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BUMEDINST 6010.13

QUALITY ASSURANCE PROGRAM

QuestionAnswer
What was originally issued in 1984 to standardize QA activities within Naval Medical Command MTF's? The Quality Assurance Program
Routine QA program material must be maintained in a secure location for what amount of time before disposal? 5 years
QA inquiries and medical records related to a PCE and JAGMAN investigation must be maintained in a secure location at the local command for how long? Minimum of 2 years
A multidisciplinary committee required when there is more than a singe professional discipline providing patient care within the facility or type command. QA Committee
Who interprets DOD, SECNAV, and CNO policies and provides guidance for Navy-wide QA program implementation? Chief, BUMED
A review of the QA program effectiveness must be completed with revisions performed how often as necessary? Annually
What is the determination concerning a monitor outcome confirmed through the peer review process? Validation
What data elements are not required for those cases closed through admin denial of payment or where the incident occurred before January 1, 1985? Provider-specific
An executive management team may perform the command QA committee function if it meets at least how often? Monthly
MTF's and DTF's will have what type of program to monitor resources used and to recommend ways to balance assigned mission statements with existing health care resources? Utilization review
What is the state in which there is a variance frm pre-established minimally acceptable standards of care? Deficiency
Identifying, assessing, and decreasing risk to patients and staff are objectives of the QA program to reduce exposure to what? Liability
The Clinical Performance Profile provides a format for compiling and summarizing individual-specific information per what instruction? BUMEDINST 6320.66
An infection is considered nosocomial if it first becomes apparent how many hours (or more) after admission? 72 hours
The NSHS Bethesda, MD will conduct how many educational workshops each year in the principles, components and management of QA programs for navy medical department personnel? Two
What is the process by which practitioners of the same or like discipline evaluate the outcomes of QA program related monitoring activities? Peer review
What is a structured approach which continuously analyzes clinical and administrative process within pre-established boundaries using various analytic tables? Continuous Quality Improvement
Naval Medical Department policy, procedures and responsiblities for navy DTF's ashore and afloat were issued in 1987 and incorporated into this instruction in what year? 1989
Fixed MTF's and DTF's meeting applicable criteria must gain maintain what by the Joint Commission? Accreditation
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
Who may elect to have a fleet-wide medical and dental QA program under the cognizance of the fleet medical and dental officer? TYCOMS
The Quality Assurance program was originall issued in what year to standardized QA activities within MTF's? 1984
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
Routine QA program-related documentation must be maintained in a secure location for a period of how many years before disposal? 5 years
BUMED submits a QA program summary report required by DOD Directive 6025.13 how often? Annually
MTF's and DTF's, with guidance from higher authority, must develop what type of programs? Clinical monitoring
Which committee is multidisciplinary and provides a forum for discussion and oversight of all nonmedical staff QA functions? QA
Who are personnel who are required to be licensed but are not included in the definition of health care practitioners? Clinical Support Staff
TYCOMS 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 HC Suppo to reeach BUMED by what date each year? 15 January
The clinic performance profile is what type of document? Internal
A medical record is considered delinquent if all required record components are not completed within how many days of patient discharge? 30 days
What is an inpatient acquired infection not present or incubation at the time of admission? Nosocomial infection
A wound infection that develops after surgery. Post-operative wound infection
Created by: hull5518