OHA, Health Care Regulation & Quality Improvement Centers for Medicare and Medicaid Services Complaint Number

#s OR7583 and OR 7617 Provider Number 38-0051

Plan of Correction

RESPONSE TO PREFIX TAG A 131

CFR 482.13(b)(2) PATIENT RIGHTS: INFORMED CONSENT The patient or his/her representative has the right to make informed decisions regarding his/her care. This STANDARD is not met as evidenced by 1 of 3 pediatric patients who received anesthesia services, it was determined that the hospital failed to ensure the patient representative's right to be fully informed of the patient's health status, including the outcome and treatments provided during recovery from anesthesia services.

Plan of Correction:
1.
Develop an Anesthesia policy describing the communication processes needed when unanticipated outcomes or adverse events occur in children undergoing anesthesia, even if the risk of the occurrence or event was discussed in the informed consent process (Procedure, Alternatives, Risk and Benefits (PARQ). Achieve approval of the policy from the Vice-President of Surgical Services and the Anesthesia Section by 8/10/2012. Educate all applicable physicians and clinical staff by 8/24/2012 prior to policy implementation on that date. Finalize metrics and monitoring plan in collaboration with Anesthesia Section and nursing staff and implement monitoring by 8/27/2012. Suggested metrics include: a. Track and analyze unanticipated outcomes and take appropriate actions as needed. b. # of times communication with family/representatives is documented when PACU recovery is >90 minutes/total number of cases with recovery time of >90 minutes (pediatric cases). Target: 95% c. Monitoring will occur until target is reached and sustained for 2 months, and then randomly thereafter. d. Results to be reported to Anesthesia Section Chief and Vice President Surgical Services monthly

2. 3. 4.

Responsible Parties: Time of Completion:

Section Chief, Anesthesia Vice President, Surgical Services As noted above

RESPONSE TO PREFIX TAG A 1003

CFR 482.52(b)(2) ANESTHESIA RECORD A pre-anesthesia evaluation is completed and documented by an individual qualified to administer anesthesia, performed within 48 hours prior to surgery or a procedure requiring anesthesia services.

This STANDARD is not met as the hospital failed to fully develop and implement an anesthesia policy and procedure to ensure a pre-anesthesia evaluation was completed and documented within 48 hours,

OHA, Health Care Regulation & Quality Improvement Centers for Medicare and Medicaid Services Complaint Number #s OR7583 and OR 7617 Provider Number 38-0051
and that that the evaluation was dated and timed to show that it occurred prior to induction of anesthesia. A routine audit of anesthesiologist documentation was done in February, 2012. The results were shared with the Anesthesia Section Chief who coached the Anesthesia members to comply with the regulatory requirements for documentation of pre-anesthesia evaluations, and the need to ensure that the note was timed. A second audit was completed in July which showed improved performance.

Plan of Correction

Plan of Correction:
Develop a Medical Staff policy for performance and documentation of a pre-anesthesia evaluation 2. Achieve approval of the policy from the Anesthesia Section and the Medical Executive Committee by 8/10/2012. 3. Educate all applicable practitioners prior to policy implementation date of 8/24/2012. 4. Monitor for compliance beginning 8/27/2012. Metrics are: a. Sample size: 1 case per credentialed anesthesiologist per month b. Number of pre-anesthesia evaluations documented/Total number of cases in sample. Target: 100% c. Number of pre-anesthesia evaluations dated and timed/total number of cases in sample. Target: 100% d. Monitoring will focus on anesthesiologists who cannot achieve and sustain performance at target. 5. The Anesthesia Section Chief will continue to have one-to-one conversations with individual anesthesiologists who are not compliant with documentation requirements. 6. Continued non-compliance following the discussion with the Section Chief will be handled through the Contract Management process.

1.

Responsible Party:

Anesthesia Section Chief Vice President, Surgical Services

Date of Completion: As noted above

RESPONSE TO TAG A 1005

CFR 482.52(b)(3) POST-ANESTHESIA EVALUATION

A post-anesthesia evaluation is completed and documented by an individual qualified to administer anesthesia, no later than 48 hours after surgery or a procedure requiring anesthesia services. This STANDARD is not met as the hospital failed to fully develop and implement its anesthesia policies to ensure a post-anesthesia evaluation was completed no later than 48 hours after surgery as required. A routine audit of anesthesiologist documentation was done in February, 2012. The results were shared with the Anesthesia Section Chief who coached the Anesthesia members to comply with the regulatory requirements for documentation of pre-anesthesia evaluations, and the need to ensure that the note was timed. A second audit was completed in July which showed improved performance.

Plan of Correction:

OHA, Health Care Regulation & Quality Improvement Centers for Medicare and Medicaid Services Complaint Number #s OR7583 and OR 7617 Provider Number 38-0051 1. Develop a Medical Staff policy for performance and documentation of a post-anesthesia
2. 3. 4. evaluation Achieve approval of the policy from the Anesthesia Section and the Medical Executive Committee by 8/10/2012. Educate all applicable practitioners prior to policy implementation date of 8/24/2012. Monitor for compliance beginning 8/27/2012. Metrics are: a. Sample size: 1 case per credentialed anesthesiologist per month b. Number of post-anesthesia evaluations documented{fotal number of cases in sample. Target: 100% c. Number of post-anesthesia evaluations dated and timed/total number of cases in sample. Target: 100% d. Monitoring will focus on anesthesiologists who cannot achieve and sustain performance at target. The Anesthesia Section Chief will continue to have one-to-one conversations with individual anesthesiologists who are not compliant with documentation requirements. Continued non-compliance by specific anesthesiologists will be handled through the Contract Management process.

Plan of Correction

5. 6.

Responsible Party:

Anesthesia Section Chief Vice-President, Surgical Services

Date of Completion: As noted above

RESPONSE TO TAG A 9999

OAR 333-505-0030{3)(d) ORGANIZATION Hospital policies which required that a hospital adopt, maintain, and follow written patient care policies that include all patient care services provided by the hospital.

Plan of Correction:
Refer to Tags A 1003 and A 1005 as stated above.

OAR 333-505-0033 PATIENT RIGHTS Requires that a hospital comply with the requirements for patient rights set out in 42 CFR 482.13

Plan of Correction:
Refer to Tag A 131 as stated above.

Plan of Correction

OHA, Health Care Regulation & Quality Improvement Centers for Medicare and Medicaid Services Provider Number 38-0051 Complaint Number #s OR7583 and OR 7617