Bumedinst 6010.13, Quality Assurance (Qa) Program

Front 1

Fixed MTF’s and DTF’s meeting applicable criteria must gain and maintain what by the Joint Commission on Accreditation of Healthcare Organizations?

Back 1

Accreditation

Front 2

MTF’s and DTF’s, with guidance from higher authority, must develop what type of programs?

Back 2

Clinical monitoring

Front 3

The Quality Assurance program was originally issued in what year to standardize QA activities within Naval Meical Command MTF’s?

Back 3

1984

Front 4

A medical record is considered delinquent if all required record components are not completed within how many days of patient discharge

Back 4

30

Front 5

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

Back 5

Validation

Front 6

What is a structured approach which continuously analyzes clinical and administrative processes within pre-established boundaries using various analytic tables?

Back 6

Continuous Quality Improvement

Front 7

The Clinical Performance Profile is what type of document?

Back 7

Internal

Front 8

BUMED submits a QA program summary report required by DoD Directive 6025.13 how often?

Back 8

Annually

Front 9

Documents and records created per this instruction are medical QA materials and are therefore exempt from the requirements of what act?

Back 9

Freedom of Information Act

Front 10

An infection is considered nosocomial if it first becomes apparent how many hours (or more) after admission?

Back 10

72

Front 11

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?

Back 11

Utilization Review

Front 12

QA inquiries and medical records related to a
po tentially 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

Back 12

2

Front 13

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

Back 13

Monthly

Front 14

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?

Back 14

Provider-specific

Front 15

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

Back 15

Peer review

Front 16

Which committee is multidisciplinary and provides a forum for discussion and oversight of all nonmedical staff QA functions?

Back 16

QA

Front 17

The Clinical Performance Profile provides a format for compiling and summarizing individual-specific information per what instruction?

Back 17

BUMEDINST 6320.66

Front 18

Identifying, assessing, and decreasing risk to patients and staff are objectives of the QA program to reduce exposure to what?

Back 18

Liability

Front 19

A review of the QA program effectiveness must be completed with revision as necessary every how often?

Back 19

Annually

Front 20

Who interprets Department of Defense (DoD), Secretary of the Navy (SECNAV), and CNO policies and provides guidance for Navy-wide QA program implementation?

Back 20

BUMED

Front 21

Routine QA program-related documentation must be maintained in a secure location for a period of how many years before disposal

Back 21

5

Front 22

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

Back 22

Clinical Support Staff

Front 23

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?

Back 23

Liability risk

Front 24

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

Back 24

Deficiency

Front 25

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?

Back 25

15 January

Front 26

What is an inpatient acquired infection not present or incubating at the time of admission?

Back 26

Nosocomial Infection

Front 27

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?

Back 27

Two

Front 28

Who may elect to have a fleet-wide medical and dental QA program under the cognizance of the fleet medical and dental officer?

Back 28

TYCOMS

Front 29

Naval Medical Department policy, procedures, and responsibilities for naval DTFs ashore and afloat were issued in 1987 and incorporated into this instruction in what year?

Back 29

1989