HT0011-20-R-0043 HFAS PWS Attachment 2f - DHA PM 6025.13 CQM in the MHS, Vol 5, Accreditation and Compliance.pdf

Defense Health Agency

PROCEDURES MANUAL

NUMBER 6025.13, Volume 5 August 29, 2019

Medical Affairs

SUBJECT: Clinical Quality Management in the Military Health System Volume 5: Accreditation and Compliance

References: See Enclosure 1.

1. PURPOSE. This Defense Health Agency-Procedures Manual (DHA-PM), based on the authority of References (a) and (b), and in accordance with the guidance of References (c) through (q), establishes the Defense Health Agency’s (DHA’s) procedures to assign responsibilities and establish procedures for managing Clinical Quality Management (CQM) in the Military Health System (MHS). This DHA-PM replaces, in full, the contents of the DoD Manual 6025.13 (Reference (e)), which is targeted for cancellation. This DHA-PM, replaces, in Volume 2, the full contents, unless otherwise stated, of the following memorandums, which are targeted for cancellation: Assistant Secretary of Defense for Health Affairs Memorandum, "Policy on Reporting Joint Commission on Accreditation of Healthcare Organizations- Reviewable Sentinel Events in the Military Health System," July 13, 2004 (Reference (h));

Assistant Secretary of Defense for Health Affairs Memorandum, "Amplifying Guidance Relating to the Reporting of Sentinel Events and Personally Identifiable Information Breaches to the Office of the Assistant Secretary of Defense (Health Affairs)," February 13, 2012 (Reference (i)) [as related to the reporting of sentinel events only]; and Assistant Secretary of Defense for Health Affairs Memorandum, "Medical Quality Assurance and Clinical Quality Management in the Military Health System Sentinel Event and Root Cause Analysis Process Improvements," March 12, 2015 (Reference (j)).

2. APPLICABILITY. This DHA-PM applies to:

a. OSD, Military Departments, Office of the Chairman of the Joint Staff and the Joint Staff, Combatant Commands, Office of the Inspector General of the DoD, Defense Agencies, DoD Field Activities, and all other organizational entities within the DoD (referred to collectively in this DHA-PM as the “DoD Components”);

b. The entire MHS, including each DoD Military Medical Treatment Facility (MTF) and all other healthcare provided by the MHS;

DHA- PM 6025.13, Volume 5

c. Uniformed services personnel of the active and reserve components (including National Guard personnel in a Federal duty status), civilian, contract, volunteer, and other medical or dental healthcare providers who are assigned to and deliver healthcare; and

(1) Credentialed healthcare providers who are members of the Army National Guard or the Air National Guard, while working in a non-federal status (Reference (k) are subject to the procedures, policies, and authorities, as prescribed by their respective Army Regulation Reference (l)) and Air Force Instruction (Reference (m)), or as defined in the policies, rules, procedures, and laws of the State, territory, or District of Columbia in which they are credentialed and/or privileged;

(2) Trainees who have been granted clinical privileges outside the training program when patient safety concerns arise;

d. Managed care support contractors (MCSCs), designated providers, and overseas contractors, consistent with their respective contracts awarded by the DoD.

3. POLICY IMPLEMENTATION. It is DHA’s instruction, pursuant to authority delegated in Reference (b) and based on authorities in Reference (a) through (q), that:

a. Establishes CQM procedures in the MHS to provide an organized structure for an integrated framework of programs to objectively define, measure, assure, and improve the quality of care received by MHS beneficiaries.

b. Strengthens MHS CQM accountability, transparency, and standardization in the MHS.

c. Affirms the MHS’s unwavering commitment to quality healthcare for our beneficiaries, joint healthcare teams, and Combatant Commands across the globe, through CQM.

4. CANCELLED DOCUMENTS. This DHA-PM replaces, in Volume 2, the full contents of DHA-Procedural Instruction (DHA-PI) 6200.01, "Comprehensive Infection Prevention and Control (IPC) Program," April 24, 2017 (Reference (n)), which is being cancelled.

5. RESPONSIBILITIES. See Enclosure 2 of Volume 1.

6. PROCEDURES. Procedures specific to each program within the MHS CQM are addressed in Volumes 2–7 of this DHA-PM.

7. INFORMATION REQUIREMENTS. CQM uses several data capture, analysis, reporting, and decision support tools for patient safety, clinical quality assurance, and improvement to include the electronic medical record, databases such as the Joint Centralized Credentials Quality Assurance System (JCCQAS), and the Joint Patient Safety Reporting (JPSR), data visualization and report tools on CarePoint (a SharePoint platform), and more.

8. RELEASABILITY. Cleared for public release. This DHA-PM is available on the Internet from the Health.mil site at: http://www.health.mil/dhapublications.

9. EFFECTIVE DATE. This DHA-PM:

a. Is effective on October 01, 2019.

b. Will expire 10 years from the date of signature if it has not been reissued or cancelled before this date, in accordance with Reference (c).

Enclosures

1. References

2. Accreditation and Compliance Glossary

4 TABLE OF CONTENTS

TABLE OF CONTENTS

ENCLOSURE 1: REFERENCES

ENCLOSURE 2: ACCREDITATION AND COMPLIANCE

GENERAL OVERVIEW

KEY OPERATIONAL DEFINITIONS

GOVERNANCE STRUCTURE

SCOPE AND CORE RESPONSIBILITIES

PROCEDURES

GLOSSARY

PART I: ABBREVIATIONS AND ACRONYMS

PART II: DEFINITIONS

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ENCLOSURE 1

REFERENCES

(a) DoD Directive 5136.01, “Assistant Secretary of Defense for Health Affairs (ASD(HA)),” September 30, 2013, as amended

(b) DoD Directive 5136.13, “Defense Health Agency (DHA),” September 30, 2013

(c) DHA-Procedural Instruction 5025.01, “Publication System,” August 24, 2018

(d) DoD Instruction 6025.13, “Medical Quality Assurance (MQA) and Clinical Quality Management in the Military Health System (MHS),” February 17, 2011, as amended

(e) DoD Manual 6025.13, “Medical Quality Assurance (MQA) and Clinical Quality Management in the Military Health System (MHS),” October 29, 2013

(f) National Defense Authorization Act for Fiscal Year 2017, Sections 702

(g) National Defense Authorization Act for Fiscal Year 2019, Sections 711 and 712

(h) Assistant Secretary of Defense for Health Affairs Memorandum, "Policy on Reporting Joint Commission on Accreditation of Healthcare Organizations-Reviewable Sentinel Events in the Military Health System," July 13, 2004

(i) Assistant Secretary of Defense for Health Affairs Memorandum, "Amplifying Guidance Relating to the Reporting of Sentinel Events and Personally Identifiable Information Breaches to the Office of the Assistant Secretary of Defense (Health Affairs)," February 13, 2012

(j) Assistant Secretary of Defense for Health Affairs Memorandum, "Medical Quality Assurance and Clinical Quality Management in the Military Health System Sentinel Event and Root Cause Analysis Process Improvements," March 12, 2015

(k) United States Code, Title 32, Sections 502 – 505

(l) Army Regulation 40–68, “Clinical Quality Management,” February 26, 2004, as amended

(m) Air Force Instruction 44–119, “Medical Quality Operations,” August 16, 2011

(n) DHA-Procedural Instruction 6200.01, "Comprehensive Infection Prevention and Control (IPC) Program," April 24, 2017, hereby cancelled

(o) United States Code, Title 10, Section 1102

(p) Public Law 104-191, “Health Insurance Portability and Accountability Act of 1996,” August 21, 1996, as amended

(q) Code of Federal Regulations, Title 32, Part 199.16

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ENCLOSURE 2

ACCREDITATION AND COMPLIANCE

1. GENERAL OVERVIEW. Accreditation and compliance focuses on a comprehensive, systematic process of review across the MHS, which allows MTFs to demonstrate their ability to meet DoD policy mandates, regulatory requirements, and healthcare standards. Achieving and maintaining accreditation by a recognized external accrediting organization (AO) provides benchmarks for measuring standards compliance and builds stakeholder confidence in the quality of healthcare delivered. Compliance reviews provide insight on an MTF’s ability to comply with policy requirements and leadership direction. These activities involve a rigorous review of policies, processes, and procedures that allow organizations to identify any areas with gaps in compliance, and supports the MHS high reliability organization (HRO) journey.

a. Purpose. Provide guidelines for the healthcare accreditation and compliance activities of the MHS. Prescribe procedures for accreditation and compliance management and reporting.

b. Functions. This enclosure outlines procedures related to the following accreditation and compliance activities: accreditation and certification, self-assessment, assist visits, compliance visits, and knowledge sharing.

2. KEY OPERATIONAL DEFINITIONS. Knowledge of these terms is essential to understanding the scope, core responsibilities, and procedures of the Accreditation and Compliance Program. A full list of definitions for this manual is included in the Glossary.

a. accreditation. Process of review that allows healthcare organizations to demonstrate their ability to meet regulatory requirements and standards established by a recognized accrediting organization (AO).

b. auditing. A process used by health professionals to assess, evaluate, and improve care in a systematic way; used by clinical governance to safeguard high quality of clinical care for patients.

c. certification. A process by which a nationally recognized organization confirms that an individual healthcare organization has met certain predetermined standards or procedures required for certification.

d. compliance. The ongoing process of meeting the legal, ethical, and professional standards applicable to a particular healthcare organization or provider.

e. data monitoring. The systematic and ongoing collection, compilation, and organization of data pertaining to indicators for the quality and appropriateness of important aspects of care in order that problems or opportunities to improve care can be identified.

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f. direct care system. Healthcare facilities and medical support organizations managed by the DoD through the Defense Health Agency (DHA) or Service Surgeons General in accordance with applicable federal laws and regulations.

g. focused review. A review that concentrates on a perceived problem area that involves a specific standard, procedure, policy or any other limited scope healthcare delivery matter.

h. medical quality assurance program (MQAP). Any peer review activity carried out before, on, or after November 14, 1986 by or for the DoD to assess the quality of medical care, including activities conducted by individuals, military medical or dental treatment facility committees, or other review bodies responsible for quality assurance, credentials, infection control, patient care assessment (including treatment procedures, blood, drugs, and therapeutics), medical records, health resources management review and identification and prevention of medical or dental incidents and risks as defined in Reference (o).

i. purchased care system. A component of the uniform program of medical and dental care for members and certain former members of the Services, and for their dependents where services are provided to beneficiaries by TRICARE-authorized civilian network and non-network healthcare providers and facilities.

3. GOVERNANCE STRUCTURE. The DHA Accreditation and Compliance (AC) Program is managed by the CQM Branch, in the Clinical Support Division, under the Deputy Assistant Director-Medical Affairs (DAD MA). The AC Program develops, promotes, and supports the DHA mission and the MHS Quadruple Aim through facilitation and support of compliance with nationally recognized healthcare standards utilizing HRO guiding principles.

4. SCOPE AND CORE RESPONSIBILITIES

a. Scope

(1) Provide guidelines for the accreditation of MTFs.

(2) Prescribe procedures for management and reporting of accreditation and compliance activities.

(3) Provide guidance on knowledge development and management of accreditation requirement and standards.

b. Core Responsibilities

(1) DHA Headquarters

(a) Monitor accreditation and certification of all MTFs.

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(b) Analyze accreditation data for system-level patterns and trends to identify opportunities for improvement.

(c) Manage accreditation aggregation tool to provide access to survey findings and survey report.

(d) Establish, manage, and maintain a centralized and single-source accreditation contract for all MTFs.

(e) Develop recommendations for accreditation waiver requests.

(f) Manage assist and compliance visits to support assigned MTFs with policy implementation.

(2) DHA Market/Intermediate Headquarters

(a) Monitor accreditation and certification status for assigned MTFs.

(b) Analyze accreditation results to identify patterns and trends for assigned MTFs to enhance standards compliance.

(c) Support assist and compliance visits to assigned MTFs with policy implementation.

(d) Comply with the corporate contract with the AO, and provide guidance on the accreditation processes.

(e) Support compliance with AO standards, queries, and communications for assigned MTFs.

(f) Review and develop recommendations for accreditation waiver requests.

(3) MTF

(a) Maintain continuous compliance with AO standards and other regulatory or accreditation requirements, as appropriate.

(b) Investigate and prepare responses to AO queries for DHA Market/Intermediate Headquarters review prior to submission.

(c) Communicate all accreditation and compliance activities with the DHA Market/Intermediate Headquarters.

(d) Establish and maintain a self-assessment program to monitor compliance standards and regulatory compliance.

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(e) Implement and maintain compliance with DoD and DHA directives.

5. PROCEDURES

a. Accreditation and Certification

(1) Requirements

(a) MTF and purchased care healthcare facilities will maintain accreditation based on the type of facility, services delivered, and programs offered (e.g., ambulatory healthcare, behavioral healthcare, home care, and hospital healthcare).

(b) The accreditation of MTFs is to demonstrate a commitment to quality care and compliance with nationally recognized standards. It is not required nor intended to demonstrate compliance with Centers for Medicare and Medicaid Services (CMS) regulations.

(c) Accreditation requirements, standards, and survey process information are contained in the AO’s policies and manuals. This information will not be duplicated in this

DHA-PM.

(d) The external AO and the ensuing accreditation activities will be incorporated into the CQM functional capability and comply with the MQAP requirements in accordance with Reference (o) and Reference (p). The management of survey and related accreditation information will meet the requirements in accordance with Reference (o) and Reference (p), and the external AO will not publicly release official accreditation survey reports or other materials that contribute to accreditation decision.

(e) On occasion, federal laws and DoD policy may exceed the standards of the AO, and in such cases, the federal law or DoD prevails. MTF procedures and policies cannot use less stringent language than DoD or DHA guidance. When military mission requirements result in a conflict with AO standards, implementing instructions will be issued by DHA leadership in coordination with Service SG. The DHA AC Program will pursue resolution of any recognized inconsistency in guidance with the AO. MTFs will immediately notify respective DHA Markets/Intermediate Headquarters CQM personnel if any inconsistencies are identified.

(f) The timing of MTF accreditation surveys will be communicated, by the DHA AC Program, with the operational medical readiness entities (e.g., Health Services Inspection Team or Medical Inspector General).

(g) MTFs will maintain required certifications to meet applicable state regulations, national standards, and federal laws. MTFs may obtain programmatic or clinical specialty certifications based on the analysis of the value of the program to ensure safe, quality care.

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(2) Direct Care Facilities

(a) In direct care, MHS MTFs must maintain facility (e.g., hospital, ambulatory, behavioral) accreditation by an external nationally recognized AO.

(b) The same healthcare facility AO will be utilized across the direct care system, unless a waiver is approved by Assistant Secretary of Defense for Health Affairs (ASD(HA)).

The use of a consistent AO will reduce variation in the accreditation standards and survey process, supporting high reliability efforts.

(c) A CMS-approved AO will be used to the maximum extent possible.

(d) MTF accreditation must be obtained through an on-site survey process at least every 3 years.

(e) Patient Centered Medical Homes (PCMHs) must obtain and maintain certification by an external AO. The same AO will be utilized across the direct care system, unless a waiver is approved by ASD(HA). The PCMH certification helps primary care clinics provide patient-centered, comprehensive, accessible, and coordinated care delivered by primary care healthcare providers working with an interdisciplinary care team.

(f) Situations in which formal agreements are established to provide care by military personnel in civilian or other healthcare facilities, the facilities must be accredited by a CMS-approved AO, or an accreditation source approved by the ASD(HA).

(g) Operational healthcare units (deployable units that while at home station are treating only active duty personnel and Reserve Component members on duty status and that are not a component of an accredited MTF) are under separate rules with respect to accreditation.

1. On a military installation in or outside the United States, unless under the operational control of Combatant Commands, if the unit provides health care services in a fixed facility, the facility is subject to accreditation. Although not under the control of an MTF on the installation, the facility may for accreditation purposes be affiliated with the MTF, such as by memorandum of agreement, so as to be covered by the MTF's accreditation. For purposes of command and control, this may affiliate with the Commander responsibilities of the dual-hatted MTF Director/Commander. Alternatively, the separate facility may obtain accreditation in its own right.

2. As an alternative to satisfying the accreditation requirement in Paragraph 5.a.(2)(g)1. of this enclosure, the facility involved may obtain from the ASD(HA), upon a request from the Military Department concerned, an exemption from accreditation based on documentation that it operates under comparable CQM compliance mechanisms established and implemented by the Military Department. At a minimum, the functions of patient safety, healthcare risk management, credentialing and privileging, clinical measurement, and clinical quality improvement programs must be included in the CQM compliance mechanisms, and

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assessments done by the Military Departments no less than every 3 years shall be sent to the DHA Headquarters AC Program.

3. Outside the United States in other locations, operational healthcare units will, to the extent practicable, operate under comparable CQM compliance mechanisms of the Military Department or Combatant Commander.

(3) Ancillary Services. All MTFs must obtain and maintain nationally recognized certification and accreditations for ancillary services to include but are not limited to:

(a) Laboratory Services Accreditation. MTF-based clinical laboratories are accredited by the College of American Pathologists (CAP). Operational healthcare unit laboratories are inspected by CAP or approved agencies, as per DoD guidance. Additional guidance for laboratory accreditation requirements can be found in the DHA-Procedural Instruction on “Establishment & Oversight of Clinical Medical Laboratories in the Military Health System.” Accreditation inspections are typically on a 2-year cycle and are generally unannounced. The DHA Center for Laboratory Medicine Services provides regulatory administration for all DoD laboratories.

(b) Blood Bank. Each MTF blood donor center and/or transfusion service activity will be licensed and/or registered by the Food and Drug Administration (FDA). MTF blood banking activities will also maintain AABB and CAP accreditation. The DHA Armed Services Blood Program Division provides regulatory guidance used by DoD and MTF blood bank facilities involved in the manufacture, storage, distribution, and transfusion of blood products.

(c) Radiology. All MTFs must obtain and maintain nationally required accreditation and certification for radiology services, based on federal regulations (Nuclear Regulatory Commission and, FDA), DoD guidance, and national standards.

(4) Purchased Care

(a) Purchased care network hospitals and other healthcare facilities used by the MCSC or designated provider in the United States, must be accredited by a CMS approved AO, or through an accreditation source approved by the ASD(HA) in accordance with Title 32, Part 199.16, of Reference (q), TRICARE manuals, and the contracts.

(b) Host nation hospitals and other places of institutional care will meet accreditation standards of the specific host nation or U.S. commonwealth or territory. The TRICARE overseas contractor evaluates the quality, safety, and compliance with licensure/certification and malpractice insurance requirements of purchased care sector institutions every 3 years at a minimum, per TRICARE manuals and contracts.

(5) Accreditation Waivers. ASD(HA) will consider accreditation waivers on a case-by-case basis.

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(a) Accreditation waivers are only to be approved in extreme circumstances. For example, a waiver may be granted when travel to the MTF poses an undue risk to the traveler.

(b) Waiver requests must include an overview of the facility (or facilities) to include location, healthcare services provided, type of beneficiaries served, the justification for the waiver, proposed implementation schedule, and quality management plan, to include monitoring of CQM programs and a reporting process.

(c) DHA Markets/Intermediate Headquarters will submit waiver requests to ASD(HA) through higher headquarters.

(d) DHA/Service higher headquarters will review all waiver requests for completeness and development of a recommendation to approve or deny request.

(e) Upon approving the waiver request, DHA/Service higher headquarters will endorse the recommendation and submit, along with the waiver request, to the ASD(HA) for decision. ASD(HA) will inform DAD-MA of any approved Service requests. The DHA AC Program will maintain a list of approved accreditation waivers and provide an annual report to ASD(HA) on the approved waivers and status of quality management activities.

(f) For any MTFs that are approved for waiver of accreditation and are exempt from the accreditation requirement, DAD MA must do the following:

1. Ensure processes are developed and implemented to ensure utilization of the same evidence-based standards for quality and PS as required for accredited MTFs.

2. At a minimum, waived MTFs will undergo higher headquarters-led comprehensive, on-site assessments of CQM every 3 years, to be submitted the DAD-MA within 30 business days of completion of the assessment visit.

(6) Accreditation Monitoring

(a) The management and administration of accreditation status and the survey process to include on-site visit, action plan development, and submission will be coordinated through DHA Markets/Intermediate Headquarters and monitored by the DHA AC Program.

(b) The DHA AC Program will monitor the timing of accreditation surveys through communication with the AO and DHA Markets/Intermediate Headquarters.

(c) Results of accreditation surveys will be aggregated for all MTFs to support the identification of system level patterns and trends for improvement. An electronic file of the accreditation findings obtained from the external AO will be uploaded at least quarterly to the accreditation aggregation tool. Accreditation findings will be reviewed for patterns and trends by subject matter experts to identify potential process improvement opportunities.

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(7) Standards and Accreditation Knowledge Development

(a) Opportunities to expand knowledge on accreditation requirements and standards will be based on roles and responsibilities.

1. MTF staff: Knowledge of the requirements for accreditation and the standards related to assigned responsibilities.

2. Leadership: In-depth knowledge of accreditation requirement and leadership responsibilities.

3. Quality Leads and Accreditation Fellows: In-depth knowledge and ability to teach and mentor others in the accreditation requirements, standards, and survey process.

(b) DHA/Service Headquarters will notify DHA Markets/Intermediate Headquarters and MTFs of available educational opportunities, such as semi-annual webinar of AO standards and trends, leading practices, and lessons learned from MTF accreditation surveys.

(c) Additional opportunities for knowledge and development may be available through the AO.

(8) Governing Body and Other Equivalencies for Use in Accreditation Surveys. The following equivalencies apply to MTFs:

(a) The DHA Director serves as the governing body for MTFs.

(b) Applicable federal law, DoD policy/directives, DHA Procedural Instructions and DHA-PMs, and local operating policies serve as the bylaws.

(c) The MTF’s strategic plan describes its purpose, goals, vision, and community responsibilities.

(d) The MTF Director/Commander acts as the Chief Executive Officer and represents the local governing body.

(e) The MTF Director/designee (e.g., Deputy Director, Senior Administrator, or another executive committee member), serves as the Chief Operating Officer.

(f) The MTF Chief Medical Officer or equivalent serves as the President of the Medical Staff.

(g) The MTF Chief Nurse serves as the Nurse Executive.

(h) The MTF executive committee formally links the functions of the governing body representative, the Chief Operating Officer, the medical and other professional staff, with other important aspects of the organization’s operation.

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(i) Executive Committee of the Medical Staff, or equivalent, monitors medical staff functions and clinical improvement activities.

(9) Accreditation Survey Report Submission

(a) The MTF Director will submit a copy of the preliminary report as soon as available and the final report to the respective DHA Market/Intermediate Headquarters and higher headquarters within 10 business days of receipt.

(b) This requirement applies to all external healthcare accreditation surveys.

(c) The DHA AC Program staff will submit accreditation reports to ASD(HA).

(d) Evidence of standard compliance reports required by the AO will be submitted to DHA Market/Intermediate Headquarters for review prior to submission.

(10) MTF After-Action Reports

(a) Within 30 business days of completion of any survey (triennial, unannounced, surveys for cause, or focused), the MTF Director/Commander will ensure submission of an after-action report to higher headquarters through the DHA Market/Intermediate Headquarters.

(b) The report will detail the survey preparation process (planned surveys), continuous compliance activities, lessons learned as a result of the survey process, and AO identified leading practices. The DHA AC Program and DHA Market/Intermediate Headquarters CQM staff will disseminate lessons learned.

b. Self-Assessment

(1) All MTFs are required to continuously assess and maintain compliance with accreditation standards, policy mandates, and regulatory requirements.

(2) An annual self-assessment of all the accreditation standards shall be conducted and documented by the MTF staff.

(a) Information from the self-assessment shall be recorded in the designated electronic tool provided by the AO.

(b) The completed self-assessment record will be shared with the DHA Market/Intermediate Headquarters for tracking of completion and monitoring for patterns or trends.

(3) Patterns and trends will be analyzed for identification of performance improvement opportunities.

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(4) Non-compliant standards, high-risk areas, and known vulnerabilities shall have ongoing monitoring.

(a) At a minimum, MTF self–assessment activities on non-compliant areas shall be performed once a month.

(b) Completed documentation shall be made available via the designated electronic tool provided by the AO.

(c) The DHA AC Program and DHA Market/Intermediate Headquarters designated staff shall have the capability and access to review self–assessment documentation.

(d) Documentation will be analyzed for patterns and trends for the identification and implementation of new and/or updates to existing procedures.

(5) Action plans shall be completed for identified non-compliant standards. Completed action plans shall be submitted via the designated electronic tool provided by the AO.

(6) DHA Markets/Intermediate Headquarters are responsible for monitoring patterns and trends and the completion of submitted action plans.

c. Accreditation Assist Visits. The accreditation assist visit is a systematic review of routine operations and ongoing quality improvement efforts at the MTF, supporting continuous compliance with accreditation standards. It is an internally driven process conducted by military, government, and/or contracted staff, available to MTFs to support compliance with a multitude of laws, regulations, policies, and accreditation standards.

(1) The DHA AC Program will administer and lead, with support of the DHA Markets/Intermediate Headquarters, the coordination of accreditation assist visits to ensure needed subject matter experts, such as an Accreditation Fellow, are included on the team.

(2) An accreditation assist visit is usually conducted in the 12–18 month timeframe prior to the projected accreditation survey date.

(3) A report containing an overview of the accreditation assist visit team; activities completed during the visit, identified areas of excellence, and opportunities for improvement will be completed and provided to the MTF and DHA Market/Intermediate Headquarters within 30 business days of the visit.

(4) MTFs will develop and submit plans of action and milestones (POAM) for identified non-compliance with laws, regulations, policies, and standards to the respective DHA Market/Intermediate Headquarters within 30 business days of receiving the accreditation assist visit report.

(a) Once corrective actions (CAs) are completed, the finalized POAM and any accompanying documents shall be submitted to DHA Market/Intermediate Headquarters staff.

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(b) The DHA Markets/Intermediate Headquarters are responsible for monitoring patterns and trends, and the completion of POAMs.

d. Focused Assist Visits

(1) A focused assist visit is a systems-based review of a specific program or process, conducted by a specialized team resulting in guidance to assist the MTF with standards compliance and improvement activities.

(2) Leadership from the MTF, DHA Market/Intermediate Headquarters, or DHA/Service Headquarters may request a focused assist visit.

(a) DHA/Service Headquarters, with support of the DHA Market/Intermediate Headquarters, will manage and lead coordination of focused assist visits to ensure needed subject matter experts are included on the focused assist visit review team.

(b) These visits may include but are not limited to: consultative assessment of quality care, significant accreditation compliance issues, subject matter expert visits for consultation and knowledge development, program implementation, and modification or assessment visits.

(3) A report containing an overview of the focused assist visit team findings will be submitted to the MTF and DHA Market/Intermediate Headquarters within 30 business days of the visit noting any discrepancies that will need follow-up actions.

(a) A POAM will be completed by the MTF and submitted to DHA Market/Intermediate Headquarters staff within 30 business days of the focused assist visit team report for identified opportunities for improvement.

(b) DHA Markets/Intermediate Headquarters are responsible for monitoring patterns and trends, and that POAMs are successfully implemented.

e. Compliance Visits

(1) A compliance visit is focused on the use of internal audits to monitor adherence to applicable statutes, regulations, and program requirements by a group of multidisciplinary subject matter experts. Auditing activities are retrospective, and may include the evaluation of an organization, system, process, or enterprise to ascertain the validity and reliability of information, and to provide an assessment of internal mandates.

(2) Compliance visits are directed by DHA Market/Intermediate Headquarters or DHA/Service Headquarters leadership.

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(3) DHA/Service Headquarters, with support of the DHA Markets/Intermediate Headquarters, will manage and lead coordination of compliance visits to ensure needed subject matter experts are included on the compliance visit review team.

(4) The MTF will be informed of the objective of the compliance visit prior to inspection.

(5) The information provided will include the purpose, goal, or target of the review. The visit may have more than one objective depending on the direction from leadership.

(6) A report containing an overview of the compliance visit team will be submitted to the MTF, and respective DHA Market/Intermediate Headquarters within 30 business days of the visit, noting any discrepancies that will need follow-up actions.

(7) MTFs will complete and submit a POAM for identified discrepancies within 30 business days of receiving the compliance visit report.

(8) DHA Markets/Intermediate Headquarters will be responsible for monitoring patterns and trends, and ensuring that the POAM are successfully implemented.

f. Knowledge Sharing and Feedback Loop

(1) Information from accreditation and compliance activities will be gathered to develop knowledge and advance skills in meeting national standards, policies, and procedures. The DHA AC Program will gather information on accreditation and assist visits to identify opportunities for knowledge development.

(2) The DHA AC Program will compile, aggregate, and disseminate information from compliance activities for MHS-wide sharing.

(3) The DHA AC Program will ensure closure of the feedback loop is accomplished for all accreditation, assist visits, and compliance visits completed.

18 GLOSSARY

GLOSSARY

PART I. ABBREVIATIONS AND ACRONYMS

Unless otherwise noted, these abbreviations and acronyms are for the purpose of this DHA-PM

AABB AABB (formerly known as American Association of Blood Banks) AAMFT American Association of Marriage and Family Therapy AAO American Academy of Optometry ABA American Board of Audiology ABCMO American Board of Certification in Medical Optometry ABMS American Board of Medical Specialties ABO American Board of Optometry AC accreditation and compliance ACS American College of Surgeons ACGME Accreditation Council for Graduate Medical Education ACLS Advanced Cardiac Life Support ACPE Accreditation Council for Pharmacy Education AD CS Assistant Director for Combat Support ADA American Dental Association ADA American with Disabilities Act ADN Associate’s Degree in Nursing AHRQ Agency for Healthcare Research and Quality ALS Advanced Life Support AMA American Medical Association ANCC American Nurses Credentialing Center AO accrediting organization AOA American Osteopathic Association APA American Psychological Association APMA American Podiatric Medical Association APN advance practice nurse APTA American Physical Therapy Association ASD(HA) Assistant Secretary of Defense for Health Affairs ASHA American Speech-Language-Hearing Association Au.D. Doctor of Audiology

BAA business associate agreement BLS Basic Life Support BSN Bachelor of Science in Nursing

CAC Common Access Card CADE Commission on Accreditation for Dietetics Education CAI Corrective Action Implementation CAP College of American Pathologists CCE Council on Chiropractic Education CDR Commission on Dietetic Registration

19 GLOSSARY

CE continuing education CFR Code of Federal Regulations CGFNS Commission on Graduates of Foreign Nursing Schools CHBC Criminal History Background Check CIS Criminal Investigative Service CLIP Clinical Laboratory Improvement Program CM clinical measurement CMO Chief Medical Officer CMS Centers for Medicare & Medicaid Services CNM certified nurse midwife CNS certified nurse specialist COAMFTE Commission on Accreditation for Marriage and Family Therapy Education COMLEX Comprehensive Osteopathic Medical Licensing Examination COR Contracting Officer’s Representative CP credentialing and privileging CPME Council on Podiatric Medical Education CQI clinical quality improvement CQIS Clinical Quality Improvement Studies CQM clinical quality management CRNA certified registered nurse anesthetist CSA Comprehensive Systematic Analysis CUSP Comprehensive Unit-based Safety Program CVO Centralized Credentials Verification Office

DAD MA Deputy Assistant Director for Medical Affairs DEA Drug Enforcement Agency DES Disability Evaluation System DHA Defense Health Agency DHA-PI Defense Health Agency-Procedural Instruction DHA-PM Defense Health Agency-Procedures Manual DHHS Department of Health and Human Services DMAT Disaster Medical Assistance Team D.O. Doctor of Osteopathic Medicine DoD RE DoD Reportable Event DSA data sharing agreement DSAA data sharing agreement application DLA Defense Logistics Agency

EDIS Educational and Developmental Intervention Services EHR electronic health record ECFMG Educational Commission for Foreign Medical Graduates EIDS Enterprise Intelligence and Data Solutions eMSM Enhanced Multi-Service Market ER emergency room ERM enterprise risk management

20 GLOSSARY

FAAO Fellowship in the American Academy of Optometry FDA Food and Drug Administration FHPQA Force Health Protection Quality Assurance FMEA Failure Mode Effect Analysis FNLH Foreign National Local Hire FNP family nurse practitioner FOIA Freedom of Information Act FPGEC Foreign Pharmacy Graduation Examination Committee FPPE focused professional practice evaluation

GME Graduate Medical Education GS General Schedule GTT Global Trigger Tool

HAI healthcare-associated infection HAR Hazards, Alerts, and Recalls HAR-NESS Hazards, Alerts, and Recalls Notice System HEDIS® Healthcare Effectiveness Data and Information Set HIPDB Health Integrity Protection Data Bank HIPAA Health Insurance Portability and Accountability Act of 1996 HIT health information technology HPSP Health Professions Scholarship Program HRM healthcare risk management HRO high reliability organization HROM High Reliability Operating Model

ICTB Inter-facility Credentials Transfer Brief IDES Integrated Disability Evaluation System IHPP Impaired Healthcare Provider Program IMA Individual Mobilization Augmentee IO Investigating Office IOM Institute of Medicine IPC infection prevention and control IPCWG Infection Prevention and Control Working Group

JCCQAS Joint Centralized Credentials Quality Assurance System JOES Joint Outpatient Experience Survey JPSR Joint Patient Safety Reporting

LEIE List of Excluded Individuals and Entities LIP licensed independent practitioner LPN licensed practical nurse LVN licensed vocational nurse

MC Medical Corps MCSC Managed Care Support Contractor

21 GLOSSARY

M.D. Doctor of Medicine MEB medical evaluation board MEDLOG Medical Logistics Division MHS Military Health System MHSPHP Military Health System Population Health Portal MOU memorandum of understanding MPL Master Privilege List MQA medical quality assurance MQAP medical quality assurance program MQAR medical quality assurance record MQSA Mammography Quality Standards Act MSM medical staff manager MSP medical staff professional MSW Master of Social Work MTF military medical treatment facility

NBDHE National Board Dental Hygiene Examination NCC National Certification Corporation NCQA National Committee of Quality Assurance NCCPA National Commission on Certification of Physician Assistants NDAA National Defense Authorization Act NGO non-governmental organization NHSN National Healthcare Safety Network NOTO Number of Times Occurred NPDB National Practitioner Data Bank NPI National Provider Identifier NPIC National Perinatal Information Center NQF National Quality Forum NSQIP® National Surgical Quality Improvement Program

OCONUS outside the continental United States ODE off-duty employment OHU operational healthcare unit OPM Office of Personnel Management OPPE ongoing professional practice evaluation OSD Office of the Secretary of Defense

PA physician assistant PA-C Physician Assistant-Certified PAF Provider Activity File PALS Pediatric Advanced Life Support PCE potentially compensable event PCMH Patient Centered Medical Home PCS permanent change of station PDCA Plan-Do-Check-Act PDSA Plan-Do-Study-Act

22 GLOSSARY

PEB physical evaluation board PEBLO Physical Evaluation Board Liaison Officer PECOS Provider Enrollment, Chain and Ownership System PG Postgraduate Pharm.D. Doctor of Pharmacy Ph.D. Doctor of Philosophy PHI protected health information PHM Population Health Management PII personally identifiable information PIV Personal Identity Verification Card P/MHNP psychiatric/mental health nurse practitioner POAM Plans of Action and Milestones POC point of contact PNCB Pediatric Nursing Certification Board PNP pediatric nurse practitioner PQDR Product Quality Deficiency Report PQI Prevention Quality Indicator PRA proactive risk assessment PS patient safety PSC personal services contract PSI Patient Safety Indicator PSIC Patient Safety Improvement Collaborative PSLC Patient Safety Learning Center PSM patient safety manager PSP Patient Safety Program PSPC Patient Safety Professional Course PSQAC Patient Safety Quality Academic Collaborative PSR patient safety report PSV primary source verification Psy.D. Doctor of Psychology

QA quality assurance QAI Quality Assurance Investigation QAIO Quality Assurance Investigating Officer

RAG Risk Assessment Grade RCA root cause analysis RDH registered dental hygienist RD registered dietitian RDN registered dietician nutritionist RMWG Risk Management Working Group RN registered nurse

SAFE Sexual Assault Forensic Exam SAMFE Sexual Assault Medical Forensic Examiner SANE-A® Sexual Assault Nurse Examiner – Adult/Adolescent

23 GLOSSARY

SDD Solution Delivery Division SE sentinel event SE MOS Sentinel Event Measures of Success SERCA Safety Event Root Cause Analysis SERE survival, evasion, resistance and escape SG Surgeon General SHEA Society for Healthcare Epidemiology of America SIP significantly involved provider SMDR senior medical department representative SME subject matter expert SOC standard of care SRE serious reportable event STEEEP safe, timely, effective, efficient, equitable, patient–centered

T-TPQ TeamSTEPPS™ Teamwork Perceptions Questionnaire TAA training affiliation agreement TDY temporary duty TeamSTEPPS™ Team Strategies and Tools to Enhance Performance and Patient Safety TJC The Joint Commission TRISS TRICARE Inpatient Satisfaction Survey

U.S.C. United States Code UCMJ Uniform Code of Military Justice UMO Undersea Medical Officer USMLE United States Medical Licensing Exam USN United States Navy USTRANSCOM United States Transportation Command USU Uniformed Services University of the Health Sciences

VA Department of Veterans Affairs VADM Vice Admiral VMC virtual medical center VTC video teleconferencing

WHNP women’s health nurse practitioner

PART II. DEFINITIONS

Unless otherwise noted, these terms and their definitions are for the purpose of this DHA-PM.

accreditation. Process of review that allows healthcare organizations to demonstrate their ability to meet regulatory requirements and standards established by a recognized accrediting organization (AO).

adverse event. See definition for patient safety (PS) event.

24 GLOSSARY

adverse practice action. Restriction, reduction, or revocation of the clinical practice of a non-privileged provider as a result of a due process professional review action, based upon evidence of misconduct, impairment, or incompetence, or any conduct that adversely affects, or could adversely affect, the health or welfare of a patient.

adverse privileging action. Denial, restriction, reduction, or revocation of clinical privileges as a result of a due process professional review action, based upon evidence of misconduct, impairment, or incompetence, or any conduct that adversely affects, or could adversely affect, the health or welfare of a patient.

Agency for Healthcare Research and Quality (AHRQ) Harm Scale. The AHRQ Harm Scale can be found in the AHRQ Common Formats – Hospital Version 2.0, and includes the following assignment categories:

No-Harm: Event reached the patient, but no harm was evident.

Mild Harm: Bodily or psychological injury resulting in minimal symptoms or loss of function, or injury limited to additional treatment, monitoring, and/or increased length of stay.

Moderate Harm: Bodily or psychological injury adversely affecting functional ability or quality of life, but not at the level of severe harm.

Severe Harm: Bodily or psychological injury (including pain or disfigurement) that interferes substantially with functional ability or quality of life.

Death

The harm scale defined by AHRQ Common Formats – Hospital Version 2.0, further delineates harm as:

Temporary Harm. Expected to revert to approximately normal (i.e., patient’s baseline)

Permanent Harm. Not expected to revert to approximately normal (i.e., patient’s baseline) approved postgraduate training. Postgraduate training program accredited by the Accreditation Council for Graduate Medical Education (ACGME), the American Osteopathic Association (AOA), or other similar entities regulating healthcare provider training programs.

auditing. A process used by health professionals to assess, evaluate, and improve care in a systematic way; used by clinical governance to safeguard high quality of clinical care for patients.

25 GLOSSARY

certification. A process by which a nationally recognized organization confirms that an individual healthcare organization has met certain predetermined standards or procedures required for certification.

clinical adverse action. Action invoked against a healthcare provider, privileged or not, with the result that the authority to practice clinically is adversely affected. Adversely affected privilege(s)/practice are the result of a due process professional review action based on evidence of misconduct, impairment, or incompetence, or any conduct that adversely affects, or could adversely affect, the health or welfare of a patient, and that leads to the inability of a provider to exercise their privilege(s)/practice with their own independent judgment. This is the collective term used in this manual that encompasses both an adverse practice action and an adverse privileging action.

clinical data evaluation. Analysis of collected, compiled, and organized data pertaining to important aspects of care. Data are compared with predetermined, clinically valid criteria;

variations from criteria are determined to be justified or unjustified; and problems or opportunities to improve care are identified.

clinical measurement (CM). CM uses tools to help evaluate and track the quality of healthcare services provided to beneficiaries in the Military Health System (MHS). Analyzing CM data and acting on identified trends for improvement helps ensure the MHS delivers safe, timely, effective, efficient, equitable, and patient-centered care.

clinical privileges. Permission granted by the Privileging Authority to provide medical and other patient care services. Clinical privileges define the scope and limits of practice for privileged providers and are based on the capability of the healthcare facility, licensure, relevant training and experience, current competence, health status, judgment, and peer and department head recommendations.

clinical privileging. The granting of permission and responsibility of a healthcare provider to provide specified or delineated healthcare within the scope of the provider’s license, certification, or registration.

clinical quality improvement (CQI). CQI consists of systematic and continuous actions that lead to measurable improvement in healthcare services and the health status of targeted patient groups. Focuses on the application of several widely accepted process improvement methodologies to improve clinical performance and desired outcomes.

clinical quality management (CQM). The integrated processes, both clinical and administrative, that provide the framework to objectively define, measure, assure, and improve the quality and safety of care received by beneficiaries. The CQM functional capability includes the following programs: Patient Safety, Healthcare Risk Management, Credentialing and Privileging, Accreditation and Compliance, Clinical Measurement, and Clinical Quality Improvement.

competency assessment. Assessment of a healthcare provider’s knowledge, skills, and ability to deliver high quality, safe patient care. The Military Health System (MHS) assesses providers

26 GLOSSARY

using standards from the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS), recognizing six areas of “General Competencies” including: patient care, medical/clinical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and system-based practice. These may serve as the basis for healthcare provider care evaluation and privileging decisions.

compliance. The ongoing process of meeting the legal, ethical, and professional standards applicable to a particular healthcare organization or provider.

Comprehensive Systematic Analysis (CSA). CSA is a thorough, credible, and acceptable analysis following a patient safety (PS) event that seeks to identify system vulnerabilities so that they can be eliminated or mitigated in a sustainable manner…