Martin Macklin, MD, PhD, Team Leader
Surveyor Program(s): Hospital
Surveyor Tenure: x 2007 – 2013??(Retired)
Lives: Ohio
TJC Bio:
- Prior to joining the Joint Commission, Dr. Macklin was the Vice President for Medical Affairs at University Hospitals Geauga Medical center in Chardon, OH.
- Prior to medical school he was an engineer in the aerospace industry and an Associate Professor of Biomedical Engineering.
- Board certified in Psychiatry
- Licensed M.D. in Ohio
- Certified by the American Society for Addiction Medicine
Other Background:
- Specialty: Addiction Psychiatry, Psychiatry (as per ZebraHealth, Aug 2008)
- Education: Medical School–Case Western Reserve University School of Medicine
- Residency: University Hospital of Cleveland, Psychiatry
Comments & Recommendations
2008
- Very thorough but friendly and collegial.
- He seemed more concerned about the history and physicals and emergency management information than he did with anything else. He only reviewed one treatment plan and didn’t seem real concerned with a tracer taking him through the medical record. We did not learn from him that he was nervous or scared of our FMHS unit until after Ms. Stewart was here and announced the immediate threat. In fact, the morning review with Macklin and Troester was very positive and then 4 hours later they put us on notice that we were placed in Immediate Threat. When this was brought up to the survey team, they didn’t answer why they were not upfront with us. It was very unusual and seemed suspect. 01/18/08
- He is brief, to the point 8/21/08
Relevant Surveying History:
| • Mary Starke Harper Geriatric Psychiatric Center 08/21/08 | • Lincoln Regional Center 01/18/08 |
| • Douglas Singer Mental Health Center 01/11/08 | • Central Louisiana State Hospital 091201 |
| • McFarland Mental Health Center 12/15/11 | • Madden Mental Health Center 1308 |
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** Sample Survey Citations (Premier Level)**
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Sample Citations:
2011
- LD.04.03.09/EP 4/ During document review: The hospital has a contract for EKG interpretation. EKGs are done at the hospital and sent to the clinic for interpretation by one of the clinic cardiologists. None of the cardiologists are credentialed by the hospital.
- LD.04.03.09/EP 6/ During document review: There is no monitoring data or review for clinical services provided to the patients at the hospital under contracts for interpreting EKGs, MOD physician services or dental services.
- MS.01.01.01/EP 3/ During document
- MS.01.01.01/EP 6/ During document review the requirements contained in EP 16 are not included in the Medical Staff Bylaws
2009
2008
- MS.4.10/EP 5/ During the review of the credentials file of a practitioner newly credentialed… it was found that there was no documentation of the viewing of a photo ID.
- MS.4.10/EP 6/ Two practitioners had their license expire on 10/1; however their current licensure status was not determined until 10/17 to verify that their licenses had been renewed.
- MS.4.10/EP 6/ One practitioner (CS) had their license expire on 3/1; however their current licensure status was not determined until 6/14 to verify that their license had been renewed observed in Medical Management Session:
- MS.4.15/ Peer review form did not have all required elements
- MS.4.20/EP 8/ None of the radiologists providing interpretive services for the patients in the hospital had been privileged to provide these clinical services. Services are provided under a contract with a professional group which is not itself a TJC accredited organization.
- MS.4.60/ Language allowed temporary extension of privileges to theoretically go beyond 2 years
- PMS.4.70/ Problems with peer references
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