BUMED 6010.13 Quality Assurance (QA)

Question 1

What year was the QA program originally issued?

Answer 1

1984

Question 2

Why was the QA program originally issued?

Answer 2

To standardize QA activities within Naval Medical Command MTFs

Question 3

When were DTFs issued and incorporated into the instruction?

Answer 3

issued: 1987

added to instruction: 1989

Question 4

How long must routine QA program-related documentation be maintained before disposal?

Answer 4

5 years

Question 5

What are the QA program objectives?

Answer 5

1. Systematically monitor services provided to identify opportunities to improve patient care
2. Identify, assess, and decrease risk to patients and staff thereby reducing exposure to liability
3. Justify resources needed to maintain and preferable exceed acceptable standards of patient care service
4. Communicate important QA information to effect sound clinical and management decision-making at all levels of the organization
5. 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

Question 6

Inpatient fixed MTFs must have the following standing committees:

Answer 6

1. ECOMS, responsible for all medical staff functions
2. Safety
3. Infection Control

Question 7

Fixed ambulatory care medical facilities must have the following committees

Answer 7

1. ECOMS, one ECOMES per individual privileging authority

2. QA

Question 8

What are the responsibilities BUMED?

Answer 8

1. Provides guidance for Navy-wide QA program implementation
2. Provides consultation, educational support, and QA-related information to Navy treatment facilities
3. Maintains a risk management database (RMDB)

Question 9

What are the responsibilities of Fleet Commanders in Chief (FLTCINCs)?

Answer 9

Ensure that subordinate commanders comply with this instruction

Question 10

What are the responsibilities of Type Commanders (TYCOM)?

Answer 10

Implement and coordinate a TYCOM-wide QA program

Question 11

What are the responsibilities of Officers in Charge of naval Healthcare Support Offices?

Answer 11

Provide technical support and assistance for QA-related issues on request to fixed and nonfixed naval medical and dental activities

Question 12

What are the responsibilities of Naval School of health Sciences, Bethesda?

Answer 12

Conduct two educational workshops each year in the principles, components, and management of QA programs for naval Medical Department personnel

Question 13

When is a medical record considered delinquent?

Answer 13

If all required record components are not completed within 30 days of patient discharge

Question 14

Define deficiency.

Answer 14

State in which there is a variance from preestablished minimally acceptable standards of care

Question 15

When is an infection considered nosocomial?

Answer 15

If it first becomes apparent 72 hours (or more) after admission

Question 16

Define postoperative wound infection.

Answer 16

Infection that develops after surgery

Question 17

Define potentially compensable event (PCE) (adverse event).

Answer 17

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

Question 18

List examples of a none or minor PCE.

Answer 18

Appendectomy with no delay in recovery, miss dx fracture, delayed recovery from anesthesia

Question 19

List examples of a temporary PCE.

Answer 19

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

Question 20

List examples of long-term PCE.

Answer 20

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

Question 21

What is CQI?

Answer 21

Continuous Quality Improvement (CQI)