The Board of Trustees for Stillwater Medical Center met for the second time in just over two weeks to talk about the hospital’s plan for improvement after the State Health Department found deficiencies at its surgery center.

On March 25, hospital CEO Jerry Moeller told the board the State Health Department had unexpectedly shown up Jan. 28 to perform an inspection of the surgery center because it had received a complaint. The department stayed for two days and found “multiple deficiencies” according to the minutes of that meeting.

They were classified as serious but not constituting an immediate danger to health or safety.

Failure to correct those deficiencies could have led to having SMC’s participation in the Medicare program terminated and the State Health Department will return for a follow-up.

In response, SMC hired a consultant to help it prepare a response to the inspection, which is officially called a “survey.”

In a special meeting April 10, Cheryl Wilkinson, the hospital’s performance improvement director, said surveyors aren’t meant to collaborate with staff; they’re trained like criminal investigators.

In that meeting, the board was presented with updates to the patient grievance and complaint policy, policies regarding contracted services and changes to the bylaws for the Board of Trustees.

A performance improvement committee has been formed to oversee the hospital’s quality program that assesses patient care, customer service and clinical performance.

A copy of the performance improvement plan was presented for review.

A report on patient grievances and complaints in 2013 found low numbers in every area except the emergency department. The most common types of complaints were care provider issues or staff attitude and behavior.

Moeller said the change in policies regarding contracted services delegates responsibility for meeting quality of care standards on medical staff instead of administration.

The medical staff is in the best position to deal with it because they have the specific knowledge needed, he said.

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