BUMEDINST 6010.13, QUALITY ASSURANCE (QA) PROGRAM

Question 1

QUALITY ASSURANCE PROGRAM

Answer 1

BUMEDINST 6010.13

Question 2

The QA program was originally issued in?

Answer 2

1984 to standardized QA activities within Naval Medical Command MTFs.

Question 3

Naval Medical Department policy, procedures, and responsibilities for naval DTFs ashore and afloat were issued in?

Answer 3

1987 and incorporated in 1989.

Question 4

Routine QA program-related documentation must be maintained in a secure location for a period of?

Answer 4

5 years before disposal.

Question 5

Quality Assurance 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 ?

Answer 5

2 years or as long as needed thereafter.

Question 6

Responsible for all medical staff functions

Answer 6

Executive Committee

Question 7

Multidisciplinary and provides a forum for discussion and oversight of all nonmedical staff QA functions.

Answer 7

Quality Assurance Committee.

Question 8

An executive management team may perform the command QA committee function if it meets at least?

Answer 8

Monthly

Question 9

1. Interprets DoD, SECNAV and CNO policies and provides guidance for Navy-wide QA program implementation.
2. Monitors implementation and coordination of medical and dental QA programs in fixed and non fixed MTFs and DTFs.
3. Provides consultation, education support, and QA-related information to Navy treatment facilities.
4. Submits annual QA program summary report.
5. Reviews PCEs and malpractice RM data reported centrally by MTFs and DTFs.
6. Serves as liaison with the Deputy Assistant Judge Advocate General
7. Maintains a risk management database.

Answer 9

Chief, BUMED

Question 10

1. Implement and coordinate a TYCOM wide QA program.
2. Ensure, at minimum QA assist visits to each subordinate medical and dental command required to maintain optimal QA program function.

Answer 10

Type Commanders

Question 11

1. Provide technical support and assistance for QA-related issues on request to fixed and non-fixed naval medical and dental activities.
2. Provide technical analysis and recommended corrective action to fixed MTF commanding officers in regards to implementation status reports to meet the JCAHO recommendations.

Answer 11

Officers in Charge of Naval Healthcare Support Offices

Question 12

1. Implement an effective, flexible, integrated, and comprehensive QA program.
2. Meeting the criteria for participation in the JCAHO survey process must maintain accreditation.

Answer 12

Commanding Officers, OICs, SMDR of MTF.

Question 13

1. Conduct 2 educational workshops each year in the principles and management of QA programs for naval Medical Department personnel.
2. Periodically evaluate and modify as necessary QA educational programs to meet user and management needs.

Answer 13

Naval School of Health Sciences, Bethesda, MD.

Question 14

MTFs and DTS (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 healthcare suppo to reach BUMED by?

Answer 14

15 January of each year.

Question 15

TYCOMS with privileging authority must forward an annual assessment of the preceding fiscal year’s TYCOM QA program to MED-3C4 to reach BUMED by

Answer 15

15 January of each year.

Question 16

1. Submit case abstract for malpractice claims, to MED-3C4 for each PCE review.
2. Submit case abstract for malpractice claims to MED-3C5 for each JAGMAN investigation initiated.

Answer 16

CO, OICs, SMDRs of MTF/DTF

Question 17

Documents and records created per this instruction are medical QA materials are exempt from the requirements of the FOIA.

Answer 17

Freedom of Information Act

Question 18

Who can independently diagnose, initiate, alter, or terminate healthcare treatment regimens?

Answer 18

Health Care practitioners.

• Physicians
• Dentist
• Nurse Practitioners
• Nurse Midwives,
• Nurse Aesthetics
• Clinical Psychologist
• Optometrist
• Dieticians
• Podiatrist
• Clinical Social Workers
• Pharmacist

Question 19

Personnel who are required to be licensed but are not included in the definition of health care practitioners?

Answer 19

Clinical Support Staff which includes pharmacist, dental hygienist, and non privileged nurses.

Question 20

Personnel who provide support services to medical, dental, clinical staffs in addition to administrative, logistical, maintenance, and other personnel not involved in direct patient care.

Answer 20

Nonlicensed support staff

Question 21

A determination concerning a monitor outcome confirmed through the peer review process?

Answer 21

Validation

Question 22

Used as a portion of the inpatient medical record review function, it is reserved for MTFs with inpatient capabilities?

Answer 22

Delinquency

Question 23

A medical record is considered delinquent if all required record components are not completed within how many day?

Answer 23

30 Days

Question 24

The state in which there is a variance from preestablished minimally acceptable standards of care?

Answer 24

Deficiency.

Question 25

An inpatient acquired infection not present or incubating at the time of admission?

Answer 25

Nosocomial Infection.

Question 26

An infection is considered nosocomial if it first becomes apparent in how many hours?

Answer 26

72 hours or more after admission.

Question 27

A wound infection that develops after surgery?

Answer 27

Postoperative Wound Infection

Question 28

The process by which practitioners of the same or like discipline evaluate the outcomes of QA program-related monitoring activities?

Answer 28

Peer Review.

Question 29

What is an event or outcome during the process of medical or dental care in which the patient suffers a lack of improvement, injury, or illness of severity greater than ordinarily experience by patients with similar procedures or illnesses.

Answer 29

Potentially Compensable Event (PCE) Adverse Event.

Question 30

What PCE includes appendectomy surgery for perforated appendix but with no delay in recovery, missed diagnosis of fracture recognized at a later date and healing with no residual deformity, or delayed recovery from anesthesia not impending overall recovery?

Answer 30

None or Minor.

Question 31

This PCE includes falls with laceration or fracture, appendectomy with a single postoperative episode of sepsis, delayed union of a fracture, incisional hernia, and fracture of a tooth during anesthesia.

Answer 31

Temporary.

Question 32

This PCE includes fall with resultant neurological injury, healed forearm fracture with loss of motion in wrist or elbow, postoperative inadvertent retention of a foreign body, loss of a thumb or finger, anesthetic-related cardiac or respiratory arrest.

Answer 32

Long-term permanent.

Question 33

The formal and systematic exercise of monitoring and reviewing medical care delivery and outcome?

Answer 33

Quality Assurance

Question 34

1. Is thought by knowledgeable, responsible clinicians to be in consonance with practice of the applicable professional community. 2. Is associated with a high probability for good clinical results. 3. Meets or exceeds policies, guidance, and general requirements of authorized accrediting organizations.

Answer 34

Quality Health Care

Question 35

A structured approach which continuously analyzes clinical and administrative processes within pre-established boundaries using various analytic tables.

Answer 35

Continuous Quality Improvement (CQI)