The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ST FRANCIS COMMUNITY HOSPITAL 34515 9TH AVENUE SOUTH FEDERAL WAY, WA 98003 July 11, 2012
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on interview and review of the hospital's quality improvement plan and governing body meeting minutes, the hospital's governing body failed to specify the frequency of data collection performed by hospital staff members.

Findings:

1. The hospital's policy and procedure entitled "Quality Improvement and Safety Plan (QISP)" (Policy 395.00; Reviewed 10/18/2011) stated that the hospital's quality committees and groups, including the Board of Directors, would determine the frequency of data aggregation and analysis.

2. Review of the governing body meeting minutes for 9/29/2011 and 1/26/2012 revealed that results of quality metrics were presented to the Board of Directors by the Vice President of Quality. There was no evidence in the minutes that board members provided feedback regarding data collection frequency.

3. On 7/11/2012 at 9:40 AM, Surveyor #1 conducted a telephone interview with the Director of Quality and Clinical Support (Staff Member #1) and a nurse representative of the healthcare system's Safety and Regulatory Compliance unit (Staff Member #2). During this interview, these hospital staff members stated that the frequency and detail of data collection regarding quality indicators was not specified by the Board of Directors. This was done by hospital leaders.
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