BUMEDINST 5040.2C - BUREAU OF MEDICINE AND SURGERY (BUMED) MEDICAL INSPECTOR GENERAL (MEDINSGEN) INSPECTION PROGRAM Flashcards
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 recieve 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
Who assigns a point of contact (POC) within the Team to serve as a liason for all issues relating to the Medical Inspector General (MEDINSGEN) inspection?
This POC will be designated in the notification letter.
Bureau of Medicine and Surgery (BUMED)
What is the MEDINSGEN team composition? (MTF)
- senior inspector as team leader
- senior comptroller to coordinate the financial and materials management inspections with the assistance from individual augments as needed
- health care administrator
- physician
- nurse
- dentist
- senior enlisted inspector
- investigator (as needed)
- safety manager
- yeoman with additional duty of trip coordinator to assist in logistical prep of sites
Who will identify the specific team composition in the inspection agenda at the time of notification?
Medical Inspector General (MEDINSGEN) point of contact (POC)
The MEDINSGEN tailors its inspection schedule for support activities based on standard inspection areas and the activity’s mission. T or F?
True
The first draft of the inspection agenda is forwarded to who? If there are any unresolved conflicts on site, who should be immediately notified?
Command POC
MEDINSGEN Team Leader
Who shall appoint primary and alternate individuals to be POCs for the inspection?
Commanding Officer
Who coordinates the preparatory activity prior to the arrival of the inspection party and provides support during the inspection?
Command POC
Who will provide the MEDINSGEN a prepared brief to review during the document review session?
Command
What are the focus group requirements?
10-12 (12 max) staff members
How many focus groups can a member participate in?
only 1
Executive Steering Committee (ESC)/Board of Director should have meeting minutes for the past ___ months shall be available.
12 months
Performance Improvement (PI) meeting minutes for the past ___ months shall be available.
12 months
Command and subordinate commands inspection and survey reports for the past ___ years shall be available.
3 years
List of investigations conducted during the past ___ months shall be available.
12 months
Management Internal Control (MIC) program reviews for the past ___ months shall be available.
12 months
Command Evaluation (CE) program reviews for the past ___ months shall be available.
12 months
Anti-Fraud Program periodic fraud risk assessments for the past ___ month shall be available.
12 months
Other on-site documents include:
- Provider coding audit training documents for MTF inspections.
- Most recent Defense Equal Opportunity Management Institute (DEOMI) Equal Opportunity Climate Survey (DEOCS) results and any other assessments profiling the EO climate, morale, teamwork, and communication within the command.
- Executive Committee of Medical Staff (ECOMS) and Executive Committee of the Nursing Staff (ECONS) meeting minutes (MTF)
T or F?
True
What form is the MEDINSGEN Position Paper?
NAVMED 5040/7
What are the transportation requirements for the following:
CONUS?
OCONUS?
MEDINSGEN and Senior Enlisted Leader courtesy calls?
CONUS = No arrangements (RENTALS/need base passes and reserve 5 parking spaces)
OCONUS = Need transportation
Courtesy Calls = Provided by inspected Command
What form is the MEDINSGEN Non-Medical Treatment Command Demographics Worksheet?
NAVMED 5040/3
What form is the MEDINSGEN Non-Medical Treatment Command Preparatory Worksheet?
NAVMED 5040/4
What form is the MEDINSGEN Medical Treatment Command Demographics Worksheet?
NAVMED 5040/5
What form is the MEDINSGEN Medical Treatment Command Preparatory Worksheet?
NAVMED 5040/6
How soon should the command point of contact ensure the navmed 5040/3 navmed 5040/4, and navmed 5040/5 be completed?
first 24 hours of IG inspection
Non-medical & Medical treatment command MEDINSGEN team compostion?
- team leader
- HCA for logistics and fiscal inspection
- physician
- nurse
- dentist
- senior enlisted inspector
- an investigator (as needed)
- a safety manager
- yoeman
Briefing should take not more than?
30-45 mins
If the MEDINSGEN Team POC cannot be reached, who can the command contact?
MEDINSGEN Team Administrative
Visits to outlying clinics, labs, or dets are designed for interaction and sharing information between personnel assigned to these activities and medinsgen. This describes what activities?
Echelon V activities
Focus groups for Non-medical treatment commands generally include who?
Executive Steering Council (ESC), Department Heads, CPO, and E-6 and below.
Focus groups for medical treatment commands generally include who?
Executive Steering Council (ESC), Executive Committee of Medical Staff (ECOMS), Department Head, Provider, CPO, and E-6 and below.
What are the IT requirements for MEDINSGEN workspaces?
4 Common Access Card (CAC) enabled computers with internet access