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Los Angeles County Harbor-UCLA Medical Center's response to 10-8-09 inspection

Los Angeles County Harbor-UCLA Medical Center's response to 10-8-09 inspection

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Published by Daily Breeze
This is Harbor-UCLA Medical Center's "Plan of Correction" in response to a federal inspection conducted on Oct. 8, 2009. Regulators found thousands of backlogged radiology reports, which meant results were not being transcribed or read by an attending doctor.

Story on the reports: http://www.dailybreeze.com/ci_20299924/harbor-ucla-medical-center-makes-changes-after-series
This is Harbor-UCLA Medical Center's "Plan of Correction" in response to a federal inspection conducted on Oct. 8, 2009. Regulators found thousands of backlogged radiology reports, which meant results were not being transcribed or read by an attending doctor.

Story on the reports: http://www.dailybreeze.com/ci_20299924/harbor-ucla-medical-center-makes-changes-after-series

More info:

Published by: Daily Breeze on Mar 31, 2012
Copyright:Attribution Non-commercial

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04/02/2012

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DEPARTM'ENTOFHE,4.LTHANDHUMANSERVICESCENTERSFORMEDICARE
s
MEDICAIDSERVICES
PRINTED:
07/20/2010
FqRMAPPP,QVE:J
OMSNO
0938-JJ3S1
STATE\tlENTOFDEFICIENCIESANDPLANOFCORRECTION
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PROVlDERlSUPPllERlClfP..IDENTlFlCATIONNl-iMBER':
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10/08/2009
(X3)
DATESURvEYCOMPLETED~ME
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STREETADDRESS,CITY,STATE,ZlPCODE
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CARSONST
TORHANCE,
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.
A
000INITIALCOMMENTSThefollowingreflectsthefindingsoftheCaliforniaDepartmentofPublicHealthduringaCOMPL.A.INTVALIDATIONsurveyforCOMPLAINTNO:CA00203658.RepresentingtheDepartmentofPublicHealth:BarbaraMeller,HFES;TerryMcElroy,HFEi\l;RaulReyes,HFEN;andDr.SanfordWeinstein,MedicalConsultantOn
9/29/09
CIt0900hours,thesurveyorsenteredthehospital.Thehospitalidentifiedtheirpatientcensusas
363.
GlossaryofAbbreviations:
i'r
CATscan-ComputerizedAxialTomographyscanCMC-ClinicalMonitoringCommitteeGI-GastrointestinalGU~Genitourinary
ncic-
HealthCareInformationCommittee
A263
11R-
lnterventionalRadoloov
i
[-1'-.
!
nforrnat.onT
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Mamm~MammographyMEC~Medical'ExecutiveCommitteeMRI-MagneticResonanceImagingQAPI~QualityAssessment&PerformanceImprovement01-OualityImprovement
I
PACS-Picture
A!gomnin
ComrUI8rJZc,cJSYSTemPSA-ProfessionalStaffAssociationSTAT-ShortTurn-AroundTimeUCLA~University
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QAP!lop,implementand
LP.BORATORYDIRECTOR'S
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UPPLIERREPRESENTATIVE'SSIGNATURE
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A263
INITIALCOMMENTS
Seeresponsesbelow
TITLE
(X6)DAlE
ChiefExecutiveOfficer10/6/10
Ar''~ficiencystatementendinthan
L
risk(*)denotesadeficiencywhichtheinstitutionmaybeexcusedfromcorrectingprovidingitisdeterminedthat~\...._afeguardsprovidesUfficie'protectiontothepatients.(Seeinstructions.)Exceptfornursinghomes,thefindingsstatedabove~:edisclo~able90daysToImlngthedateofsurveywhetherornotaplanofcorrectionisprovided.Fornursinghomes,
me
abovsfindingsandplansofcorrectionaredlsclcsable14daysfollowingthedatethesedocumentsaremadeavailable
to
the
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c:iEd.,
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planofcorrectionisrequisitetocontinuedprogramparticipation.
FORMCMS-2557(02-S9)PreviousVersions
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EventID:QDHHi1F2ciiityIV.
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IfcontinuationsheetPage1of29
 
DEPARTMENT
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MEDICAFE&MEDICAIDSERVICES
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BUILDING
PRINTED:
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STATEMENTOFDEFICIENCIESANDPL~NOFCORRECTlON(X1)PROVIDERfSUPPUERfCLLA.IDENTIFICATlONNUMBER;'(X3)DATESURVEYCOMPLETEDNAMEOF?ROVIDERORSUPPliEr:;
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10
PREFIXTAGPROVIDER'SPLANOFCORRECT10N(EACHCORRECTIVEACTIONSHOULDBECROSS-REFERENCEDTOTHEAPPROPRIATEDEFICIENCY)
A263ContinuedFrompage1maintainaneffective,cngoin-g,hospital-wide,data-drivenqualityassessmentandperformanceimprovementprogram..Thehospital'sgoverningbodymustensurethattheprogramreflectsthecomplexity
of
thehospital'sorganizationandservices;involvesallhospitaldepartmentsandservices(includingthoseservicesfurnishedundercontractorarrangement);andfocusesonindicatorsrelatedtoimprovedhealthoutcomesandthepreventionandreductionofmedicalerrors.ThehospitalmustmaintainanddemonstrateevidenceofitsQAPIprogramforreviewbyCMS.ThisCONDITIONisnotmetasevidencedby:Basedoninterviewandrecordreview,thehospitalfailedtoensure:.1.Datacollectedwasusedtomakechangestoensurepromptinterpretationofx-rayimages.See
A276.
I
i
2.!\.:
topriorft;~(~
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IjT1prCYVeservices
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t~c;
i
RadiologyDepartmentasevidenced
by
criticalradiologyprocedurereportsnotbeingtranscribedand/orauthenticatedinatimetymanner.SeeA285.3.Executive,administrative,andmedica!staffset
clear
expectations
iorthe
timelycompletionofradiologyreportssotheywereavailable.forclinicalcareofthepatients.TheAdministratorfailedtoensureongoingproblemswithradiologyreportcompletionwereforwardedtotheGoverningBodyforaction.SeeA31
O.
Thecumulativeeffectofthesesystemicproblems
A2631
I
QUALITYASSESSMENT
&
PERFORMANCEIMPROVEMENT(QAlPI)
CORRECTIVEACTIONS-Findings1-3
1.
RefertoTagA276
i
I
i
2.
F;,,:er
11
TagA2853.RefertoTagA312
FORM
CMS-2567(02-99)
PreviousVersionsObsoleteEventID:QDHH11
IfcontinuationsheetPage2of29
aciliiyID:
CA060000027
 
DE:PARTMENTOFHEA.LTHANDHUMANSERVICES
CENTERSFORMEDICARE
&
MEDICAIDSERVICES
PRINTED:
07/20/2010
FORMAPPRO\/ED
OMNO09380<Q'
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STATEN!ENTOFDEFICIENCIES(X1)PROVlDEPJSUPPUEPJCLiA(X2)MULTIP'_ECONSTRUCTION
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NAMEOFPROVIDERORSUPPLIER.STREETADQP,ESS,GITY,STATE,
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DEFICIENCY;.
I
A263Continued
From
page2A263.limitedthehospital'sability
to
providequalitycare
I
inasafesetting..
1
A276482.21(b)(2)(il)QAPIIDENTIFYIMPROVEMENTA276
CAP!IDENTIFYIMPROVEMENT
[Thehospitalmustusethedatacollectedto-J
CORRECTIVEACTIONS
I
(ii)
Identifyopportunitiesforimprovementand
Establishedandconvenedinterdisciplinary
I
hanges
that
willleadtoimprovement.
RadiologyProcessImprovementTeam(RPIT)
,
ThisSTANDARDisnotmetasevidencedby:toa)identity,prioritizeandmitigateprocess,informationtechnology(IT),equipmentand
Based
onrecordreviewandstaffinterview,thepersonnelbarrierstotimelyinterpretation,hospitalfailedtoeffectivelyusethedatacollectedtranscriptionandauthenticationofradiologytomakechangestoensurepromptinterpretationimages,andb)toprioritize,implementandofx-rayimages.
This
resultedinongoingmonitorimprovement-actionoutcomes.RIPTtoproblemswithclinicalinformationnotbeingincluderepresentativesfromAdministration,readilyavailableforhospitalandclinicstaffandRadiology,InformationManagement,MedicalStaff,andQualityImprovement.
I'-
otherprovidersofcareforthehospital'spatients.(RPITmetweeklytrom:
10/19/09-9/6/10.
Beginning
9/13110,
RPITmeetingscheduleFindings:changedtotWice-monthly.)Attachment
1:
RPITcharter
-10/29/09
On
10/6/09,
per
review
ofthehospital'sminutesAttachment
2:
RPITActionPlanoftheExecutiveLeadershipCouncilmeeting
ID
#15-
Assessedandprioritized
11/30/09
executedon
8113/08,
delinquentradiologyreportsequipmentneeds.(SeeD.Processes
#3
tor
j
had
beenpresented
by
theHCIC
tothe
equipmentpurchases.)
I.
(F:;v:rtOtTnrJnc>~_.
C__
shbc).;~r·dof
thecounc,'.lssucs
,
with
incompleteradiologydictation,suchas,reportsthatweredictatedandnotsigned,andreportsthatwereneverdictatedwere
identified,
(Note:IDreferstotasknumbersenumeratedinAttachment
2
RPITActionPlan)Per
review
oftheClinicalRadiologyCommitteeQuarterlyDataTrackingForm,fromyear
,12iCl1-1/05,24--42·;S
genera!
radiology
reports
wereuntranscribed;15-26%ofbodyCTscanswereincomplete;17-23%ofheadCTscanswereincomplete;34-52%ofgeneraldiagnosticradiologyreportswereincomplete;20-78%ofGIradiologyreportswereincompleteand36-61
%
ofneuroradiologyreportswereincomplete.
By.
6/15/05,
theClinicalRadiologyCommitteeID
#
16-
Analyzedworkflowprocessesfromthepointwhenthestudyisorderedtothe
point
thereportis
'finalized";
identif!ed
ceflciencrss:
priorinzec
actionplans
tocorrectandstreamlinetheprocesses.(SeeD.Processes
1-2
forprocesschanges.)ID
#
17-
Assessedandprioritizedstaffingneeds.(SeeE.Personnel
1-4
forincreasedFTEboard-certifiedradiologists.).
11/16/0911/9/09
;;ORM
CMS-2567(02-99)PreviousVersionsObsoleteEvent
ID:
QDHH11FacilityID:
CAD6000D027
IfcontinuationsheetPage3of29

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