regional Medical Center (West Campus) located at 1003 Willow Creek, Prescott Arizona, are separately licensed healthcare institutions. The hospitals also maintain separate and distinct Medicare provider numbers.

The two (2) hospital share one (1) governing body, and co-mingle the following:

(1) Infection Control Plan and Committee
(1) Continuous Quality Improvement and Steering committee
(1) Medical Executive Committee (separate medical staffs)
(1) Pharmacy and Therapeutics Committee
(1) Emergency Preparedness Plan (each hospital conducts their own drills)
(1) Chief Executive Officer
(1) Medical Staff Bylaws, Rules, and Regulations

The Governing Body Meeting Minutes (2010 - 2011) demonstrate that the Governing Body meets to discuss and plan for both hospitals, at the same meeting. The minutes do not demonstrate that the Governing Body focuses on each hospital entirety (hospital specific), but rather as one (1) institution.