Tab_15_-_Attachment_4_-_MDGI_44-147.pdf

BY ORDER OF THE COMMANDER 48 MEDICAL GROUP INSTRUCTION 44- 147

48TH MEDICAL GROUP 17 OCTOBER 2016

Medical

PLAN FOR THE PROVISION OF PATIENT CARE (PA)

COMPLIANCE WITH THIS PUBLICATION IS MANDATORY

ACCESSIBILITY: This publication is available digitally on the 48th Medical Group

(48 MDG) Intranet site.

https://ice.usafe.af.mil/sites/48MDG/Topics/MDGI/MDGI/Forms/AllItems.aspx

RELEASABILITY: There are no releasability restrictions on this publication.

OPR: 48 MDG/SGH Certified By: 48 MDG/SGA (Col Paul Brezinksi)

Supersedes 48 MDGI 44-147, 26 February 2013 Pages: 107

This Medical Group Instruction (MDGI) implements Air Force Policy Directive (AFPD) 44-1, Medical Operations and The Joint Commission’s (TJC) accreditation standards. It establishes policies and procedures relating to the scope of 48 MDG’s clinical services consistent with the organization’s in-garrison health care and readiness mission requirements. This plan directly supports the 48 MDG’s mission, vision, values, and goals and applies to all personnel assigned to the 48 MDG. Refer recommended changes and questions about this publication to the Office of

Primary Responsibility (OPR) using Air Force (AF) Form 847, Recommendation for Change of

Publication, prescribed by Air Force Instruction (AFI) 11-215, USAF Flight Manuals Program;

route AF Forms 847s from the field through publications/forms manager and also AFI 33-360, Publications and Forms Management. Ensure all records created as a result of processes prescribed in this publication are maintained in accordance with Air Force Manual (AFMAN) 33-

363, Management of Records, and disposed of in accordance with Air Force Records Information

Management System (AFRIMS) Records Disposition Schedule (RDS).

This publication requires the collection and/or maintenance of information protected by the

Privacy Act of 1974 authorized by 10 U.S.C. 8013, AFMAN 41-120, Medical Resource

Management Operations, 5 U.S.C. 552a (b) of the Privacy Act, and Department of Defense

Instruction (DoDI) 6025.18, Privacy of Individually Identifiable Health Information in DoD

Health Care Programs. The applicable Privacy Act Systems of Records Notice (SORN) F044 AF

SG F, Uniform Business Office Records is available at http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-

View/Article/569862/f044-af-sg-f/. Policy is delineated in DoDI 6025.18, AFPD 33-3, Information Management, AFI 33-332, The Air Force Privacy and Civil Liberties Program, and https://ice.usafe.af.mil/sites/48MDG/Topics/MDGI/MDGI/Forms/AllItems.aspx

2 48 MDGI 44-147 17 OCT 2016

AFI 41-210, TRICARE Operations and Patient Administration Functions. These publications establish procedures designed to protect personal information from unauthorized use or release and prescribe use and disclosure of Protected Health Information (PHI).

SUMMARY OF CHANGES

This document has been revised to reflect current standards and practices to include attachments for sections that provide patient services. All references have been updated. This document must be reviewed in its entirety.

1. Overview. The 48 MDG is located at Royal Air Force (RAF) Lakenheath in the East Anglia region of England and provides direct medical support to RAF Lakenheath, RAF Feltwell, and

RAF Mildenhall.

1.1. The 48 MDG is the largest military treatment facility (MTF) in United States Air Forces in

Europe (USAFE) and the only United States (US) bedded MTF in the United Kingdom (UK). It is a full-service community hospital, providing in-garrison services to DoD beneficiaries throughout the UK and Northern Europe. 48 MDG leaders plan, direct, organize, and deliver healthcare services to personnel in the 48th Fighter Wing (48 FW) at RAF Lakenheath, the 100th

Air Refueling Wing (100 ARW) at RAF Mildenhall and tenant units to include the 352d Special

Operations Wing (352 SOW) at RAF Mildenhall. In addition to the main hospital campus on

RAF Lakenheath, the 48 MDG operates a Flight and Operational Medicine Clinic and a Dental

Clinic on RAF Mildenhall and maintains medical warehouses on RAF Feltwell. A small number of patients are referred from the European continent, Azores, and Africa. The Group delivers services on-site, across the UK, and across USAFE by personnel who travel individually and in teams to deliver specialty care and services.

1.2. The 48 MDG provides clinical, logistical, administrative and functional assistance for two

Limited Scope Military Treatment Facilities (LSMTF) assigned to the 501st Combat Support

Wing (501 CSW) under a MOU. These LSMTFs include two clinics: 422d Medical Squadron

(422 MDS) at RAF Croughton and 423d Medical Squadron (423 MDS) at RAF Alconbury. In addition, the 48 MDG provides oversight to one Independent Duty Medical Technician (IDMT) assigned to the 426th Air Base Squadron in Stavanger, Norway.

1.3. The 48 MDG has a robust medical readiness mission to provide Expeditionary Medical

Support (EMEDS), as well as an extensive War Readiness Materiel support mission with worldwide implications.

2. Host Nation Medical Treatment Facilities In the Area. When patient requirements exceed the capability of the 48 MDG, host-nation providers and hospitals are used. These include, but are not limited to:

2.1. Addenbrooke's National Health Service (NHS) Trust Hospital, Cambridge; Papworth

Hospital NHS Trust, Cambridge; West Suffolk Hospital, Bury St. Edmunds; Cambridge Lea

Hospital, Cambridge; Hospital Norwich, Norwich; Nuffield Evelyn Hospital, Bury St. Edmunds;

The Bury St Edmunds Nuffield Hospital; Norfolk/Norwich University Hospital, Norwich;

Queen Elizabeth Hospital, Kings Lynn; Ipswich Hospital, Ipswich; Peterborough Hospital, 48 MDGI 44-147 17 OCT 2016 3

Peterborough; James Paget Hospital, Gorleston; Hinchingbrooke Hospital, Huntingdon; London facilities - Capio Nightingale, London Sleep Center, and the Princess Grace Hospital, Great

Ormond Street (pediatrics), and the Priory Hospitals, Staffordshire, Nottingham, and

Roehampton).

2.2. In addition, the North Great Sea Medical Center in Great Yarmouth is the area’s primary hyperbaric unit; it is classified as a Category 1 chamber, and is capable of receiving patients in any diagnostic category who may require advanced life support either immediately or during hyperbaric treatment. Refer to 48 MDGI 48-115, Evaluation and Treatment of Decompression

Sickness, for additional information.

3. Beneficiaries Served. There are 18,000 DoD beneficiaries at RAF Lakenheath, RAF Feltwell, and RAF Mildenhall.

4. 48 MDG’s Vision and Mission. The 48 MDG supports the AFMS, USAFE, 48 FW and 100

ARW visions, missions, and goals. The 48 MDG vision establishes an attainable direction for the organization. It is a statement of where the organization wants to be in the future. The 48 MDG mission statement is the foundation for planning within the organization. In the provision of patient care, these shall be applied within an environment of compassion at every level.

4.1. 48 MDG Vision: To be the DoD’s premier hospital with the healthiest and highest performing population.

4.2. 48 MDG Mission: Innovative expeditionary medics ensuring mission-ready Airmen and healthy families.

5. 48 MDG Organizational Priorities. The four 48 MDG priorities Readiness, Access, People and Quality/Safety combine the requirements of a high operations tempo with its in-garrison and medical readiness missions and the requirement to operate a comprehensive healthcare system in the UK.

5.1. Readiness: Optimize medical readiness for all Airmen and ensure AF medics are trained and equipped to deliver “Trusted Care, Anywhere” to support the full spectrum of military operations.

5.2. Access: Provide reliable access to safe, quality care for all we serve, promoting positive patient experiences and outcomes.

5.3. People: Focus on the appropriate utilization of people and resources applied through effective management. Encourage healthy resilient lifestyles.

5.4. Quality/Safety: Paramount in all care and services provided by the MDG.

6. 48 MDG Organization. The 48 MDG is organized into six squadrons IAW AFI 38-101, Air

Force Organization and AFMS Flight Path Guidance. The overall organizational structure of the

48 MDG is delineated in Attachment 41.

4 48 MDGI 44-147 17 OCT 2016

6.1. 48th Medical Support Squadron (48 MDSS) is comprised of eight flights to include: Clinical

Laboratory and Pathology; Medical Information Services and Personnel Administration;

Medical Logistics; Medical Readiness; Nutritional Medicine; Pharmacy; Resource

Management; and TRICARE Operations and Patient Administration.

6.2. 48th Medical Operations Squadron (48 MDOS) is organized into seven flights: Family

Health; Emergency Services (ES); Medical Services; Pediatrics; Mental Health; Educational and

Developmental Intervention Services (EDIS), and Physical and Occupational Therapy.

6.3. 48th Inpatient Operations Squadron (48 IPTS) is organized into two flights: Maternal-Child

Unit and Multiservice Unit.

6.4. 48th Surgical Operations Squadron (48 MSGS) is comprised of four flights: Operating

Room (OR); Surgical Services; Obstetrics/Gynecology; and Diagnostic Imaging.

6.5. 48th Dental Squadron (48 DS) is divided into four flights: Clinical Dentistry, Dental

Laboratory, Dental Support and the RAF Mildenhall Dental Clinic.

6.6. 48th Aerospace Medicine Squadron (48 AMDS) is divided into five flights: Flight and

Operational Medicine, Public Health, Bioenvironmental Engineering, Aerospace and

Operational Physiology and Optometry.

7. Patient Safety. The 48 MDG leaders are dedicated to providing safe care in the outpatient and inpatient settings and comply with TJC National Patient Safety Goals.

8. Risk Management. The Risk Management Program functions IAW AFI 44-119, Medical

Quality Operations, and is committed to providing a safe and secure environment within its facilities and grounds for all patients, visitors, staff, volunteers and contractors. The Risk

Management program is established within Quality Services and focuses on identification, mitigation and prevention of harmful patient events through a process of risk-reduction strategies.

The SGH shall assist the Risk Manager with event identification and analysis including Sentinel

Events (SE), Medical Incident Investigations (MIIs), medical malpractice claim management, and peer standard of care reviews. Likewise, the Chief Nurse (SGN) and Chief of Dental Services

(SGD) will provide similar consultation in dealing with incidents involving nursing or dental care.

The Risk Manager or Legal Office attorney will provide a quarterly report of claims activity to the

Executive Committee of the Medical Staff (ECOMS).

9. 48 MDG Outpatient and Inpatient Services.

9.1. Outpatient Services.

9.1.1. Outpatient services include: 24-hour Level III Emergency Services with an ambulance service operated out of the RAF Lakenheath and RAF Mildenhall Fire Stations; Alcohol and

Drug Abuse Prevention and Treatment (ADAPT); Allergy; Anesthesiology; Audiology;

Cardiopulmonary; Dermatology; Diagnostic Imaging; Educational Development and

48 MDGI 44-147 17 OCT 2016 5

Interventional Services (including Developmental Pediatrics, Child Psychiatry, Psychology, Social Work, Early Education Specialists, Speech Therapy, Physical Therapy, and

Occupational Therapy); Endodontics; Family Advocacy; Family Health; Flight and

Operational Medicine; General Dentistry; General Surgery; Health Promotions; Immunization;

Internal Medicine; Laboratory; Mental Health; Neurology; Nutritional Medicine;

Obstetrics/Gynecology; Optometry; Oral Surgery; Orthodontics (limited eligibility);

Orthopedic Surgery; Otolaryngology (ENT); Pain Management; Pathology; Pediatrics;

Pediatric Dentistry; Periodontics; Pharmacy; Physical Medicine (Physical and Occupational

Therapy); Plastic Surgery (on a periodic basis); Podiatry; Prosthodontics; Public Health; and

Urology.

9.1.2. Ambulatory Procedures Unit (APU)/Peri-Anesthesia Care Unit (PACU) provides same-day (less than 24 hours) surgical service support utilizing 6 beds.

9.1.3. Operating Suite with three ORs.

9.2. Inpatient Services. The 48 MDG has a total of 20 beds on two inpatient units.

9.2.1. Multiservice Unit (MSU) provides care for acute, chronic, surgical, and pediatric patients on 7 MSU beds. Additionally, there are 3 co-located Special Care Unit (SCU) beds that can be utilized for a variety of seriously ill medical and surgical patients on a case-by-case basis.

9.2.2. Maternal Child Unit (MCU) has 10 inpatient beds that include 7 labor, delivery, recovery, postpartum (LDRP) beds and 3 surgical postpartum recovery beds; additionally, there are 2 triage beds; 11 infant cribs; and a 3-bed observation nursery.

9.2.3. One dedicated Cesarean-Section Operating Room.

10. 48 MDG Annual Workload Data.

10.1. Average annual outpatient visits: 123,000

10.2. Average annual surgeries: 1,700

10.3. Average annual deliveries: 500

10.4. Average annual number of prescriptions: 291,000

10.5. Average annual number of laboratory procedures: 234,000

10.6. Average annual number of dental weighted values: $13,200,000

10.7. Average number of radiology procedures: 18,000

11. Planning and Designing Services. The 48 MDG’s vision, mission, and goals form the

6 48 MDGI 44-147 17 OCT 2016

cornerstone of planning and designing services. Every facet of the organization strives, in concert, to support other sections, find opportunities to improve services, facilitate top quality patient care, and maintain a professional level of excellence for the patients. The 48 MDG leaders embrace and comply with DoD, Air Force and TJC standards. The leaders develop interrelated processes, policies, and procedures to ensure the standards are met.

12. Patient-Focused Functions. The patient-focused functions consist of: Ethics, Rights, and

Responsibilities (patient rights); Provision of Care, Treatment, and Services (patient treatment);

Medication Management (medication safety); and Surveillance, Prevention, and Control of

Infection (infection control). The processes in each function are integral to the provision of high quality patient care consistent with the National Standards of Practice Guidelines.

12.1. Ethics, Rights, and Responsibilities.

12.1.1. The use of chaperones. The 48 MDG respects the dignity, worth, and personal feelings of patients. Every effort will be made to protect the privacy and respect the personal wishes of patients.

12.1.1.1. Responsibilities: Flight Commanders, Flight Chiefs, Element Chiefs, and

Noncommissioned Officers in Charge (NCOIC) will ensure personnel comply and are properly trained to perform chaperone duties and supervise chaperones. This will include the identification and reporting of suspected misconduct of chaperones.

12.1.1.2. General Examination Requirements: When a patient is required to disrobe, the nature and purpose of the examination or treatment and the extent and purpose of disrobing will be communicated to the patient. When disrobing is required, strict privacy for both disrobing and robing will be assured. Privacy will be assured for examination and treatment.

12.1.1.3. Chaperone Requirements: Whenever a patient of either sex is required to disrobe for an examination or procedure, they must be given the opportunity to have a chaperone present during examination. In light of the current DoD position on non-discrimination based on sexual orientation, when an exam requires the presence of a chaperone, the patient will be asked whether they would prefer a male or female chaperone, and the MTF will attempt to accommodate the request as long as staffing allows.

12.1.1.3.1. All patients must have a chaperone present during the following procedures:

12.1.1.3.1.1. Genital, vaginal, rectovaginal, rectal, breast, and total integumentary examinations.

12.1.1.3.1.2. Examination of any patient suspected to be the victim of a sexual abuse or rape.

12.1.1.3.2. Patients undergoing sedation, either in a conscious or unconscious state, 48 MDGI 44-147 17 OCT 2016 7 requiring monitoring will have a staff member/chaperone.

12.1.1.3.3. Practitioners also have the right to have a chaperone present if they feel it is professionally prudent. Should the patient refuse a chaperone for routine non-emergent matters, the provider has the right to refuse to examine the patient. This will be documented in the medical record. In such cases, the provider must arrange care for the patient with another provider able to provide appropriate examination and treatment.

12.1.1.3.4. Chaperones will be hospital personnel or appropriately trained Red

Cross volunteers.

12.1.1.3.5. During emergencies or life-threatening situations, medical personnel are not required to offer the presence of a chaperone.

12.2. Provision of Care, Treatment, and Services. The care, treatment, and services provided at the 48 MDG are through the successful coordination and completion of a series of processes that include appropriate initial assessment of needs; development of a plan for care, treatment, and services; the provision of care, treatment, and services; ongoing assessment of whether the care, treatment, and services provided are meeting the patient’s needs, and either the successful discharge of the patient or referral or transfer of the patient for continuing care, treatment, and services.

12.2.1. Planning and Providing Care, Treatment and Services. The 48 MDG has a process

IAW Health Insurance Portability and Accountability Act (HIPAA) guidelines to receive or share relevant patient information to facilitate appropriate coordination and continuity when patients are referred to other care, treatment, and service providers. Through the TRICARE

Overseas Program, the 48 MDG has a robust provider network that includes licensed independent practitioners as well as hospitals.

12.2.2. Coordination and Continuity of Care to Include Discharge and Transfer. Utilization

Management assists with coordinating patient care activities related to Utilization

Management, Discharge Planning, and Case Management. Patients may be transferred to continental Europe or the US for care, treatment and/or services vice host-nation providers and hospitals, if required.

12.2.3. Patient Education, Nutritional Care, and Pain Management. The 48 MDG supports patient and family education activities to improve overall patient health outcomes by promoting healthy behaviors, supporting recovery and speedy return to function when health is not at its optimum and appropriately involving individuals in their care and care decisions.

In addition, a disease manager helps standardize inpatient/outpatient and community health education.

12.2.3.1. It is vital patients are educated on the safe and effective use of medical equipment and supplies to include demonstration of proper use with validation by return

8 48 MDGI 44-147 17 OCT 2016

demonstration, maintenance instructions and resource name for obtaining additional information. Outside vendors will educate patients on any contracted equipment from that particular company.

12.2.3.2. 48 MDG staff will educate patients on rehabilitation techniques to help them reach their maximum independence possible.

13. The Organization Functions. The organization functions include: Leadership, Access to

Clinical Services; Coordinating and Integrating Care; Communication; Improving Organization

Performance; Management of the Environment of Care; Management of Human Resources; and

Management of Information.

13.1. Leadership.

13.1.1. Communication and Collaboration. The 48 MDG leadership is responsible for governance and management and collaborate in decision-making with other appropriate personnel. The 48 MDG Commander (CC), 48 MDG Deputy Commander (CD), squadron commanders, functional advisors, flight commanders, and element chiefs will collaborate in the development of group-wide patient care programs, policies and procedures that describe how patient care needs will be assessed and met; development and implementation of the hospital’s plan for providing patient care; decision-making structures and processes; and implementation of an effective and continuous program to measure, assess and improve performance to ensure the top-notch delivery of healthcare. This collaboration is done informally and formally through the committee structure IAW MDGI 44-134.

13.2. Access to Clinical Services.

13.2.1. Times of Care and Primary Care Manager (PCM) Contact. In general, routine medical and dental services will be provided Monday through Friday from 0730 to 1630, except for holidays, goal days, family days and monthly group training days. Family Health and

Pediatrics start seeing patients at 0700. The 48 MDG provides emergency services 24 hours a day, 7 days a week. Patients seeking clinical services may gain access through the clinic in which they are assigned. All clinic services will be provided by appointment only at 01638-

52-8010, unless otherwise specified. Secure Messaging via MiCare between the patient and the provider-led team can also be utilized to communicate non-urgent matters. Tricare On

Line (TOL) is also another web-based application that can allow patients to book appointments with their PCM, as well as to access results of ancillary tests that may have been performed in an MTF. Access to specialty services is by referral from the patient’s PCM. The PCMs are assigned to the following clinics: Family Health, Flight and Operational Medicine, Internal

Medicine, and Pediatrics.

13.2.2. Patient Population Served (beneficiary types). Routine care is available and prioritized

IAW AFI 41-210, based on the categories of Military Health System (MHS) beneficiaries.

13.2.3. Access to Care. The 48 MDG follows the TRICARE Prime access standards.

48 MDGI 44-147 17 OCT 2016 9

13.2.3.1. Specialty Referrals. The PCM determines the need for specialty referrals. All attempts are made to schedule specialty referral appointments within 28 days. As the 48

MDG falls under private pay for referral care, access is faster than for NHS patients.

However, due to long waits in the NHS, those waiting for specialty care appointments in the NHS may expect to wait longer than 30 days due to the high demand on the system.

13.2.4. The delivery of patient care at the point of service is further prioritized on the basis of an assessment of the severity of the patient’s illness.

13.2.5. A Nurse Advice Line is provided through a centrally contracted service to support

TRICARE Eurasia-Africa beneficiaries in accessing nurse advice 24 hours/7 days a week by calling a toll-free phone number.

13.3. Coordinating and Integrating Care.

13.3.2. Patient care services are integrated throughout the 48 MDG. Leaders at all levels are responsible for the appropriate integration of patient care services and to accomplish these as seamlessly as possible. Integration enables specific services to coordinate processes with those of other services and participate in concerted efforts to improve the 48 MDG’s overall performance.

13.3.3. Patient Flow. Leaders assess and mitigate impediments to efficient patient flow across the 48 MDG to enhance patient safety and the delivery of quality healthcare.

13.3.4. Patients with comparable needs receive the same standard of care, treatment, and services throughout the 48 MDG. Care will be rendered without regard to ability to pay or source of payment. The 48 MDG will assure uniform performance of care through organizational-wide mechanisms for the identification of key functions and processes. These include, but are not limited to: use of internal and external benchmarks; use of clinical practice guidelines; peer review processes; medical record review processes; organization-wide instructions on key functions and processes; standardized training and education of non-credentialed staff members; credentialing of healthcare providers; ongoing performance improvement initiatives; patient safety initiatives; and customer satisfaction.

13.3.5. Communication.

13.3.5.1. Communication and transfer of information between and among healthcare professionals is essential to seamless, safe, effective processes to deliver top-quality healthcare. Internal methods used for communication and transfer of patient information will include, but are not limited to, face-to-face discussions, telephonic discussions, HIPAA protected e-mail communication, and the consultation module in Armed Forces

Health Longitudinal Technology Application (AHLTA) or Composite Health Care

System (CHCS).

13.3.5.2. There are several mechanisms to communicate general, relevant information

10 48 MDGI 44-147 17 OCT 2016

throughout the hospital in a timely manner. Examples include, but are not limited to:

commander’s calls, e-mail, telephone recalls, tiered verbal notifications using the chain of command, group, and section meetings. In addition, the 48 MDG/CC briefs incoming personnel on the 48 MDG’s mission and vision during the MDG’s Newcomers

Orientation and has weekly extended staff or “stand-up” meetings. Mechanisms to share information with personnel across the Wing include: the Wing Newcomers Orientation programs, as well as various Public Affairs venues, the Wing Information Dissemination

Tool Channel via television, and wing magazines (both on-line and hard copy).

13.3.6. 48 MDG Organ Donation Program. The 48 MDG networks with the host nation to provide an Organ Donation Program.

13.3.7. Clinical Practice Guidelines (CPGs): The 48 MDG embraces the use of research-based and peer-reviewed CPGs to enhance the quality of patient care by reducing practice variance.

Many tools and programs are available to: assess population health status, risks, and preventive medicine needs; enhance the delivery of preventive services; manage disease and other medical conditions; and evaluate health-status improvement and delivery-system effectiveness and efficiency. CPGs help providers, staff, and patients in making decisions about preventing, diagnosing, treating, and managing selected conditions. CPGs can be used in designing clinical processes or checking the design of existing processes.

13.4. Improving Organizational Performance.

13.4.1. Performance improvement is a continuous activity and involves measuring the function of important processes and services. The 48 MDG leadership is committed to establishing and maintaining an environment which encourages improvement at all levels. The leaders establish a planned systematic and organization-wide approach to set priorities and ensure the scope of care and services across the organization work collaboratively to enhance performance. Larger

Continuous Process Improvement (CPI) projects are reported annually by each squadron in the

Executive Committee (EXCOM). The Executive Compliance Committee (ECC) provides a forum for the Executive Committee to track program compliance and to identify areas needing improvement. Its functions are addressed in MDGI 44-134, Committes, Councils and

Functions. Initiatives include clinical and management improvement and are executed within the framework of the organization’s strategic plan and vision, mission, and goals. These changes will be incorporated into new and existing work processes, products or services and performance will be monitored to ensure the improvements are sustained. An important aspect of improving organization performance is effectively reducing factors that contribute to unanticipated adverse events and/or outcomes.

13.4.2. Patient Safety. Leaders are committed to a strong patient safety program. The Patient

Safety Function’s purpose is to continuously improve patient safety by identifying areas of weakness and vulnerability and by developing and implementing strategies to strengthen our weaknesses and minimize vulnerabilities in order to ensure the highest quality and safest healthcare possible. It provides oversight for the education of 48 MDG personnel on all

National Patient Safety Goals.

48 MDGI 44-147 17 OCT 2016 11

13.4.3. The 48 MDG performance improvement model is the Continuous Process

Improvement (CPI) 8-Step Practical Problem Solving Method (Figure 1). The priority is on data collection and metrics that are most meaningful to the provision of quality patient care and critical to the functioning of the organization and may include high-risk, high-volume and problem-prone processes, compliance issues, and/or strategic challenges .

13.4.4. Data Collection. The 48 MDG collects data and information about the individual patient; groups of patients; the care provided; care referred to other healthcare organizations;

the results of care; and the performance of the organization.

13.4.5. Performance Measures and Data Analysis. Performance measures will include those required by the AFMS, HQ USAFE, the USAFE Command Surgeon’s office, the 48 FW and the 100 ARW, as well as those measures required to comply with TJC standards and the 48

MDG Strategic Plan. Data will be analyzed within the appropriate committees and councils.

Opportunities to improve will be identified and used to enhance organizational performance, as indicated.

13.4.6. Notice To Airman (NOTAMS) and TJC’s Sentinel Alerts. NOTAMS are messages from the Air Force Surgeon General that share important lessons learned throughout the

AFMS. NOTAMS are assigned via Swank Health to the executive committee members and to the respective members for which it is relavant. Sentinel Alerts are presented by e-mail and reviewed in the MDG/CC’s weekly stand-up meetings.

13.5. Management of the Environment of Care (EOC).

Step 1

• Define the Problem

Step 2

• Breakdown the Problem & Identify Performance Gap

Step 3 • Set Measureable Improvement Target

Step 4 • Determine the Root Cause

Step 5

• Develop Countermeasures

Step 6

• See Countermeasures Through

Step7

• Monitor Process and Confirm (Measure) Results

Step 8 • Standardize, Share and Sustain Successful Processes

Figure 1. 48th Medical Group Continuous Process Improvement Model

12 48 MDGI 44-147 17 OCT 2016

13.5.1. The 48 MDG leaders will ensure a safe, aesthetic, and functional environment for patients, staff, and visitors through a variety of processes. EOC references used to implement plans and processes will include: TJC’s standards, AF standards, EOC Committee guidance, and MDGIs. Personnel receive training in applying EOC instructions and plans through a variety of mechanisms that may include, but are not limited to: Newcomers’ Orientation, annual training, e-mail, Commander’s Calls, committee and working group meetings, as well as upon request.

13.6. Management of Human Resources.

13.6.1. The goal of identifying and allocating resources is to assure sufficient competent staffing, equipment, supplies, and infrastructure to provide the scope of care required and expected by the community through direct care and appropriate referrals. Cross utilization of personnel adds flexibility and depth to the 48 MDG. Staff members who are pulled to work in other areas will be trained and oriented to new tasks and responsibilities before working independently.

13.6.2. Orientation, education and on-going training of staff is accomplished through, but not limited to: Newcomers’ Orientation, unit-specific training, annual training, professional staff meetings, Commander’s Call briefings, the 48 MDG Intranet and the 48 MDG’s common computer drive. All credentialed providers receive additional Medical Staff orientation from the SGH.

13.7. Management of Resources.

13.7.1. The goal of resource optimization is to maximize the allocation of staff, materials and financial resources to provide the same level of quality care throughout the organization.

13.7.2. Types of staff assigned. The 48 MDG is staffed by Active Duty (AD) military personnel; Department of Defense (DoD) civilian employees; Local National Direct Hire

(LNDH) employees, employees of the Ministry of Defence (MOD), and contract personnel.

Volunteers generally serve under the auspice of the American Red Cross (ARC). Non-privileged clinical staff includes registered nurses, clinical laboratory officers, public health officers, dental hygienists, enlisted medical technicians and civilian equivalents.

13.7.3. Manpower and Personnel. Manpower authorizations (military and civilian) are allocated on the basis of the Medical Planning and Programming Guidance (MPPG) process.

Budgeting occurs through the development and submission of an annual financial plan to the

Air Force Medical Operations Agency. This is the basis for year-to-year financial programming authority, once the federal budget is approved by Congress. Recommendations for manpower and financial programmatic adjustments may occur through the Executive

Committee’s oversight and the Manpower Steering Function. Military personnel assignments occur through MDG dialogue the Air Force Personnel Center based on requirements and authorizations. Placement decisions within the 48 MDG’s squadrons, flights, and elements is based on Air Force Personnel Center actions and input from 48 MDG leaders.

48 MDGI 44-147 17 OCT 2016 13

13.7.4. Practice Parameters For Privileged and Non-Privileged Providers.

13.7.4.1. Privileged providers practice within their scope of approved privileges.

13.7.4.2. Registered Nurses (RN). The practice of nursing is defined by state licensing acts and standards set by national professional organizations. The practice of professional nursing means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based on principles of psychological, biological, physical, prevention and social sciences. The nursing process provides a framework for nursing practice to ensure quality patient care. RNs will be responsible and accountable for planning, providing, delegating, and coordinating nursing care and will adhere to established standards of nursing practice and patient care. Specific job descriptions and performance standards will clearly and specifically delineate responsibilities.

13.7.4.3. Licensed Practical Nurses (LPN) and Aerospace Medical Service Technicians

(4N0XX). The practice of nursing by a LPN or medical technician is acceptable within their scope of practice and under the supervision of a RN or credentialed provider.

Exceptions to this may be permitted through training/competency verification. Refer to

MDGI 41-112, Staff Education and Training. Parts of the nursing process that may be completed by a LPN or medical technician include collection of data such as vital signs, chief complaints, allergies, current medications, and intake and output information. LPNs and medical technicians will document their findings.

13.7.4.4. Registered Dental Hygienist (RDH). RDHs are vital members of the oral health team providing essential preventive care and services that are integral to the maintenance of the oral and systemic health of our patient population. RDHs are authorized to provide routine preventive dental care to include subgingival scaling and root planning procedures to eligible beneficiaries in a variety of clinical settings. With additional specific skills training and credentialing, RDHs can contribute to the efficiency and productivity of the dental clinic by performing expanded functions such as administration of local anesthesia and the monitoring of nitrous oxide inhalation sedation and palliative temporization of carious teeth or fractured restorations in preparation for restorative care by a dentist.

RDHs can provide individualized disease prevention education and oral hygiene instructions to patients. They can also manage community-based oral health education and training programs.

13.7.4.5. Ancillary support personnel in clinical areas such as the laboratory, pharmacy, diagnostic imaging, and nutritional medicine will perform their duties within their scope of practice as defined within their educational background and/or within the specific specialty training standard.

13.7.5. Mechanisms to Ensure Competency of Those Providing Patient Care.

13.7.5.1. Privileged providers will complete Newcomers Orientation, Medical Staff

Orientation, and unit-specific orientation. Privileges will be requested at the 48 MDG

14 48 MDGI 44-147 17 OCT 2016

IAW AFI 44-119.

13.7.5.2. Non-privileged RNs and LPNs will complete Newcomer’s Orientation, and unit-specific orientation. A preceptor will be assigned to orient, evaluate, and assist in completing all required skills and successfully completing unit-specific orientation. All nurses will maintain a current license at all times. This will be verified, maintained and monitored by the Education and Training Office. Refer to MDGI 41-112, and pertinent sections of AFI 44-102, Medical Care Management, and AFI 41-106, Medical Readiness

Program Management for additional information.

13.7.5.3. Enlisted Personnel. Guidelines for scope of practice for all enlisted personnel are outlined in their respective military Master Job Qualifications Standards and/or Career

Field Education and Training Plan (CFEPT).

13.7.5.3.1. A training plan based on local and career broadening training needs shall be established by the supervisor.

13.7.5.3.2. 4N0XXs and dental technicians will perform their duties within their scope of practice as outlined in their military training records. Exceptions to this must have a USAFE waiver.

13.7.5.3.3. All 4N0XXs assigned to the 48 MDG shall maintain certification as a

Nationally Registered Emergency Medical Technician (NREMT).

13.7.5.3.4. Independent Duty Medical Technicians (IDMTs) shall have an initial specialized training program accomplished and then maintain annual certification.

They do not practice independently where physicians are assigned. They do function as IDMTs when deployed to a medical aid station. IDMTs will complete their annual training under the direct supervision of a physician.

13.7.5.4. Contract personnel shall follow the same standards of practice required for equivalent DoD personnel in their specialty.

13.7.5.5. Personnel may be used cross-functionally after the appropriate training and if it is within their scope of practice.

13.7.5.6. Volunteers will complete Newcomer's Orientation prior to reporting to their volunteer duty section.

13.7.5.7. Individual Mobilization Augmentees (IMAs) and other reserve component or temporary-duty military personnel shall follow the same requirements as their AD counterparts, except for variations in handling of credentials files as may be specified in

AFI 44-119.

13.7.6. Staffing Plan to Ensure Quality Patient Care.

48 MDGI 44-147 17 OCT 2016 15

13.7.6.1. Staffing requirements for all areas within the 48 MDG are outlined in the Unit

Manning Document maintained by Resource Management (RM).

13.7.6.2. Privileged Providers. Flight commanders will ensure sufficient providers are assigned to specific clinics and available for duty. Leaves and projected absences shall be coordinated through the flight commander to the appropriate squadron commander, as necessary.

13.7.6.3. Nursing Staffing. On a day-to-day basis, the scope of care frames the requirements for nursing service resources and drives staffing patterns. Flight commanders, element chiefs, nurse managers, and flight chiefs/NCOICs are responsible to review workloads and realign personnel as required. Nursing leaders in flights shall validate this daily. The inpatient nursing leaders review census and acuity daily for placement of day-to-day staffing on inpatient care units. Collaboration among organization leaders in the placement of staff ensures patient needs are met. Staffing adjustments are made to provide for required care; flight commanders or element leaders are notified whenever surges in patients or patient acuity occur. The in-house supervisor is available after duty hours or holidays as a resource. The SGN is available 24/7 as an expert and/or resource.

13.7.6.4. Ancillary services (laboratory, pharmacy, diagnostic imaging, and nutritional medicine) shall provide personnel on-duty or on-call to support patient care demands.

13.7.6.5. Administrative personnel may be assigned to inpatient units and the APU to handle non-clinical duties.

13.7.7. Cross Utilization of Personnel.

13.7.7.1. Privileged Providers. When circumstances dictate, providers may be required to assist other areas within the 48 MDG in the provision of medical care consistent with privileging and current competency.

13.7.7.2. RNs, LPNs and 4N0XXs will assist in areas commensurate with their education, training and experience. Nursing staff members will not be pulled to work in any patient care area as a primary staff member unless they have documented training, experience, and area competency. However, they may assist with duties they normally perform under the supervision of a permanently assigned staff member.

13.8. Management of Information. The provision of healthcare is a complex endeavor that is highly dependent on accurate and timely information. Information management, including health records and data quality, is a critical linchpin between those providing healthcare and those receiving the care.

14. Attachments 2 through 40 provide details for the 48 MDG sections that provide patient services. Attachment 41 provides the 48 MDG Organizational Chart.

16 48 MDGI 44-147 17 OCT 2016

PAMELA D. SMITH, Colonel, USAF, MC, CFS

Commander, 48th Medical Group

41 Attachments

1. Glossary Of References And Supporting Information

2. Alcohol And Drug Abuse Prevention And Treatment (ADAPT)

3. Allergy Clinic

4. Ambulatory Procedure Unit (APU)

5. Anatomic Pathology

6. Anesthesiology

7. Cardiopulmonary Laboratory

8. Dentistry

9. Dermatology Clinic

10. Diagnostic Imaging

11. Education And Training

12. Educational And Developmental Intervention Services (EDIS)

13. Emergency Services (ES)

14. Family Advocacy Program (FAP)

15. Family Health Clinic (FHC)

16. Flight and Operational Medicine (FOM)

17. General Surgery

18. Health Promotion (HP)

19. Immunizations Clinic

20. Internal Medicine (IM)

21. Laboratory

22. Maternal Child Unit (Inpatient Obstetrics) (MCU)

23. Medical Management (MM)

24. Mental Health Clinic (MHC)

25. Multiservice Unit (MSU)

26. Neurology

27. Nutritional Medicine

28. Obstetrics/Gynecology Clinic (OB/GYN)

29. Operating Room (OR) Services

30. Optometry

31. Orthopedic/Podiatry

32. Otolaryngology/Audiology

33. Pain Management

34. Patient Administration

35 Pediatric Clinic

36. Pharmacy

37. Physical Medicine (Physical Therapy (PT)/Occupational Therapy (OT))

48 MDGI 44-147 17 OCT 2016 17

38 Public Health (PH)

39. TRICARE

40. Urology

41. 48 MDG Organizational Chart

18 48 MDGI 44-147 17 OCT 2016

Attachment 1

GLOSSARY OF REFERENCES, SUPPORTING INFORMATION, AND

ABBREVIATIONS/ACRONYMS

References

Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191)

Privacy Act of 1974, 5 U.S.C. § 552a

Title 10, United States Code, Section 1102, Confidentiality of medical quality assurance records: qualified immunity for participants

DoDD 5400.11, DoD Privacy Program, 29 October 2014

DoDI 6025.18, Privacy of Individually Identifiable Health Information in DoD Health Care

Programs, 2 December 2009

AFI 33-332, The Air Force Privacy and Civil Liberties Program, 12 January 2015

AFI 33-360, Publications and Forms Management, 1 December 2015

AFI 36-2905, Fitness Program, 21 October 2013

AFI 38-101, Air Force Organization, 16 March 2011

AFI 40-101, Health Promotion, 17 October 2014

AFI 40-104, Health Promotion Nutrition, 17 October 2014

AFI 40-301, Family Advocacy, 16 November 2015

AFI 41-106, Medical Readiness Program Management, 22 April 2014

AFI 41-201, Managing Clinical Engineering Programs, 15 October 2014

AFI 41-210, TRICARE Operations and Patient Administration Functions, 6 June 2012

AFI 44-102, Medical Care Management, 17 March 2015

AFI 44-119, Medical Quality Operations, 16 August 2011

AFI 44-171, Patient Centered Medical Home Operations, 28 November 2014

AFI 44-173, Population Health Management, 19 November 2014

AFI 44-176, Access to Care Continuum, 30 October 2014

AFI 47-101, Managing Air Force Dental Services, 20 February 2014

AFI 48-110, Immunizations and Chemoprophylaxis for the Prevention of Infectious Diseases, 7

October 2013

AFI 48-116, Food Safety Program, 19 August 2014

AFI 48-123, Medical Examinations and Standards, 5 November 2013

AFI 90-505, Suicide Prevention Program, 6 October 2014

AFJI 44-117, Ophthalmic Services, 14 May 2015

AFMAN 41-120, Medical Resource Management Operations, 6 November 2014

AFMAN 44-144, Nutritional Medicine, 20 January 2016

48 MDGI 44-132, Identification and Instruction on Potential good Drug Interaction, 7 May

48 MDGI 44-134, Committes, Councils and Functions, 26 February 2013

48 MDGI 44-158, Outpatient Nutritional Screening, Nutritional Assessment and Medical

Nutritional Therapy, 19 March 2013

48 MDGI 44-177, Labor and Delivery Unit Diversion Plan, 17 May 2013

American Academy of Audiology

American Academy of Child and Adolescent Psychiatry

48 MDGI 44-147 17 OCT 2016 19

American Academy of Familiy Physicians

American Academy of Pediatrics

American Occupation Therapy Association

American Physical Therapy Association

American Psychological Association

American Society of Addiction Medicine Patient Placement Criteria for the Treatment of

Substance-Related Disorders (ASAM-PPC-2R)

American Society of Post Anesthesia Nurses Standards

American Speech Language Hearing Association

Association of Operating Room Nurses Standards

Code of Ethics for the Profession of Dietetics, The American Dietetic Association

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

The Joint Commission, Comprehensive Accreditation Manual for Hospitals: The Official

Handbook

Manual of Clinical Dietetics, The American Dietetic Association

Social Work National Association of Social Workers

Uniform Code of Military Justice

Adopted Form

AF Form 847, Recommendation for Change of Publication

Abbreviations and Acronyms

4NOXX - Aerospace Medical Service Technician

A&D - Admissions and Dispositions

AAFES - Army & Air Force Exchange Service

AB - Air Base

ACOG - American College of Obstetrians and Gynecologists

ACSCL - Aircrew Soft Contact Lens

AD - Active Duty

ADAPT - Alcohol And Drug Abuse Prevention And Treatment

ADHD - Attention Deficit Hyperactivity Disorder

AE - Aeromedical Evacuation

AF - Air Force

AFI - Air Force Instruction

AFMAN - Air Force Manual

AFPD - Air Force Policy Directive

AFMS - Air Force Medical Service

AFRIMS - Air Force Records Information Management System

AFSC - Air Force Specialty Code

AHLTA - Armed Forces Health Longitudinal Technology Application

AMDS - Aerospace Medicine Squadron

AND - Academy of Nutrition and Dietetics

AOP - Aerospace Operational Physiology

APU - Ambulatory Procedure Unit

20 48 MDGI 44-147 17 OCT 2016

APV - Ambulatory Procedural Visit

ARC - American Red Cross

ASA - American Society of Anesthesiologists

AWHONN - Association of Women’s Health, Obstetric and Neonatal Nurses

BE WELL - Balanced Eating, Workout Effectively, Live Long

BHOP - Behavioral Health Optimization Program

CAP - College of American Pathologists

CC - Commander

CD - Deputy Commander

CDC - Centers for Disease Control and Prevention

CDC - Child Development Center

CHCS - Composite Health Care System

CM - Case Manager

CONUS - Continental United States

CSC - Case Study Committee

CSW - Combat Support Wing

CT - Computerized Tomography

DM - Disease Management

DNIF - Duty Not Involving Flying

DoD - Department of Defense

DoDDS - Department of Defense Dependents Schools

ECC - Executive Compliance Committee

EDIS - Educational and Developmental Intervention Services

EFMP-M - Exceptional Family Member Program-Medical Component e.g. - Exempli Gratia = for example

EIS - Early Intervention Services

EKG - Electrocardiogram

EMEDS - Expeditionary Medical Support

ENT - Ears, Nose, And Throat (Otolaryngology)

EOC - Environment of Care

ES - Emergency Services etc. - et cetera = and so forth

FAA - Federal Aviation Administration

FAP - Family Advocacy Program

FDA - Food and Drug Administration

FHC - Family Health Clinic

FW - Fighter Wing

GYN - Gynecology or Gynecological

HAI - Healthcare Associated Infection

HCI - Health Care Integrator

HIPAA - Health Insurance Portability and Accountability Act

HP - Health Promotion

HQ - Headquarters

IAW - In Accordance With

IBHC - Internal Behavioral Health Consultant

IBT - Immunization Backup Technician

48 MDGI 44-147 17 OCT 2016 21

IC - Infection Control

ICE - Interactive Customer Evaluation

IDMT - Independent Duty Medical Technician

IDS - Integrated Delivery System i.e. - id est = that is (to say); in other words

IEP - Individual Education Plan

IFSP - Individual Family Service Plan

IM - Information Management

IMA - Individual Mobilization Augmentee

IMC - Internal Medicine Clinic

LRMC - Landstuhl Regional Medical Center

LDRP - Labor, Delivery, Recovery, Postpartum

LEEP - Loop Electrosurgical Excision Procedure

LPN - Licensed Practical Nurse

LSMTF - Limited Scope Medical Treatment Facility

MCU - Maternal Child Unit

MDG - Medical Group

MDGI - Medical Group Instruction

MEB - Medical Evaluation Board

MH - Mental Health

MHC - Mental Health Clinic

MHS - Military Health System

MII - Medical Incident Investigation

MM - Medical Management

MOD - Ministry of Defense

MRI - Magnetic Resonance Imaging

MSU - Multiservice Unit

MTC - Medical Training Complex

MTF - Military Treatment Facility

NCOIC - Noncommissioned Officer in Charge

NHS - National Health Service

NMF - Nutritional Medicine Flight

NOTAM - Notice To Airman

NPSP - New Parent Support Program

NREMT - Nationally Registered Emergency Medical Technician

OB - Obstetrical

OI - Operating Instruction

OPR - Office of Primary Responsibility

OR - Operating Room

OSHA - Occupational Safety and Health Administration

PACU - Post Anesthesia Care Unit

PCM - Primary Care Manager

PCMH - Patient Centered Medical Home

PFB - Pseudofolliculitis Barbae

PHA - Preventive Health Assessment

PHI - Protected Health Information

22 48 MDGI 44-147 17 OCT 2016

POCT - Point Of Care Test

PRP - Personnel Reliability Program

P&T - Pharmacy and Therapeutics Review Function

RAF - Royal Air Force

RM - Resource Management

RN - Registered Nurse

SCU - Special Care Unit

SGA - Administrator

SGB - Senior Biomedical Sciences Corps Executive

SGD - Chief, Dental Services

SGH - Chief of the Medical Staff

SGN - Chief Nurse

SGP - Chief, Aerospace Medicine

SI - Sacroiliac

SI - Seriously Ill

SME - Squadron Medical Element

TDY - Temporary Duty

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