Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 010001	(X3) Date Survey Completed 09/29/2017
Name of Provider or Supplier Southeast Health Medical Center	Street Address, City, State 1108 Ross Clark Circle, Dothan, AL
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.

(X4) ID Prefix Tag

Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)

A0283

QUALITY IMPROVEMENT ACTIVITIES
CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3)

(b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained.

This STANDARD is not met as evidenced by:
Based on review of the Quality Improvement Plan - Policy and interviews, it was determined the hospital failed to implement corrective actions focusing on performance improvement, ensure actions taken have a positive affect on patient outcomes, safety and quality of care. This had the potential to negatively affect all patients served by the hospital. Findings include: Quality Improvement Plan- Policy Fiscal Year 2016 I. Purpose ... the fiscal year 2017 Quality Improvement Plan is designed to establish, organize, implement, monitor and document evidence of an ongoing and systematic quality improvement process... V. Goals and Objectives The fundamental goal of Southeast Alabama Medical Center is to continuously improve the quality of all patient care and other services, as needed by the customer. This will be achieved by: A. Implementing a systemic, organization-wide process that identifies area with opportunities, including planning for performance improvement, and determining the number of individuals and types of skills needed to accomplish these improvements... D. Utilize a dashboard reporting tool to improve communication and transparency throughout the organization of quality indicators, metrics, and benchmarks. E. Evaluating the processes by which care and services are delivered and implementing changes to improve these processes... H. Overseeing and evaluating the effectiveness of quality improvement activities through internal and external benchmarking and modifying processes as necessary to improve the care and services provided to customers. Fiscal year 2017 Quality Improvement Goals ... The organization will focus on improving performance processes so that the customers will receive safe, timely, efficient, effective, equitable and patient centered care. Organization Performance Scorecard "Quality Metrics" a) Decrease Hospital Acquired Conditions (HAC) and improve outcomes related to the following: ... 3. Surgical Site Infections (SSI) Regulatory Required Tracking and Trending Quality Metrics (Hospital)... K) Anesthesia/ moderate sedation/ deep sedation adverse events 1. The Department of Quality Management monitors Rapid Response and Code 4 calls for any potential over sedation concerns. 2. The Department of Quality Management and Anesthesia monitors deep cases performed in the Emergency Department for compliance with policy. 3. The Department of Quality Management and Anesthesia monitors cases where a reversal agent (that was medically necessary) was administered following procedure. VIII. Scope of (Quality Improvement ) QI Activities... The Quality Management Director has the responsibility for the overall support of all performance improvement activities in Southeast Alabama Medical Center (SAMC)... This includes assisting with the mechanism for data collection, data display, report preparation, data trending, data integration, team and department support. X. Methodology For Improving Organizational Performance... All appropriate individuals, departments, and committees shall work collaboratively, using the following process as a model of continuous improvement, when starting a new improvement project, when developing a new or improved design of a process, product or services, when defining a repetitive work process, when planning data collection and analysis in order to verify, prioritize problems or root causes and when implementing any change to improve outcomes and other hospital processes... During an interview conducted on 9/26/17 at 10:15 AM with Employee Identifier (EI) # 12, Registered Nurse (RN) Operations Leader Pre/Post Anesthesia and same day Surgery, the surveyor asked EI # 12 the types of data she is collecting for post-anesthesia care unit (PACU). EI # 12 informed the surveyor she collects information related to hold times such as waiting for a bed on the nursing floors and the information gathered is submitted monthly to Surgical Services Committee only. In an interview conducted on 9/26/17 at 2:55 PM with EI # 14, Certified Registered Nurse Anesthetist (CRNA) and EI # 15, Surgical Services Medical Director, the surveyor was informed the CRNA and the Medical Director of Anesthesia collects and reviews the same indicators monthly, but submits the collected audits to 2 different outside vendors. EI # 26, Medical Director, Anesthesia Department submits his/ her audits to E-preop reporting system. EI # 26 informed the surveyor that his/ her department had not receive any results/findings from E-preop since the first of the year. EI # 14 provided the surveyor with his/her reports. The surveyor further asked EI # 14 and EI # 15 if the results of audits are submitted to the hospital-wide Quality, both informed the surveyor that their reports of audits are sent to the Surgical Committee and both are unsure if it goes to any other committee. An interview was conducted on 9/27/17 at 11:00 AM with EI # 1 Director of Quality, who verified Surgical Services, including Operating Room, Anesthesia and PACU do not send their audit reports and results to her.