Quality assurance Flashcards
All treatment facilities must fully integrate into their QA program Risk Management procedures requiring review of cases and events that represent liability or injury risk to patients and staff, and must recommend methods of decreasing what?
Liability risk
Who are personnel who required to be licensed but are not included in the definition of health care practitioners?
Clinical Support Staff
Which committee is multidisciplinary and provides a forum for discussion and oversight of all nonmedical staff QA functions?
QA
The Quality Assurance program was originally issued in what year to standardize QA activities within Naval Medical Command MTF’s?
1984
What is a determination concerning a monitor outcome confirmed through the peer review process?
Validation
Who interprets Department of Defense, Secretary of the Navy (SECNAV), and CNO policies and provides guidance for Navy-wide program implementation?
BUMED
Documents and records created per this instruction are medical QA materials and are therefore exempt from the requirements of what act?
Freedom of Information Act
MTF’s and DTF’s (claimancy 18 only) must forward an annual assessment of the preceding fiscal year’s QA program to MED-3C4 with a copy to the cognizant responsible line commander and HLTHCARE SUPPO to reach BUMED by what date of each year?
15 January
A medical record is considered delinquent if all required record components are not completed within how many days of patient discharge?
30
The Clinical Performance Profile is what type of document?
Internal
MTFs and DTFs will have what type of programs to monitor resource use and to recommend ways to balance assigned mission statements with existing health care resources?
Utilization review
BUMED submits a QA program summary report required by DOD Directive 6025.13 how often?
Annualy
A review of QA program effectiveness must be completed with revision as necessary every how often?
Annually
The Clinical Performance Profile provides a format for compiling and summarizing individual-specific information per what instruction?
BUMEDINST 6320.66
What is the process by which practitioners of the same or like discipline evaluate the outcomes of QA program-related monitoring activities?
Peer review
An infection is considered nosocomial if it first becomes apparent how many hours (or more) after admission?
72
Routine QA program-related documentation must be maintained in a secure location for a period of how many years before disposal?
5
What data elements are not required for those cases closed through administrative denial of payment or where the health care incident occurred before January 1, 1985?
Provider specific
What is a structured approach which continuously analyzes clinical and administrative processes within pre-established boundaries using various analytic tables?
Continuous Quality Improvement
An executive management team may perform the command QA committee function if it meets at least how often?
Monthly
Naval Medical Department policy, procedures, and responsibilities for navl DTFs ashore and afloat were issued in 1987 and incorporated into this instruction in what year?
1989
What is the state in which there is a variance from preestablished minimally acceptable standards of care?
Deficiency
QA inquiries and 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 how many years or as long as needed thereafter?
2
Fixed MTFs and DTFs meeting applicable criteria must gain and maintain what by the Joint Commission on Accreditation of Healthcare Organizations?
Accreditation
MTFs and DTFs, with guidance from a higher authority, must develop what type of programs?
Clinical monitoring
The Naval School of Health Sciences in Bethesda Maryland will conduct how many educational workshops each year in the principles, components, and management of QA programs for naval Medical Department personnel?
2
What is an inpatient acquired infection not present or incubating at the time of admission?
Nosocomial Infection
Identifying, assessing, and decreasing risk to patients and staff are objectives of the QAprogram to reduce exposure to what?
liability
Who may elect to have a fleet-wide medical and dental QA program under the cognizance of the fleet medical and dental officer?
TYCOMS
