medical inspector general – update on inspection program and navy medicine trends lcdr rich...
TRANSCRIPT
Medical Inspector General – Update on Inspection Program
and Navy Medicine Trends LCDR Rich Masannat, MSC, USN
Naval Medical Inspector General’s Office
19 July 2006
Current Process/Status MEDINSGEN Trends MEDOSH Trends Organizational/Systemic Trends JCAHO Trends JCAHO Issues Impact of Regionalization on MEDINSGEN
Inspection Process Hotline Investigations
Objectives
Current Process
CONUS
OCONUS
Non-MTF
NotificationMEDINSGEN
& JCAHO
present
MEDINSGEN/JCAHO out brief
Final report released to activity and Regional Commander
Activity submits required POA&Ms
Program reviews and focus groups
Staff and customers surveyed via NMO
MEDINSGEN concludes process or conducts re-inspection
5 business days Prior Day 1 Day 3 - 4
NLT 30 days after inspection
Due 90 days after final report
NotificationMEDINSGEN
& JCAHO
present
MEDINSGEN/JCAHO out brief
Final report released to activity and Regional Commander
Activity submits required POA&Ms
Program reviews and focus groups
Staff and customers surveyed via NMO
MEDINSGEN concludes process or conducts re-inspection
30 calendar days prior Day 1 Day 3 - 4
NLT 30 days after inspection
Due 90 days after final report
NotificationMEDINSGEN
presentsMEDINSGEN/out brief
Final report released to activity and Regional Commander
Activity submits required POA&Ms
Program reviews and focus groups
Staff and customers surveyed via NMO
MEDINSGEN concludes process or conducts re-inspection
30 calendar days prior Day 1 Day 3 - 4
NLT 30 days after inspection
Due 90 days after final report
MEDINSGEN Trends
23 Commands Inspected During CY05
113 Findings Requiring Improvement
0
10
20
30
40
50
60
MEDOSH Trends
MEDOSH Trends Jan '05 - Jun '06
05
1015202530
Sur
veys
/Sel
f-A
sses
smen
t/Exp
osur
e M
onito
ring
Sta
ffing
Blo
odbo
rne
Pat
hoge
ns/T
BC
ontro
l
Aw
ards
Pro
gram
Trai
ning
Mis
hap
Rep
ortin
g/In
vest
iga
tion
Oth
er
Organizational/Systemic Trends
CHCS II Deployment/Implementation – 4 of 12 sites
Continuity of Care/Referral Management – 4 of 12 sites
JCAHO Trends
JCAHO Findings Jan '05 - Jun '06
05
1015202530
JCAHO Standards
Nu
mb
er
of
Fin
din
gs
Recommendation for Improvement
Supplemental Finding
JCAHO Issues
Periodic Performance Review (PPR) Surveyor out brief vs. final survey results Potential increase of Requirements for
Improvement New Emergency Management Tracer >200 beds
Impact of Regionalization on MEDINSGEN Inspections
NAVINSGEN– Improved working relationships and communication
CNI– Hotline Investigations for Claimancy 18 transferred to Navy Medicine– Programs formerly reviewed by RLCs transferred to Navy Medicine– Opportunity to share/augment expertise
HQMC(IGMC)– Pending MOU to delineate roles and responsibilities for hotline complaints
MEDINSGEN– Echelon III inspections beginning FY07
MEDOSH– Establish MEDOSH billet at MEDINSGEN– Regional Command responsibility for MEDOSH oversight
Hotline Investigation Structure
MEDINSGEN HotlineProgram Coordinator
CNMW CNME CNMNCR
CNMW Activities CNME Activities CNMNCR Activities
CNMSC
CNMSC Activities
Echelon II
Echelon III
Echelon IV
Hotline Investigations
BUMED Hotline Instruction (Pending Signature) Certified Investigators (waivers & scheduled
training) Cases referred to higher authority
– When case involves Flag or Commanding Officer – Improper mental health referral – Cases of retaliation or whistleblower
Predominant Reasons for Hotline Complaints
– Waste, Fraud and Inefficiency Requirement– Three “A”s –Avarice, Adultery, Arrogance– Perception of retaliation in performance appraisal– Mental Health Referral– HIPAA Violations
Questions?