***2019*** BUMEDINST 6010.13 QUALITY ASSURANCE (QA) PROGRAM Flashcards
QA program issued in what year?
1984 (FUR)
DTFs added to program in what year?
1989 (FIB)
What must be gained by Joint Commission?
Accreditation
Retain QA docs for how long?
5 yrs
QA inquiries requiring JAGMAN retained how long?
2 yrs
QA program reviewed how often?
Annually
Clinical performance profile is what type of document?
Internal
MTF/DTF must develop what?
Clinical monitoring
MTF/DTF must recommend methods of decreasing?
Liability risk
Program to monitor resource usage?
Utilization review
Multidisciplinary committee provides forum for discussion and oversight of nonmedical staff functions?
The QA
Executive management may perform command QA committee if they meet how often?
Monthly
Interprets policies and provides guidance for QA program implementation?
BUMED
BUMED submits QA summary report required by DoD directive 6025.13 how often?
Annually
Data elements not required for cases closed before Jan 1, 1985
Provider-specific
Who may elect to have fleet-wide medical and dental QA program under the cognizance of the fleet medical and dental officer?
TYCOMS
Bethesda will conduct how many annual workshops?
2
Forward annual assessment by what date each year?
15 Jan
Documents and records created per this instruction are exempt from?
Freedom of Information Act
Personnel required to be licensed but not included in the definition of health care practitioners?
Clinical support staff
Monitor outcome confirmed through peer review process?
Validation
Med record delinquent if not complete after how many days of Pt discharge?
30
Nosocomial must be apparent how many hrs or more after admission?
72
Analyze processes with pre-established boundaries using analytic tables?
Continuous Quality Improvement
What is the instruction for the Quality Assurance Program?
BUMEDINST 6010.13
Who is held accountable for the implementation of the QA Program within Naval Medical and Dental Treatment Facilities?
All health care personnel providing services
Name three main objectives of the QA program?
- exposes areas of the command and patient care that need improvement
- it identifies areas of education and training needed by health care providers
- affords providers the opportunity to comply with JCAHO
Key element that makes the QA program effective?
Continuous Monitoring of the quality and appropriateness of health care
What set of procedures must all treatment facilities fully integrate into their QA program?
Risk Management procedures
four examples of Potentially Compensable Events (PCE) for Medical and Dental treatment facilities.
- Death including suicide
- Any complication of treatment resulting in: brain damage, sensory nerve damage, or loss of a limb
- Inadvertent blood transfusion with HIV or hepatitis virus contaminated blood
- Procedure preformed on the wrong patient or body part including wrong tooth extracted.
Provides technical support and assistance for QA related issues and recommending corrective action JCAHO requirements?
Officer in Charge of Naval Healthcare Support Offices
After BUMED reviews (PCEs) and malpractice claims, data is abstracted and reported to what two places?
Assistant Secretary of Defense (Health Affairs) (ASD/HA)
National Practitioner Data Bank created by P.L. 99-660
What DD Form does MED-3C4 use to report closed malpractice claims to the Assistant SECDEF (Health Affairs) (ASD/HA)?
DD 2526 (notch) Case Abstract for Malpractice Claims instruction sheet
Who is responsible for maintaining a Risk Management Database (RMDB)?
BUMED
Who ensures that subordinate commanders comply with the Quality Assurance Program, BUMEDINST 6010.13?
Fleet Commanders in Chief
