1. BUMEDINST 6010.13; BUMEDINST 6220.9B; NMCPHC-TM 6220.12; BUMEDINST 5040.2C; & BUMEDINST 6110.14; SECNAVINST 6120.3; OPNAVINST 5215.17A Flashcards
What is the instruction for Quality Assurance (QA) Program?
BUMEDINST 6010.13
Who does Quality Assurance apply to?
All health care personnel providing services in naval MTFs and DTFs, fixed and non-fixed.
Who must participate in ongoing monitoring and evaluation processes designed to assess the quality and appropriateness of the services they provide?
All active duty (ACDU), Reserve and civilian medical and dental personnel.
Who must fixed MTFs and DTFs gain and maintain accreditation from?
Joint Commission on Accreditation of Healthcare Organization (Joint Commission, JCAHO).
How many years does routine Quality Assurance program related documentation must be maintained in a secure location before disposal?
5 years.
How many years does Quality Assurance (QA) inquiries, medical records related to a potentially compensable event (PCE) and Judge Advocate General (JAGMAN) investigations, must be maintained in a secure location at the local command for?
A minimum of 2 years or as needed.
Medical staff functions are under the direction of who?
Executive Committee of the Medical Staff (ECOMS)
Who are the Dental Staff functions under the direction of?
Executive Committee of Dental Staff (ECODS)
Nursing staff and administrative staff functions are under the direction of?
Command Quality Assurance (QA) Committee
Who’s responsibility is it to interpret Department of Defense (DoD), Secretary of the Navy (SECNAV) and CNO policies and provides guidance for Navy-wide Quality Assurance program implementation?
Chief, Bureau of Medical and Surgery (BUMED)
Who ensures that subordinate commanders comply with the Quality Assurance (QA) program?
Fleet Commanders in Chief (FLTCINCs)
Who may elect to have a fleet-wide medical and dental Quality Assurance (QA) program under the cognizance of the fleet medical and dental officer?
Type Commanders (TYCOM)
Who’s responsibility is it to implement an effective, flexible, integrated and comprehensive Quality Assurance (QA) program, guided by a written plan?
Commanding Officers, Officers in Charge and Senior Medical and Dental Department Representative of Treatment Facilities.
Who conducts two educational workshops each year in the principle, components, and management of Quality Assurance (QA) program for naval Medical Department personnel?
Naval School of Health Sciences, Bethesda, MD
What date must fixed MTFs and DTFs forward an annual assessment of the preceding fiscal year’s Quality Assurance (QA) program to MED-3C4 with a copy to the cognizant responsible line commander and HLTHCARE SUPPO to reach BUMED by?
15 January of each year
Who does TYCOM forward a copy to reach BUMED of the annual assessment of the preceding QA program to by 15 January?
Submit original to MED-3C4 and copies to the cognizant FLTCINC and HLTHCARE SUPPO to reach BUMED
Who submits case abstract for malpractice claim to MED-3C4 for each Potentially Compensable Event (PCE) review that is required or JAGMAN investigation initiated?
Commanding Officers, Officers in Charge and Senior Medical and Dental Representatives of Treatment Facilities
What is the assigned report control symbol for risk management case review and malpractice information reports?
DD-HA (AR) 1782 (6010)
A medical record is considered delinquent if all required record components are not completed within how many days of patient discharge?
30 days
An infection is considered nosocomial if it first becomes apparent in how many hours after admission?
72 hours
What is an event or outcome during the process of medical or dental care in which the patient suffers a lack of improvement, injury or illness of severity greater than ordinarily experienced by patients with similar procedures or illness?
Potentially Compensable Event (PCE, Adverse Event)
What is the formal and systematic exercise of monitoring and reviewing medical care delivery and outcome; designing activities to improve health care and overcome identified deficiencies in providers, facilities, or support systems?
Quality Assurance (QA)
Who’s goal is to improve efficiency and effectiveness of such process by addressing and eliminating special cause variations, eliminating non-value added steps, identifying and solving process problems, and making other carefully planned and tested changes to reduce overall process variation?
Continuous Quality Improvement (CQI)
What form is the case abstract for malpractice claims?
DD 2526
How many days must cognizant treatment facilities forward the DD2526 to MED-3C4?
30 days of the event for all PCEs.
Who are committed in providing the highest quality medical and dental care to DON beneficiaries?
Chief of Naval Operations (CNO) and the Commandant of the Marine Corps (CMC)
What instruction and form is the BUMEDINST 6010.13 canceling?
NAVMEDCOMINST 6010.6 and NAVMED 6010/20
The QA program was originally issued to standardize all medical treatment facilities. In what year was the QA program originally issued?
1984
Naval medical policy, procedures and responsibilities for DTFs were issued in ____ (what year) and they were incorporated into the QA program in ______ (what year)?
1987 and 1989
Commands must ensure that all personnel, including direct and indirect care providers, administrators, ancillary services, volunteers, students, and other who come within how many feet of patients receive and maintain appropriate vaccination against seasonal influenza?
3 feet
Regulated Medical Waste (RMW) and general trash must be collected, treated, stored, disposed of, and managed following relevant local regulations and guidelines provided in what reference?
BUMEDINST 6280.1A
Healthcare Associated Infection (HAI) prevention principles and procedure training must occur during initial indoctrination, as needed, and at least how often thereafter?
Annually
Commanders, COs, OICs will appoint an Infection Prevention and Control Committee (IPCC) to implement the Healthcare-Associated Infection Prevention and Control (HAIPC) Program per what reference?
BUMEDINST 6010.13
What reference requires Infection Prevention and Control Committees (IPCCs) to be established in MTFs and DTFs?
BUMEDINST 6010.13
What allows data comparisons at multiple levels for purposes of performance improvement?
Benchmarking
Who will oversee the Navy Infection Preventionist (IP) program to interpret requirements and facilitate interoperability?
BUMED Infection Preventionist (IP) SME
Command must oversee reporting of communicable diseases per local or state requirements and per what reference?
BUMEDINST 6220.12B
What program covers all aspects of health care operations?
Healthcare-Associated Infection Prevention and Control (HAIPC)
Freestanding ambulatory care facilities, including DTFs, must have the recommended staffing of at least 1.0 Fulltime Equivalent (FTE) for up to how many ambulatory care and dental visits per year?
200,000
The Healthcare-Associated Infection Prevention and Control (HAIPC) is guided by a written plan that includes at a minimum amongst other items an Infection Control Risk Assessment (ICRAs) how often?
Annually
Who will act as liaisons for construction/renovation/mitigation projects by providing Infection Control Risk Assessments (ICRAs) and working with facilities, administration, construction workers, and others to help ensure patient safety from transmission of infectious diseases related to each project?
BUMED Infection Preventionists (IPs)
All bedded health care facilities as well as clinics attached to a bedded facility are eligible for participation in HHSN as of what year?
September 2010
All cases in MTF and DTFs involving serious injury, prolonged disability, or death secondary to Healthcare-Associated Infection Prevention and Control (HAIPC) problem, regardless of wether the patient is in active duty or civilian status, need to be reported to what both locally and at BUMED?
Patient Safety and Risk Management
Dental unit waterline monitoring and treatment must follow CDC Dental Guidelines and EPA standards of less than how many Colony-forming units per milliliter (CFUs/ml)?
500
How often must all Navy Infection Prevention and Control Committees (IPCCs) meet?
Quarterly
Who interprets DoD, Secretary of the Navy, and Chief of Naval Operations policies and provides guidance for Navy-wide Healthcare-Associated Infection Prevention and Control (HAIPC) Program implementation?
BUMED Infection Control Consultant (BUMED-M3/5)
By what means shall all eligible MTFs and DTFs report Healthcare Associated Infections (HAIs)?
CDC’s National Healthcare Safety Network (NHSN)
Routine microbiological surveillance of hospital or clinic environments adds littler to infection prevention/control and should be restricted to investigations of outbreaks when recommended by the IP or who else?
Infection Prevention and Control Committee (IPCC) Chairman
What is critical in identifying outbreaks, emerging infectious diseases, antibiotic-resistant organisms (AROs), and bioterrorism events so that infection prevention measures can be instituted?
Infection Surveillance
What is defined as an organism that is capable of producing infection or infectious disease?
Infectious Agent
What term is defined as an illness due to a specific infectious agent or toxic products which arises through transmission of that agent or its products from an infected person, animal, or inanimate reservoir to a susceptible host, either directly or indirectly?
Communicable Disease
What is an infection whose manifestations are not evident either at admission or within a likely incubation period for acquisition outside the health care facility?
Healthcare Associated Infection (HAI)
What confer a high risk for infection if they are contaminated with any microorganism, including bacterial spores?
Critical Devices
In general, infections are not considered Healthcare Associated Infections (HAIs) unless the onset of the infections occurs more than how many hours after the time of admission or treatment?
48
What type of medical devices contact mucous membranes or non-intact skin?
Semi-critical
What concept is the quantity of materials or supplies required to treat a single patient?
Unit Dose
Each day should begin with a hand wash with a minimum duration of how many seconds from fingertips to the wrist with soap and lukewarm water?
15
What items must be heat sterilized after cleaning following local Central Sterilization Room (CSR) standard operating procedures?
Critical and Semi-Critical
The method of transporting contaminated instruments from the DTR to Central Sterilization Room (CSR) is based on the result of the clinic’s risk assessment and may require more stringent containment and labeling per what standards?
OSHA
What technique should be used to recap anesthetic needles?
One handed “scoop”
For routine dental treatment output water there must be less than or equal to what amount of CFUs per ML of heterotrophic water bacteria to meet EPA standards for drinking water?
500
Clinical dentistry is practiced under how many basic conditions that require the application of infection control measures to mitigate the risk of cross-contamination?
2
Water and air must be flushed for how many seconds after each patient from any device connected to the dental water system that enter’s the patient’s mouth?
20-30
Aerosols take considerable energy to generate, consists of particles less than how many microns in diameter, and are not typically visible to the naked eye?
10
What are incompatible with infection control principles and should not be in DTRs?
Electric fans
What must be used when there is potential for splash, spatter, spray, or exposure to aerosols created while working with contaminated materials or performing disinfection procedures?
Face masks
What form should be used to clearly label the method of disinfection used for contaminated items?
DD Form 2322
What are the two most common patient care items that rely on dental laboratory support and carry a multitude of oral microorganisms originating from dental plaque, blood, and saliva?
Prostheses and oral impressions
Before turning on the lathe ensure that protective eye-wear is worn, plexiglass is properly positioned, and the vacuum ventilation system is activated (at least how many feet per minute continuous suction)?
200
What are the two functional areas that need to be considered when developing dental laboratory infection control procedures?
DTR and Dental Laboratory
How many separate work areas should each dental laboratory have whenever possible?
three (receiving area, production area for new work, and a production area for repair work)
Some microorganism with prosthetic materials are known to survive up to how many days?
7
How often should pumice brushes be cleaned, disinfected, and sterilized?
Daily
What should never be used to polish wax patterns on Denture Wax-up?
Saliva
What indicates that all blood, saliva, and body fluids in the health car setting should be treated as potentially infectious as indicated by Occupational Safety and Health Administration (OSHA)?
Standard precautions
What regulations are materials that originate from either the treatment area or dental laboratory that are not decontaminated subject to regarding transportation and shipping of potentially infectious materials?
Occupational Safety and Health Administration (OSHA)
What should be used on film packets to minimize the risk of contamination of the fabric light shield sleeves?
Plastic infection control barrier
Digital sensors and other high-tech instruments that come into contact with oral mucous membranes are considered to be what type of devices?
Semi-critical
How often must all counter surfaces be disinfected in the Darkroom?
Daily
Which reference defines medical surveillance?
DoD Directive 6490.02E
What are the two types of surveillance and reporting covered this manual?
Reportable Medical Event (RME); Syndromic and Categorical injury
Which type of events, usually disease or etiologic agent specific, may pose an inherent, significant threat to public health and military operations?
Reportable Medical Event (RME)
What have the potential to affect large numbers of people, to be widely transmitted within a population, to have severe/life threatening clinical manifestations, and/or disrupt military training and deployment?
Reportable Medical Event (RME)
What publishes the agreed upon Reportable Medical Events (RME) list along with specific case definitions as the Armed Forces Reportable Medical Events Guidelines and Case Definitions?
The Armed Forces Health Surveillance Center (AFHSC)
Reportable Medical Events (RMEs) are commonly referred to as?
Medical Event Reports (MERs)
Which instruction requires any medical event that meets the case definition of a reportable event to be reported
BUMEDINST 6220.12
When submitting Medical Event Reports (MERs) of outbreaks or disease clusters, reporters need not include identifying information about individual patients or file a MER for each individual case unless instructed by who?
Navy Environmental and Preventative Medicine Unit (NEPMU)
Urgent medical event reports are required within how many hours for some events?
24 hours
How many calendar days must routine reports for all non-urgent medical events be submitted after their identification?
7 days
What is the Navy’s official system to submit, view and track Medical Event Reports?
Disease Reporting System Internet (DRSi)
If reporters are affected by connectivity limitations, Medical Event Reports (MERs) may be made by what communication means?
Phone, naval message, or e-mail to the nearest Navy Environmental and Preventative Medicine Unit (NEPMU)
For the prevention of disease and reporting of communicable disease, regulations promulgated by the Chief, Bureau of Medicine and Surgery in the Navy’s Manual of the Medical Department mandate that all Navy Medical Officers will cooperate with the what agencies?
Public Health Services and other Federal, State, and local agencies
Which type of surveillance involves monitoring the incidence of specific pre-diagnostic syndromes and injury occurring in specific populations to identify important clusters of disease/injury at the earliest time possible?
Syndromic and Categorical Injury Surveillance
Syndromic and Categorical Injury Surveillance is also known as?
Disease and non-battle injury (DNBI) surveillance
Base off of new guidance Disease and non-battle injury (DNBI) surveillance is imply referred to as?
D&I surveillance
What is performed either electronically or manually depending on a unit’s ability to complete and transmit healthcare encounter records to central Military Health System (MHS) data repositories?
D&I surveillance
What is the preferred D&I surveillance and reporting method that involves the analysis and monitoring of D&I related information stored in Military Health System (MHS) data repositories with the aid of analytic systems such as Electronic Surveillance System for the Early Notification of Community-Based Epidemics (ESSENCE), the Joint Medical Workstation, or the Theater Medical Data Store web interface?
Electronic D&I Surveillance and Report method
Which program will be used to compile and submit manual reports of their unit’s D&I information to the Navy and Marine Corps Public Health Center (NMCPHC)?
Microsoft Excel
For manual reporting, how will you name the Microsoft (MS) Excel spreadsheet file before submitting your weekly report?
unitname.xls
In general, the classification of Medical Event Reports (MERs) are considered?
unclassified
Before releasing the report, reports who are concerned that a report from their unit might have an adverse impact on their unit’s operational security or our national security should consult who for report classification?
Information Security/CO
All Medical Event Reports (MERs) and D&I reports contain sensitive medical information, so all reports made through email should be?
Digitally signed and encrypted
What are the Navy’s primary consultative resource for disease/outbreak confirmation and response assistance including implementation of prevention and control measures?
Navy Environmental and Preventative Medicine Units (NEPMUs)
Inspections conducted by the Medical Inspector General (MEDINSGEN) are restricted to _______ command activities?
Bureau of Medicine and Surgery (BUMED)
Inspections for medical treatment facilities (MTFs) are conducted in conjunction with the Joint Commission. T or F?
TRUE
What are the following information considered as?
- Assess command efficiency and effectiveness of Budget Submitting Office (BSO)-18 activities.
- Improve an organization’s mission readiness and performance based on program specific policies and direction.
Program Objectives
What program is designed to promote enterprise-wide organizational improvement by sharing best business practices and identifying systemic issues that require headquarters attention?
Bureau of Medicine and Surgery (BUMED) Medical Inspector General (MEDINSGEN) Inspection Program (BUMEDINST 5040.2C)
To ensure adequate attention is given and/or resources are made available to correct such finding, who are findings (initial or repeat) are briefed to?
Chief of BUMED and appropriate BUMED Leadership
If indicated, the Medical Inspector General (MEDINSGEN) may require an organization to submit plans for correcting deficiencies and/or conduct a focused inspection in how many months?
6-12 months
Inspected programs WITHOUT deficiencies are categorized as?
Compliant
Inspected program WITH deficiencies may receive what?
Requirement for Improvement (RFI) or Supplemental Finding
What identifies a nonexistent program or one that is deficient in major elements so that it does not fulfill the intent of policy?This requires the command to respond with an Implementation Status Report (ISR) outlining the command’s plan to initiate the program or correct its deficiencies.
Requirement for Improvement (RFI)
What form is used to submit the Implementation Status Report (ISR)?
OPNAV 5040/2
The Implementation Status Report (ISR) and supporting documents will be forwarded through the chain of command. How many days after the receipt of the Final Report is the ISR due to Medical Inspector General (MEDINSGEN)?
How often are the follow-up ISR’s due to MEDINSGEN?
60 days
Every 90 days until closed by MEDINSGEN
What is the procedure if a Requirement for Improvement (RFI) remains open greater than a year?
followed up by a letter to the respective regional commander to address why the RFI remains open
What identifies a program that has an effective and formal process in place, but requires modification to achieve full compliance?
Supplemental Findings
What are recommendations that will enhance a program’s effectiveness?
Opportunities for Improvement
The Medical Inspector General (MEDINSGEN) Inspection and Joint Commission Accreditation survey is a concurrent assessment. T or F?
TRUE
What allows MEDINSGEN staff to capture Joint Commission concerns for dissemination throughout the Navy Medicine while simultaneously providing a source of information and clarification to the Joint Commission surveyors regarding military unique factors?
The Medical Inspector General (MEDINSGEN) and the Joint Commission Accreditation survey concurrent assessment
Who notifies the Medical Inspector General (MEDINSGEN) liason of required special announced or unannounced, focused, follow-up, or random unannounced surveys by the Joint Commission of Navy MTFs as they develop?
The Joint Commission Account Representative (AR)
Navy Medicine commands will be notified of impending inspections by the Medical Inspector General (MEDINSGEN) and the Joint Commission Account Representative (AR) ___ business days in advance in CONUS or ___ business days in advance OCONUS.
CONUS = 7 business days
OCONUS = 30 business days
From the end of the inspection, Medical Inspector General (MEDINSGEN) will electronically forward the final inspection report to the command and a copy to the regional commander in HOW LONG?
Approximately 4 weeks
The Joint Commission surveyors will provide commands a copy of their preliminary findings at the conclusion of the survey. Any additional information related to the survey results will be posted WHERE?
the Joint Commission’s Web site
What echelon is the Bureau of Medicine and Surgery (BUMED) categorized in?
Echelon 2
Bureau of Medicine and Surgery (BUMED) conducts Medical Inspector General (MEDINSGEN) site assessments (inspection) in what TIME cycle?
1-4 year cycle