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29 Cards in this Set

  • Front
  • Back
Fixed MTF’s and DTF’s meeting applicable criteria must gain and maintain what by the Joint Commission on Accreditation of Healthcare Organizations?
MTF’s and DTF’s, with guidance from higher authority, must develop what type of programs?
Clinical monitoring
The Quality Assurance program was originally issued in what year to standardize QA activities within Naval Meical Command MTF’s?
A medical record is considered delinquent if all required record components are not completed within how many days of patient discharge
What is a determination concerning a monitor outcome confirmed through the peer review process?
What is a structured approach which continuously analyzes clinical and administrative processes within pre-established boundaries using various analytic tables?
Continuous Quality Improvement
The Clinical Performance Profile is what type of document?
BUMED submits a QA program summary report required by DoD Directive 6025.13 how often?
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
An infection is considered nosocomial if it first becomes apparent how many hours (or more) after admission?
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
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
An executive management team may peform the command QA committee function if it meets at least how often?
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?
What is the process by which practitioners of the same or like discipline evaluate the outcomes of QA program-related monitoring activities?
Peer review
Which committee is multidisciplinary and provides a forum for discussion and oversight of all nonmedical staff QA functions?
The Clinical Performance Profile provides a format for compiling and summarizing individual-specific information per what instruction?
Identifying, assessing, and decreasing risk to patients and staff are objectives of the QA program to reduce exposure to what?
A review of the QA program effectiveness must be completed with revision as necessary every how often?
Who interprets Department of Defense (DoD), Secretary of the Navy (SECNAV), and CNO policies and provides guidance for Navy-wide QA program implementation?
Routine QA program-related documentation must be maintained in a secure location for a period of how many years before disposal
Who are personnel who are required to be licensed but are not included in the definition of health care practitioners?
Clinical Support Staff
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
What is the state in which there is a variance from preestablished minimally acceptable standards of care?
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
What is an inpatient acquired infection not present or incubating at the time of admission?
Nosocomial Infection
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?
Who may elect to have a fleet-wide medical and dental QA program under the cognizance of the fleet medical and dental officer?
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?