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 higher authority, must develop what type of programs?
Clinical monitoring
What is a structured approach which continuously analyzes clinical and administrative processes within the pre-established boundaries using various analytic tables?
Continuous Quality Improvement
What is an inpatient acquired infection not present or incubating at the time of admission?
Nosocomial infection
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
Who may elect to have a fleet wide medical and dental QA program under the cognizance of the fleet medical and dental officer?
TYCOMS
A medical record is considered delinquent if all required record components are not completed within how many days of patient discharge?
30
Which committee is multidisciplinary and provides a forum forum for discussion and oversight of all non medical staff QA functions?
QA
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
An infection is considered nosocomial if it first becomes apparent how many hours (or more) after admission?
72
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
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
Two
Naval medical department policy, procedures and responsibilities for naval DTFs ashore and afloat we’re issued in 1987 and incorporated into this instruction in what year?
1989
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 oh how many years or as long as needed thereafter?
2
Indentifying, assessing and decreasing risk to patients and staff are objectives of the QA program to reduce exposure to what?
Liability
Routine QA program related documentation must be maintained in a secure location for a period of how many years before disposal?
5
MTFs and DTFs (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
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
What is the process by which practitioners of the same or like discipline evaluate the outcomes of QA program related monitoring activities?
Peer review
Who are personnel who are required to be licensed but are not included in the definition of health care practitioners?
Clinical support staff?
What is a determination concerning a monitor outcome confirmed through the peer review process?
Validation
Who interprets DOD, SECNAV, and CNO policies and provides guidance for Navy-wide QA program implementation?
BUMED
An executive management team may perform the command QA committee function if it meets at least how often?
Monthly
The clinical performance profile provides a format for compiling and summarizing individual-specific information per what instruction?
BUMEDINST 6320.66
A review of the QA program effectiveness must be completed with revision as necessary every how often?
Annually
The clinical performance profile is what type of document?
Internal
BUMED submits a QA program summary report required by DoD Directive 6025.13 how often?
Annually
The quality assurance program was originally issued in what year to standardize QA activities within naval medical command MTFs?
1984
What is the state in which there is a variance from preestablished minimally acceptable standards of care?
Deficiency
