Update to our Community...

In our ongoing commitment to transparency in our work and performance, Inland wants our community to hear the latest from us about a recent federal survey of the hospital that is related to an alleged EMTALA violation. EMTALA is the Emergency Medical Treatment and Labor Act, a federal law designed to ensure appropriate treatment for emergency department patients. The case centered on a patient who was transferred to another facility when treatment could have been provided at Inland.

Officials from the Maine Division of Licensing and Regulatory Services, on behalf of the Centers for the Medicaid and Medicare Services (CMS), conducted an unannounced inspection of Inland March 1-3. Preliminary survey results show that while the majority of Inland departments and processes were deficiency-free, there were a few areas where the hospital was out of compliance with CMS guidelines. The areas include:

1-Completing our corrective action plan on the EMTALA case. Even before the surveyors arrived at Inland, we began implementing a corrective action plan (which state surveyors found acceptable) but that plan hasn’t been completed yet. The plan includes re-orientating medical and nursing staff about on-call procedures and monitoring all patient transfers and contacts with on-call providers. While we believe the initial case was the result of miscommunication between providers and not deliberate inaction, our plan will ensure that a similar situation does not happen again.

2-Medical Staff, Quality Improvement, and Governing Body. Surveyors noted that improvements were needed in the documentation of our Medical Staff quality improvement projects. They also pointed to the lack of linkage between the quality improvement work going on in our employed physician practices and our formal performance improvement process. In addition, surveyors identified a need to improve documentation of our Board of Trustees’ engagement in the oversight of quality. We know that we are doing the work to keep our patients safe; now it is a matter of improving our documentation and communicating it in ways that meet both the letter and spirit of the CMS regulations.

We are confident that these are areas that we can address and remedy quickly. Inland will submit plans of correction for each issue noted and the state will return for a re-inspection, sometime over the next few months.

The federal inspection was conducted by a team of seven surveyors with expertise in medicine, nursing, pharmacy, diagnostic services, fire safety and facilities management. They interviewed patients and staff; assessed Inland’s care and quality processes, procedures, policies and documentation; and they reviewed hospital departments and physician offices. It was a rigorous inspection, similar to the survey we went through last spring with the American Osteopathic Association. We received full re-accreditation in that survey.

After the survey, Inland leaders praised staff for their hard work during the review and for demonstrating the hospital’s main purpose - to always put patients first in all that we say and do. We’re proud of our culture of excellence and remain committed to continuous improvement and delivering high quality healthcare. To view Inland Hospital’s performance results in 70 areas including clinical quality and patient satisfaction, visit “Quality Matters” at www.inlandhospital.org. 

If you have any questions or concerns, please email me at jdalton@emh.org.  

Sincerely,
John Dalton
President and CEO
Inland Hospital

~March 4, 2010