BUMED 6010.13 Quality Assurance (QA) Flashcards
What year was the QA program originally issued?
1984
Why was the QA program originally issued?
To standardize QA activities within Naval Medical Command MTFs
When were DTFs issued and incorporated into the instruction?
issued: 1987
added to instruction: 1989
How long must routine QA program-related documentation be maintained before disposal?
5 years
What are the QA program objectives?
- Systematically monitor services provided to identify opportunities to improve patient care
- Identify, assess, and decrease risk to patients and staff thereby reducing exposure to liability
- Justify resources needed to maintain and preferable exceed acceptable standards of patient care service
- Communicate important QA information to effect sound clinical and management decision-making at all levels of the organization
- Integrate, track, and trend QA information to identify significant patterns or processes which may need in-depth review, addressed by CQI techniques or other intervention
Inpatient fixed MTFs must have the following standing committees:
- ECOMS, responsible for all medical staff functions
- Safety
- Infection Control
Fixed ambulatory care medical facilities must have the following committees
- ECOMS, one ECOMES per individual privileging authority
2. QA
What are the responsibilities BUMED?
- Provides guidance for Navy-wide QA program implementation
- Provides consultation, educational support, and QA-related information to Navy treatment facilities
- Maintains a risk management database (RMDB)
What are the responsibilities of Fleet Commanders in Chief (FLTCINCs)?
Ensure that subordinate commanders comply with this instruction
What are the responsibilities of Type Commanders (TYCOM)?
Implement and coordinate a TYCOM-wide QA program
What are the responsibilities of Officers in Charge of naval Healthcare Support Offices?
Provide technical support and assistance for QA-related issues on request to fixed and nonfixed naval medical and dental activities
What are the responsibilities of Naval School of health Sciences, Bethesda?
Conduct two educational workshops each year in the principles, components, and management of QA programs for naval Medical Department personnel
When is a medical record considered delinquent?
If all required record components are not completed within 30 days of patient discharge
Define deficiency.
State in which there is a variance from preestablished minimally acceptable standards of care
When is an infection considered nosocomial?
If it first becomes apparent 72 hours (or more) after admission
Define postoperative wound infection.
Infection that develops after surgery
Define potentially compensable event (PCE) (adverse event).
An event or outcome which the patient suffers a lack of improvement, injury, or illness of severity greater than ordinarily experienced by patients with similar procedures or illnesses
List examples of a none or minor PCE.
Appendectomy with no delay in recovery, miss dx fracture, delayed recovery from anesthesia
List examples of a temporary PCE.
Falls with laceration/fracture, appendectomy with a single postoperative episode of sepsis, delayed union of a fracture, incisional hernia, fracture of a tooth during anesthesia
List examples of long-term PCE.
Fall with neurological injury, healed forearm fracture with lost of motion in wrist or elbow, postoperative inadvertant retention of a foreign body, loss of a thumb or finger, anesthetic-related cardiac or respiratory arrest, death
What is CQI?
Continuous Quality Improvement (CQI)
