HT0011-20-R-0043 HFAS PWS Attachment 2g - DHA PM 6025.13 CQM in the MHS, Vol 6, Clinical Measurement.pdf

Defense Health Agency

PROCEDURES MANUAL

NUMBER 6025.13, Volume 6 August 29, 2019

Medical Affairs

SUBJECT: Clinical Quality Management in the Military Health System, Volume 6: Clinical Measurement

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 6

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 References (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. These tools 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. Clinical Measurement Glossary

TABLE OF CONTENTS

ENCLOSURE 1: REFERENCES

ENCLOSURE 2: CLINICAL MEASUREMENT

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) VA/DoD Clinical Practice Guidelines, U.S. Army Medical Department Office of Quality Management, 20191

(q) National Patient Safety Foundation Lucian Leape Institute. Shining a Light: Safer Health Care Through Transparency, Boston, MA: National Patient Safety Foundation, 20152

1 This reference can be found at: https://www.qmo.amedd.army.mil/pguide.htm 2 This reference can be found at: http://www.ihi.org/resources/Pages/Publications/Shining-a-Light-Safer-Health- Care-Through-Transparency.aspx

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ENCLOSURE 2

CLINICAL MEASUREMENT

1. GENERAL OVERVIEW. Clinical Measurement (CM) is an integral part of the CQM framework with a goal to objectively define and measure the quality of care provided in the MHS. CM activities include assessment of quality care delivered, identification of improvement opportunities, comparative analysis with benchmarks from professional organizations, and assessment of participation in Clinical Quality Improvement (CQI) by MHS healthcare personnel in becoming a learning organization guided by high reliability organization (HRO) principles. In addition to using measures to assess the quality and safety of care delivered, CM is used to identify trends, serve as the basis of studies when more information is needed, and focus quality improvement efforts in performance plans across the healthcare delivery system. CM provides point of care providers, clinical support staff, and MHS leadership with the data and information needed to assess clinical quality processes, outcomes, patient perceptions, and organizational structure and systems. The MHS participates with and monitors quality assessment programs and activities in other Federal Agencies and external clinical quality management organizations.

a. Purpose. Provide information and guidance regarding the management of CM in the

MHS.

b. Function. This enclosure outlines procedures related to clinical quality measurement sets, national quality databases and registries, clinical quality assessment, and clinical quality data transparency.

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

a. 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.

b. 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.

c. 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.

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d. 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.

e. denominator. The part of a fraction that is below the line and that functions as the divisor of the numerator; the population at risk in the calculation of a rate or ratio.

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. measure sets. Sets of measures that focus on different aspects of healthcare delivery and are used to improve healthcare quality, and help drive improvement through a consistent approach.

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. medical quality assurance record (MQAR). The proceedings, records, minutes, and reports that emanate from quality assurance program activities and are produced or compiled by the DoD as part of a medical quality assurance program as defined in Reference (o).

j. outcomes. The result of performance (or nonperformance) of a function, process, or series of processes. States or conditions of individuals and populations attributed or attributable to antecedent healthcare. They can include adverse or beneficial results of care, short- or long-term results of care, complications, or occurrences, and are the product of the performance (or nonperformance) of one or more functions or processes.

k. process. A goal-directed, interrelated series of actions, events, mechanisms, or steps.

Processes should always be designed with flexibility in mind and the ability to periodically introduce controlled, measurable changes.

l. 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.

m. quality healthcare. The degree to which healthcare services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Care that is evidence-based and provided in a technically and culturally

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competent manner with good communication and shared decision making as defined in the Institute of Medicine’s (IOM) Crossing the Quality Chasm: A New Health System for the 21st Century.

3. GOVERNANCE STRUCTURE. The DHA CM Program is managed from the CQM Branch, in the Clinical Support Division (CSD), under the DHA, Deputy Assistant Director for Medical Affairs (DAD MA). As one of the programs included in the CQM functional capability, the CM Program supports the MHS Quadruple Aim and DHA strategic priorities.

4. SCOPE AND CORE RESPONSIBILITIES

a. Scope

(1) Provide management and administration of the CM Program.

(2) Prescribe procedures for management of CM and quality assessment.

(3) Provide guidance on participation in national quality databases and registries.

(4) Provide expertise and guidance to efforts in support of all data transparency domains.

b. DHA Headquarters/Military Departments Designees

(1) Identifies priorities for CMs to be included in MHS Dashboard critical initiatives supporting the MHS Quadruple Aim and strategic priorities.

(2) Monitors CM of all MTFs.

(3) Analyzes CM data for system-level patterns, trends, and MHS-wide learning.

(4) Ensures compliance with statutory requirements, including the National Defense Authorization Act (NDAA).

c. DHA Market/Intermediate Headquarters

(1) Identifies MTF and DHA Market/Intermediate Headquarters priorities, and forwards to DHA Headquarters/Military Departments designees for consideration for the MHS Dashboard critical initiatives.

(2) Monitors CM performance at assigned MTFs.

(3) Provides support, as needed, to assigned MTFs for performance improvement on CMs.

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(4) Analyzes CM data to identify patterns and trends for assigned MTFs.

d. MTF/Military Department Designees

(1) Monitors, and provides feedback on, CM data to point-of-care staff supporting CQI initiatives.

(2) Communicates concerns with meeting measurement goals with DHA Market/Intermediate Headquarters.

5. PROCEDURES

a. CM Sets

(1) Assessment of clinical quality, to include the effectiveness of the CQM programs, the effectiveness of the organization’s clinical quality plan to achieve the clinical quality strategic goals, and how well these efforts support the organization’s strategic priorities, is dependent on the utilization of a variety of external and internal CM sets. The use of nationally recognized consensus measures provides consistency of methodology and the potential for comparison with established benchmarks. Where no nationally recognized consensus measures exist, the MHS develops measures to support strategic priorities, the MHS Quadruple Aim, and to provide insight into a variety of care functions (include increased readiness and better health) and settings (to include the operational environment). Evidence-based practice guidelines, such as those produced collaboratively by the U.S. Department of Veterans Affairs (VA) and the Department of Defense (DoD) (Reference (p)), and the MHS Clinical Communities, Clinical Support Services, and Enabling Expertise supporting the MHS High Reliability Operating Model (HROM), provide critical input to the organization’s quality and larger organizational strategies and plans. CM data is available on the CM repository on the CarePoint Information Portal: https://carepoint.health.mil.

(2) Internal CM Sets: the MHS core dashboard supports strategic management of the MHS Quadruple Aim. An established set of core measures help drive system-wide improvement down to the MTF level.

(a) DHA Markets/Intermediate Headquarters can utilize the MHS core dashboard and other quality assessment tools to monitor MTF performance on strategic priorities and critical initiatives, and support improvement efforts as indicated. The core dashboard includes consensus and prioritized quality assessment measures. Other available quality assessment measures are mentioned throughout this enclosure.

(b) MHS Clinical Communities identify clinical improvement priorities through key clinical process analysis, and appropriate measurement priorities for patient-centered, condition based, CQI initiatives.

https://www.carepoint.health.mil/

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(c) MTFs can utilize the MHS core dashboard to monitor performance and support improvement efforts as indicated.

(d) MTFs should communicate issues, concerns, and suggestions for clinical quality and/or strategic improvement initiatives to DHA Market/Intermediate Headquarters and MHS Clinical Communities as appropriate.

(e) Access to information and data on the MHS core dashboard is located at https://carepoint.health.mil/sites/MHSP4I/SitePages/HomeMHS.aspx. All MHS staff with a common access card (CAC) or personal identity verification (PIV) card can request and obtain access to CarePoint (some applications within CarePoint are permission restricted).

(3) External CM Sets:

(a) Inpatient Quality Measurement. Evidence-based measures that provide a perspective on the quality of care in hospitals. These CMs generate process and outcome data to evaluate inpatient clinical care. Examples of inpatient quality measures used in the MHS include the Agency for Healthcare Research and Quality (AHRQ) Indicators, National Hospital Inpatient Quality Measures, National Perinatal Information Center (NPIC) measures, and the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP®).

(b) Ambulatory Quality Measurement. Evidence-based measures that provide a perspective on the quality of care in outpatient settings. Examples of ambulatory quality measures used in the MHS include AHRQ Prevention Quality Indicators and National Committee for Quality Assurance Healthcare Effectiveness Data and Information Set (HEDIS®).

(c) Patient Safety Measurement. In the MHS direct care system, the DoD Patient Safety Program (PSP) aims to promote a culture of safety to end preventable patient harm by engaging, educating, and equipping patient care teams to put evidence-based, safe practices in place across the organization. Through continuously monitoring, measuring, analyzing, and reporting trends in patient safety data, the PSP enables the identification and prioritization of focus areas for patient safety improvement. Examples of measures used by the DoD PSP include the National Healthcare Safety Network Measures and the AHRQ Patient Safety Indicators.

(d) Experience of Care Measurement. Results of patient surveys have become increasingly important in measuring health plan performance and in directing action to improve the beneficiary experience and quality of services provided. The MHS utilizes key beneficiary surveys to measure self-reported access to, and satisfaction with, direct and purchased care experiences. Examples of surveys used include the TRICARE Inpatient Satisfaction Survey (TRISS), the Joint Outpatient Experience Survey (JOES), and the Health Care Survey of DoD Beneficiaries.

(e) Access to Care Measurement. Access to healthcare in within the MHS is measured in multiple ways: by the JOES which asks beneficiaries about their experience in obtaining needed care or an appointment; by examining institutionally recorded data indicating whether appointments were offered within certain access standards; and by administrative data

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recording the number of successful visits to providers over time. Examples of access measures include Primary Care Manager Continuity, Getting Care When Needed, and Timeliness of Specialty and Primary Care Appointments.

(f) Better Health. Better Health measurement is in development and addressed in the DHA-PI on “Population Health Management (PHM), Operation, and Integration across the Military Health System (MHS).”

b. National Quality Programs

(1) National quality databases, registries, or networks are recognized as leading practices. MHS participation in these national quality programs is based on strategic priorities and the current healthcare environment.

(a) The DHA CM Program, in coordination with the MHS Clinical Communities and other clinical subject matter experts, formulate recommendations for DAD MA to request DHA Director approval for MHS participation in national quality programs.

(b) The DHA CM Program will monitor which national quality programs in which the MHS participates.

(c) MTFs participate in approved national quality databases, registries, or networks as directed by higher headquarters. Participation provides MTFs opportunities to collaborate on and implement leading practices.

(2) Participation and submission of data to a non-DoD clinical quality database/registry must be approved by the DHA Director and meet the following criteria:

(a) Confidentiality of Medical Quality Assurance Records in accordance with Reference (o).

(b) Participation agreements must be compliant with federal laws. Participation agreements usually contain language inconsistent with federal law as the agreements are written with a focus on civilian organizations. Common topics that require modification for MTFs to participate include, but are not limited to: automatic renewals, indemnification, and limited liability.

(c) Data management practices must be compliant with cybersecurity regulations.

Database or registry organizations must meet current DoD information security requirements and provide documentation for an annual information assurance review and validation.

(d) Acquisition activities required for participation in external databases or registries must be compliant with contracting law. Participation in external quality databases or registries frequently require a contract for multi-year participation. If multiple organizations meet the DoD

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requirements for participation in a database or registry, a centralized contract should be established to support a systems-level performance review of the data and reduce the administrative burden of multiple contracts.

(3) Requests to participate in a national quality program requiring the input of clinical quality or safety data will be routed to the DHA CM program through the respective DHA Markets/Intermediate Headquarters, and the respective MHS Clinical Community as appropriate, using the data registry request form. The request will include:

(a) Name of requestor and facility;

(b) Name of the database or registry;

(c) Description of the mission;

(d) Description of the value of participation;

(e) Type (identified or de-identified) and volume of data required for participation;

(f) Examples of participation, business associate, and data sharing agreements;

(g) Cost for participation membership; and

(h) Projected cost for data collection and other efforts related to registry participation to include manning resources required to execute these duties.

(4) The DHA CM Program will inform DHA Markets/Intermediate Headquarters and MHS Clinical Communities of DHA Director approval of national quality program participation, and support, as appropriate, resourcing requests to the MHS request submission portal.

c. Assessment of Clinical Quality

(1) In coordination with CQM leadership, the CM Program assesses clinical quality annual plan performance in achieving the clinical quality strategic goals, as aligned with the organization’s strategic goals. Assessment of CQM includes a variety of methods and types of measures to include structure, process and outcome measures.

(2) The MTF CM Programs roll up their assessments to DHA Market/Intermediate Headquarters, who in turn roll up their assessments to the DHA CM Program.

(3) Annual assessments of clinical quality plans should include recommendations for improving clinical quality plan development and input for adjustment to clinical quality strategic goals.

(4) Assessment of clinical quality annual plan performance will likely need clinical quality analytic and senior clinical subject matter expert (SME) support.

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(a) Clinical Quality Analytics

1. The creation of actionable information, and its presentation in an understandable format, allows clinical and executive decision-makers to prioritize CQI efforts.

2. Clinical quality analytic capabilities across the MHS range from novice to expert with numerous years of healthcare data experience and skills. The MHS is dedicated to building a stable and networked analytical expertise that is available to support analysis and assessment of clinical quality and clinical quality improvement. Analytic expertise will support:

a. MTF, DHA Market/Intermediate Headquarters, and DHA/Service Headquarters in the utilization of available analytic tools to support analysis of CMs data to validate quality of care and identify opportunities.

b. MTF, DHA Market/Intermediate Headquarters, and DHA/Service Headquarters with analysis of data to create information needed to optimize analysis of clinical care processes and outcomes.

c. MHS CarePoint self-service CMs and analysis tools.

(b) Senior Clinical SME Support. Advanced clinical analysis of clinical quality information is a core Enabling Expertise for MHS Clinical Communities that can provide hindsight, insight, and foresight regarding clinical processes and their associated outcomes. This capability is a critical component of a comprehensive, patient-centered, outcome-based, and value-driven approach to analytics in healthcare and requires clinical interpretation in the execution of the following types of advanced analytical analysis, in direct collaboration with the respective Clinical Communities and their domain-specific measures at DHA Headquarters:

1. Hindsight. Descriptive analytics organizes and analyzes what has occurred in a population’s health, typically describing the variance in the distribution of health outcomes across subgroups, by demographics, geography, time, socioeconomic status, and cost. This capability is critical for describing the magnitude of illness in a population, a key driver for identifying priorities and associated high-impact interventions.

2. Insight. Diagnostic analytics addresses attribution or the question of why something happened. Leverages historical data to identify factors determined to be significantly associated with the outcome of interest. This is also known as exploratory analysis. It generally uses more advanced techniques such as data-mining and data discovery techniques.

3. Foresight. Predictive analytics can be the most powerful as it uses advanced analytic techniques to predict targets for intervention that can help accomplish the goal (decreasing or increasing) of the outcome of interest.

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4. Prescriptive Analytics. Prescriptive analytics is where analytics meets decision management. It attempts to answer the question of “what should be done” and uses some of the same techniques as predictive analytics. This is the “tip of the spear” as it translates the analytic work into a clinical workflow based on modeling results and SME input.

d. Transparency

(1) The MHS adopted the National Patient Safety Foundation’s four domains in its Transparency Framework. The rationale behind enhancing transparency is that culture of safety and transparency are interwoven concepts in high reliability organizations. Transparency promotes accountability, allowing patients and policymakers to ensure providers and organizations deliver exceptional care. This accountability can lead to improvements in quality and safety and enhance trust between healthcare provider and patients.

(2) The CM Program directly supports three of the four domains, with support to CQM for an overall assessment for MHS transparency efforts.

(a) Transparency Between Clinicians and Patients. This domain describes a more personal relationship and/or co-creation of care rather than displays of CM to improve care. The CM Program collaborates with patient experience and engagement groups to support assessments for MHS transparency efforts.

(b) Transparency Between Clinicians Themselves. This domain concerns sharing and open communication of information about hazards, errors, and adverse events among healthcare providers to improve systems of care (Reference (q)). In particular the Sentinel Event Root Cause Analysis tool on CarePoint, a permission-controlled tool for protected information for peer or quality review of DoD Reportable Events, supports this kind of transparency and learning.

(c) Transparency Between Healthcare Organizations. Transparency supported by an infrastructure facilitates sharing of leading practices. CarePoint (a SharePoint platform), is the main infrastructure the MHS uses to support transparency around CM. Examples of tools on CarePoint include:

1. MHS Dashboard. This shared dashboard is an ongoing collaboration driven by the 2014 Secretary of Defense MHS Review mandate to establish clear MHS performance goals with a standardized measurement tool supporting continuous improvement. Link to this dashboard at https://carepoint.health.mil.

2. MHS Population Health Portal (MHSPHP). The MHSPHP transforms direct and purchased care administrative data into actionable information. The portal utilizes healthcare action lists to identify MTF TRICARE Prime and Plus enrollees in need of potential clinical preventive services, disease management, and/or case management. The HEDIS® methodologies and DoD/VA Clinical Practice Guidelines outline the specific data sources and methodologies used within MHSPHP. The data available through this applet provide both

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patient-level and general population statistics concentrating on demographics, disease management, and preventive services information. To request access, visit:

https://carepoint.health.mil.

(d) Transparency Between Clinicians and Healthcare Organizations and the Public.

Current data displays for MHS data for beneficiary and public viewing include:

1. Transparency Site on Health.mil. The MHS is committed to promoting a culture of transparency and the transparency site provides access to facility-level, clinical quality performance data. The site provides easy access for beneficiaries and the public, to obtain information on MTFs’ performance. The data provided includes MTF accreditation status, scores on industry standard measures for patient safety and quality care, healthcare outcomes, patient experience, and access to care. The link is: health.mil/transparency.

2. Hospital Compare. Centers for Medicare and Medicaid Services initiative that provides public access to facility-level data on nationally recognized patient experience of care measures and timeliness and effectiveness of care measures. Participation in Hospital Compare supports MHS transparency goals by enhancing beneficiary availability of MTF clinical performance data. The link is: https://www.medicare.gov/hospitalcompare.

3. Accreditation, Certification, or Clinical Quality Improvement Organizations.

Organizations that accredit or certify either the MTF or aspects of care delivered in the MTF, and improvement organizations or networks with whom the MHS has partnered, might also display DoD patient safety and clinical quality performance data on their respective websites as per agreements approved by the DHA Director (e.g., participation in Leapfrog).

16 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

17 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

18 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

19 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

20 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

21 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.

22 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.

23 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

24 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 to prevent reoccurrence. A root cause analysis (RCA) is one type of CSA. CSAs can also be conducted for performance improvement purposes for those events that have the potential to be catastrophic. The following guidelines support the identification of causal factors in CSAs:

Clearly show cause and effect relationships.

Use specifics and accurate descriptions of events.

Human errors must have a preceding cause.

Violations in procedure must have a proceeding cause.

Failure to act is only causal when there is a pre-existing duty to act.

continuing education. Education beyond initial academic or professional preparation approved by an appropriate certifying professional organization that is relevant to the type of care or service delivered in an organization.

Corrective Action Implementation (CAI) Plan Report. The CAI Plan Report describes the effectiveness of the corrective action after implementation. The CAI Plan Report should include identified solutions, corrective actions implemented, and measures of effectiveness and sustainment to show that a corrective action has been implemented and is reducing or eliminating the risk of reoccurrence in a lasting way.

credentialing. The process of obtaining, verifying, and assessing the qualifications of both privileged and non-privileged providers to provide safe patient care services. This assessment serves as the basis for decisions regarding delineation of clinical privileges, as well as appointments and reappointments to the medical staff. The required information should include qualification data such as relevant education, training, and experience; current licensure; and specialty certification (if applicable) as well as performance data, such as current competency, and the ability to perform the selected privileges.