FMC, which is part of Flagstaff-based Northern Arizona Healthcare, must make five specific improvements, as a hospital can only be noncompliant with three or fewer standards to earn or maintain a verification status, according to an Aug. 9 statement from NAH shared with Becker’s.
The five citations for the hospital include:
1. Two standards for staffing in the trauma registrars record-keeping role. The hospital is currently experiencing an industry wide challenge with a trauma registrars shortage.
2. Two standards for documentation standards pertaining to when specific surgeons were called to care for patients, the time the surgeons arrived and how long it took for them to get to the hospital. The hospital has already implemented new processes to ensure the documentation happens, the statement said.
3. One standard for performance improvement and patient safety. “Our process for following up on issues needs to better define system issues and their resolution, we are already implementing new processes to ensure this occurs,” the statement said.
The issues are being resolved so the hospital can submit a new application with anticipation that ACS will conduct a new survey and restore the hospital’s Level 2 status.
FMC remains a Level 1 Trauma Center, as designated by the Arizona Department of Health Services. The state’s health department will closely monitor the hospital’s progress and plans to retain the designation.
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