HospitalInspections.org

Based on document review and interview, the hospital failed to ensure that as part of its quality assessment and performance improvement program, the hospital selected and conducted performance improvement projects. Findings include:

On 1/14/2011 at approximately 0850 hours, the Director of AQ/QI stated that the performance quality indicators that will be monitored for fiscal year 2010-2011 are based on the deficiency citations from the most recent survey by the Centers for Medicare and Medicaid. The Director of QA/PI confirmed apart from the selected performance quality indicators, no performance improvement projects have been selected and promulgated.

The Director of QA/QI stated that at this time, only a limited number of "data points" have been collected, trending of collected data has not occurred, and confirmed that benchmark indicators have not been identified that would serve as an indicator for initiating corrective action aimed at performance improvement. The Director of QA/QI did not present any data demonstrating that on the basis of collected QAPI data that actions aimed at performance improvement were taken and measurements related to the success of the actions were also taken, and continued to track performance to ensure that improvements were sustained.