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Medical Inspector General – Update on Inspection Program and Navy Medicine Trends

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. Objectives. Current Process/Status MEDINSGEN Trends MEDOSH Trends Organizational/Systemic Trends JCAHO Trends

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Medical Inspector General – Update on Inspection Program and Navy Medicine Trends

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  1. 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

  2. Objectives • Current Process/Status • MEDINSGEN Trends • MEDOSH Trends • Organizational/Systemic Trends • JCAHO Trends • JCAHO Issues • Impact of Regionalization on MEDINSGEN Inspection Process • Hotline Investigations

  3. NLT 30 days after inspection Due 90 days after final report 5 business days Prior Day 1 Day 3 - 4 Staff and customers surveyed via NMO Program reviews and focus groups Final report released to activity and Regional Commander MEDINSGEN concludes process or conducts re-inspection MEDINSGEN & JCAHO present MEDINSGEN/JCAHO out brief Activity submits required POA&Ms Notification NLT 30 days after inspection Due 90 days after final report 30 calendar days prior Day 1 Day 3 - 4 Staff and customers surveyed via NMO Program reviews and focus groups Final report released to activity and Regional Commander MEDINSGEN concludes process or conducts re-inspection MEDINSGEN & JCAHO present MEDINSGEN/JCAHO out brief Activity submits required POA&Ms Notification NLT 30 days after inspection Due 90 days after final report 30 calendar days prior Day 1 Day 3 - 4 Staff and customers surveyed via NMO Program reviews and focus groups Final report released to activity and Regional Commander MEDINSGEN concludes process or conducts re-inspection MEDINSGEN presents MEDINSGEN/out brief Activity submits required POA&Ms Notification Current Process CONUS OCONUS Non-MTF

  4. MEDINSGEN Trends 23 Commands Inspected During CY05 113 Findings Requiring Improvement

  5. MEDOSHTrends

  6. Organizational/Systemic Trends • CHCS II Deployment/Implementation – 4 of 12 sites • Continuity of Care/Referral Management – 4 of 12 sites

  7. JCAHOTrends

  8. JCAHOIssues • Periodic Performance Review (PPR) • Surveyor out brief vs. final survey results • Potential increase of Requirements for Improvement • New Emergency Management Tracer >200 beds

  9. 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

  10. Hotline Investigation Structure Echelon II Echelon III Echelon IV

  11. 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

  12. Questions?

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