BUMEDINST 6010.13 Quality Assurance Program

Inpatient fixed MTFs are required to have the following standing committees:      (1) ECOMS      (2)  QA Committee      (3)  __________(Fill in the blank) Committee      (4)  Infection Control Committee Fixed ambulatory care medical facilities must have the following committees:      (1)  ECOMS      (2)  QA Committee In non-fixed medical facilities the privileging authority is required to have an ECOMS In fixed and non-fixed dental facilities the privileging authority is required to appoint an ECODS

Inpatient fixed MTFs are required to have the following standing committees:      (1) ECOMS      (2)  QA Committee      (3)  Safety Committee      (4)  __________ __________(2 words.  Fill in the blank) Committee Fixed ambulatory care medical facilities must have the following committees:      (1)  ECOMS      (2)  QA Committee In non-fixed medical facilities the privileging authority is required to have an ECOMS In fixed and non-fixed dental facilities the privileging authority is required to appoint an ECODS

A Potentially Compensable Event (PCE) is an adverse event.  It 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 experienced by patients with similar procedures or illnesses.  Injury or disability must be classified as follows:      a.  None or Minor.  Examples include 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 impeding overall recovery.      b.  __________(1 word).  Examples include 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.      c.  Long-Term / Permanent.  Examples include 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, and loss of life other than in terminal illness.

Inpatient fixed MTFs are required to have the following standing committees:      (1)  __________ (Fill in the blank)      (2)  QA Committee      (3)  Safety Committee      (4)  Infection Control Committee Fixed ambulatory care medical facilities must have the following committees:      (1)  ECOMS      (2)  QA Committee In non-fixed medical facilities the privileging authority is required to have an ECOMS In fixed and non-fixed dental facilities the privileging authority is required to appoint an ECODS

A Potentially __________ Event (PCE) is an adverse event.  It 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 experienced by patients with similar procedures or illnesses.  Injury or disability must be classified as follows:      a.  None or Minor.  Examples include 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 impeding overall recovery.      b.  Temporary.  Examples include 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.      c.  Long-Term / Permanent.  Examples include 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, and loss of life other than in terminal illness.

A Potentially Compensable Event (PCE) is an adverse event.  It 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 experienced by patients with similar procedures or illnesses.  Injury or disability must be classified as follows:      a.  None or Minor.  Examples include 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 impeding overall recovery.      b.  Temporary.  Examples include 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.      c.  Long-Term / __________(1 word)  Examples include 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, and loss of life other than in terminal illness.

Individuals responsible for Quality Assurance (QA) Program management must be afforded educational opportunities commensurate with their responsibilities.  Education may be inservice military or outservice civilian sponsored.  QA education for key program managers must be sufficient in scope and frequency to enable effective program oversight.

• True

• False

According to the instruction, Medical and Dental Treatment Facilities must have programs for continuous monitoring of the quality and appropriateness of health care.  These programs must review data on demographics of patient populations, customer needs and expectations, productivity of the health care facility, access to care, morbidity, mortality, processes of care, outcomes of care, occurrence screening, resources (personnel, facilities, and equipment), and management of effectiveness.

• True

• False

Continuous Quality Improvement (CQI) is defined as a structured approach which continuously analyzes clinical and administrative processes within pre-established boundaries using various analytic tables.  The goal is to improve efficiency and effectiveness of such processes by addressing and eliminating special cause variations, eliminating nonvalue added steps, identifying and solving process problems, and making other carefully planned and tested changes to reduce overall process variation.

• True

• False

The purpose of BUMED's Quality Assurance (QA) Program is to establish policy, procedures, and assign responsibility for quality assurance (QA) and risk management (RM) activities in Navy fixed (shore-based with permanent structures) and nonfixed (moveable shore or fleet-based) medical and dental treatment facilities.

• True

• False

The Quality Assurance (QA) Program applies to all health care personnel providing services in naval MTFs and DTFs, fixed and non-fixed.

• True

• False

A Potentially Compensable Event (PCE) is an adverse event.  It 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 experienced by patients with similar procedures or illnesses.  Injury or disability must be classified as follows:      a.  None or Minor.  Examples include 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 impeding overall recovery.      b.  Temporary.  Examples include 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.      c.  Long-Term / Permanent.  Examples include 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, and loss of life other than in terminal illness.

• True

• False

Inpatient fixed MTFs are required to have the following standing committees:      (1) ECOMS      (2)  ____________(Fill in the blank) Committee      (3)  Safety Committee      (4)  Infection Control Committee Fixed ambulatory care medical facilities must have the following committees:      (1)  ECOMS      (2)  QA Committee In non-fixed medical facilities the privileging authority is required to have an ECOMS In fixed and non-fixed dental facilities the privileging authority is required to appoint an ECODS

In accordance with the Navy's Quality Assurance (QA) Program, the Naval School of Health Sciences in Bethesda is required to:      (1)  Conduct two educational workshops each year in the principles, management, and components of QA programs for naval Medical Department personnel.      (2)  Periodically evaluate and modify as necessary QA educational programs to meet user and management needs.

• True

• False

Potentially Compensable Events (PCEs) for Medical and Dental Treatment Facilities include the following:      1.  Unexpected deaths (including suicides).      2.  Any complication of treatment which results in:           a.  A corrective operative procedure           b.  Brain damage           c.  Motor weakness           d.  Sensory nerve injury           e.  Total or partial loss of limb           f.  Loss of use of limb           g.  Sensory organ loss or impairment           h.  Reproductive organ loss or impairment 3.  Inadvertent blood transfusion with HIV or hepatitis virus contaminated blood. 4.  Procedure performed on wrong patient or body part (includes extraction of wrong tooth)

• True

• False

What is the purpose of BUMED's Quality Assurance (QA) Program?

• To minimize legal action against Medical Officers and their staff caused by negligence or malpractice

• Required policy at military treatment facilities who treat dependent and civilian personnel

• Required policy at military treatment facilities who employ civilian personnel

• To establish policy, procedures, and assign responsibility for quality assurance (QA) and risk management (RM) activities in Navy fixed (shore-based with permanent structures) and nonfixed (moveable shore or fleet-based) medical and dental treatment facilities.

In accordance with the Navy's Quality Assurance (QA) Program, the responsibilities of Chief, Bureau of Medicine and Surgery (BUMED) are:      (1)  Interprets Department of Defense (DoD), Secretary of the Navy (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 (shore-based with permanent structures) and nonfixed (moveable shore or fleet-based) MTFs and DTFs by the Medical IG oversight and healthcare support office (HLTHCARE SUPPO) assistance visits as requested or required.      (3)  Provides consultation, educational support, and QA-related information to Navy treatment facilities      (4)  Submits an annual QA program summary report      (5)  Reviews Potentially Compensable Events (PCEs) and malpractice Risk Management (RM) data reported centrally by MTFs and DTFs.  Uses data abstracted from every malpractice claim for central reporting to the Assistant Secretary of Defense (Health Affairs) (ASD/HA) and to the National Practitioner Data Bank.       (6)  Serves as liaison with the Deputy Assistant Judge Advocate General (Claims and Tort Litigation) and ensures the completion and accuracy of DD 2526.        (7)  Maintains an RM database (RMDB)

• True

• False

A command's Quality Assurance (QA) Program is to be reviewed annually for effectiveness.

• True

• False

What is the definition of a nosocomial infection?

• Infection made worse by incorrectly prescribed or administered antibiotics

• Wound infection that develops after surgery

• Inpatient acquired infection that is not present or incubating at the time of admission. Considered nosocomial if it becomes apparent 72 hours or more after admission.

• Infection made worse by improper wound care

The purpose of a command's Utilization Review (UR) program is to monitor resource use and to recommend ways to balance assigned mission statements with existing healthcare resources.  At a minimum, UR monitoring will include the following subjects:      (a)  For inpatient fixed MTFs, planned review of care received by hospitalized patients with excessive lengths of stay for diagnoses, diagnosis related groups (DRG), or procedures as specified by MTF or higher authority.      (b)  For inpatient fixed MTFs, policies on discharge planning      (c)  Under, over, or misuse of medical or dental resources      (d)  Review and assessment of resource usage statistics on accessibility of care, personnel and staffing, and volume of care actually delivered to patients.      (e)  Equipment maintenance and procurement policies

• True

• False

Information derived through the Quality Assurance process and other continuous quality improvement (CQI) activities must be used to support performance appraisal for privileged practitioners, clinical support staff, and other healthcare personnel.

• True

• False

Quality Assurance (QA) Program 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 2 years or as long as needed thereafter.

• True

• False

BUMEDINST 6010. 13 calls for inpatient fixed MTFs to have the following standing committees:      (1)  ECOMS.  Responsible for all medical staff functions      (2)  QA Committee.  Multidisciplinary and provides a forum for discussion and oversight of all nonmedical staff QA functions.  An executive management team may perform the command QA function if it meets at least monthly.      (3)  Safety Committee      (4)  Infection Control Committee

• True

• False

Which of the following terms is used to describe an inpatient acquired infection that was not present or incubating at the time of admission?  It is considered to be this if it first becomes apparent 72 hours or more after admission.

• Inpatient Infection

• Nosocomial Infection

• Community Acquired Infection (CAI)

• Ulcerative Colitits

• None of the above

Fixed MTFs and DTFs meeting applicable criteria must gain and maintain accreditation by the Joint Commission on Accreditation of Health Care Organizations (Joint Commission, JCAHO).

• True

• False

Inpatient fixed MTFs are required to have the following standing committees:      (1) ECOMS      (2)  QA Committee      (3)  Safety Committee      (4)  Infection Control Committee Fixed ambulatory care medical facilities must have the following committees:      (1)  ECOMS      (2)  QA Committee In non-fixed medical facilities the privileging authority is required to have an ECOMS In fixed and non-fixed dental facilities the privileging authority is required to appoint an ECODS

• True

• False

At a minimum, a command's Risk Management (RM) program must include procedures for reviewing the following subjects:      (a)  All malpractice claims      (b)  JAGMAN investigations      (c)  All Potentially Compensable Events (PCEs)      (d)  Management variance reports for nonpatient related events      (e)  Results of occurrences screening or other appropriate clinical monitoring processes      (f)  Patient complaints or requests through Inspector General (IG), congressional, and patient assistance and contact offices      (g)  Collecting, tracking, and trending of patient contact and patient satisfaction information including procedures for using such information in TQL efforts

• True

• False

What is the instruction number of BUMED's Quality Assurance (QA) Program?

• BUMEDINST 6024.13

• BUMEDINST 6010.13

• BUMEDINST 6310.13

• BUMEDINST 6240.58

• None of the above

BUMEDINST 6010.13 is BUMED's instruction covering the Quality Assurance (QA) Program.

• True

• False

Routine Quality Assurance (QA) Program-related documentation must be maintained in a secure location for a period of 10 years before disposal.

• True

• False

Monitoring and evaluation activities of the Quality Assurance (QA) program include:      (1)  An ongoing, planned, and systematic approach to information collection      (2)  Comprehensive monitoring activities that encompass all aspects of patient care services provided by the clinical and support services, trainee groups not permitted to practice independently, and administrative staff      (3) Use of predetermined written criteria that reflect current knowledge and clinical experience to evaluate services provided      (4)  Evaluation of information collected to identify opportunities to improve patient care services, clinical performance, and support service processes.      (5)  Integration of information derived from monitoring and evaluating activities with appropriate departments and services to aid facility-wide tracking and trending of information.      (6)  Documentation of findings, conclusions, recommendations, actions taken, and followup of actions taken to ensure problem resolution.      (7)  Communication of appropriate information through established channels.      (8)  Use of practitioner-specific results of QA monitoring activities, in part, to support staff appointments and the grating of clinical privileges.      (9)  Use of QA monitoring activities to support performance appraisal of those not holding clinical privileges

• True

• False

What is the instruction number of BUMED's Quality Assurance (QA) Program?

• BUMEDINST 6817.78

• BUMEDINST 6012.28

• BUMEDINST 6009.17

• BUMEDINST 6001.13

• None of the above

A medical record is considered delinquent if all required record components are not completed within 30 days of patient discharge.

• True

• False

The Quality Assurance Program objectives are to:      a.  Systematically monitor services provided to identify opportunities to improve patient care      b.  Identify, assess, and decrease risk to patients and staff thereby reducing exposure to liability      c.  Justify resources needed to maintain and preferably exceed acceptable standards of patient care service      d.  Communicate important QA information to effect sound clinical and management decision-making at all levels of the organization      e.  Integrate, track, and trend QA information to identify significant patterns or processes which may need indepth review, addressed by CQI techniques or other intervention.      f.  Support credentials review and privileging activities      g.  Identify educational and training needs      h.  In fixed MTFs that meet criteria for accreditation, gain and sustain compliance with Joint Commission accreditation

• True

• False

Commanding Officers, Officers in Charge, and Senior Medical and Dental Department Representatives of Treatment Facilities are to submit case abstracts for malpractice claims to MED-3C5 for each JAGMAN investigation initiated.

• True

• False

The three classifications of Potentially Compensable Events (PCEs) are:      None or Minor         Temporary      Long-Term or Permanent

• True

• False

Using the links we have to Amazon.com to the right of this quiz is an excellent idea when purchasing your music for the following three reasons: 1 - It's cheaper than iTunes and the songs you purchase will always be DRM-Free (You can play them on any computer, any mp3 player, etc.) 2 - It's very simple to use and all the songs you purchase get automatically added to your iTunes or Windows Media Player file. 3 - You help support the site.  Every song you purchase contributes 10 cents towards the monthly operating cost of battalionaidstation.com

• True

• False

What is the instruction number of BUMED's Quality Assurance (QA) Program?

• BUMEDINST 6010.13

• BUMEDINST 6013.10

• BUMEDINST 6010.10

• BUMEDINST 6013.13

• None of the above

Quality Assurance (QA) inquiries and medical records related to a potentially compensable event (PCE) and Judge Advocate General (JAGMAN) investigations must be maintained for a minimum of 2 years at the local command.

• True

• False

In accordance with the Navy's Quality Assurance (QA) Program, the responsibilities of a Commanding Officer, Officer in Charge, and Senior Medical and Dental Department Representatives of Treatment Facilities are:      (1)  Implement an effective, flexible, integrated, and comprehensive QA program, guided by a written plan      (2)  Ensure that their MTFs, if they meet the criteria for JCAHO accreditation, maintain JCAHO accreditation.      (3)  All Potentially Compensable Events (PCEs) and all other cases involving serious injury or prolonged disability regardless of whether the patient is ACDU or civilian status must be included in MTF or DTF databases for analysis and be reported to MED-34C.

• True

• False

The Quality Assurance (QA) Program is guided by a plan that includes, at a minimum, the following:      (1)  Program objectives      (2)  Organization and responsibilities      (3)  Scope of the QA program to include the methodology for obtaining customer's input on quality      (4)  Required QA functions including what is to be done, by whom, and how frequently      (5)  Information flow and review needs      (6)  Annual review of program effectiveness with revision as necessary      (7)  Methodology by which data generated by the QA program is used to continuously improve the command and patient care  

• True

• False

Which of the following Quality Assurance (QA) related committees is responsible for all medical staff functions?

• ECOMS

• LSANTS

• CMS

• LRS-AHS

A patient at your hospital had an anesthesia related cardiac arrest during surgery.  What is the classification of this Potentially Compensable Event (PCE)?

• This is not a PCE

• None or Minor

• Temporary

• Long-Term or Permanent

The term "Clinical Support Staff" refers to personnel who are licensed to perform certain procedures and services, but are not included in the definition of healthcare practioners such as pharmacists, dental hygienists, and nonprivileged nurses.

• True

• False

Using the links we have to Amazon.com to the right of this quiz is an excellent idea when purchasing your music for the following three reasons: 1 - It's cheaper than iTunes and the songs you purchase will always be DRM-Free (You can play them on any computer, any mp3 player, etc.) 2 - It's very simple to use and all the songs you purchase get automatically added to your iTunes or Windows Media Player file. 3 - You help support the site.  Every song you purchase contributes 10 cents towards the monthly operating cost of battalionaidstation.com

• True

• False

This quiz has over a hundred questions, however, we've programmed it so that only 25 - 33% show up each time it loads.  We also add questions to all of our quizzes every few days. Keeping this in mind, which of the following is the best way to practice and use all of our questions to help you study this subject?

• Emailing this page to yourself so that you can easily find it from home or work

• Bookmarking this page so that you can do this quiz again later

• Hitting the "refresh" button on your browser when the quiz is complete to load up a new set of questions (many of which you haven't yet seen) in a random order

• Any of the above

Which of the following is NOT one of the Quality Assurance (QA) Program plan requirements?    

• Scope of the QA program to include the methodology for obtaining customer's input on quality

• Program objectives

• Annual review of program effectiveness with revision as necessary

• Required QA functions including what is to be done, by whom, and how frequently

• All of the above are among the requirements of a QA Program

Which of the following is NOT one of the four standing QA Program Committees required at an inpatient fixed MTF?

• QA Committee

• ECOMS

• Infection Control Committee

• Safety Committee

• All of the above are the four required standing committees at an inpatient fixed MTF