Volume 2 ALL Units

What is the mission of The Joint Commission?

To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.

What does the accreditation process add to an institution's medical practices?

Credibility

What does TJC evaluate during a survey visit?

Performance of functions and processes aimed at continuously improving patient outcomes

What determines the length of a Joint Commission survey?

Organization size and scope of services

What does TJC need to objectively measure to see the "big picture" of an organization's performance and improvement activities?

The organization's past, current, and future performance.

The Joint Commission organized its accreditation standards to address what two functional areas?

Accreditation Requirements and Accreditation Process Information.

List the characteristics of TJC standards?

They are reasonable, achievable, and surveyable.

How does TJC evaluate pharmacy operations?

independently

What chapter of TJC's CAMH addresses medication storage?

Medication management.

What does TJC provide to help avoid multiple interpretations of its standards?

A rationale

What Joint Commission survey components detail specific performance expectations, are scored, and determine a hospital's overall compliance with a standard?

EPs.

How long can a pharmacy be awarded accreditation by TJC?

Three years.

What is the mission of the Accreditation Association for Ambulatory Health Care?

To remain the preeminent leader in developing standards to advance and promote patient safety, quality, value, and measurement of performance for ambulatory health care through peer-based accreditation processes, education, and research.

AAAHC developed its standards to encourage high-quality care in what type of health care setting?

Ambulatory

Regardless of the type of organization, how many AAAHC core standards are applied to an organization seeking an accreditation survey?

Eight

In addition to the core standards, how many adjunct standards does AAAHC have?

Seventeen

Describe the overall standard AAAHC places on an accreditable organization.

Pharmaceutical services are provided or made available to meet the needs of the patients and are provided in accordance with ethical and professional practices and legal requirements.

What must be reported to the physician responsible for the patient and documented in the record?

Adverse reactions.

AAAHC selects what type of individuals to conduct their accreditation surveys?

Health care professionals and administrators who are actively involved in ambulatory health care settings.

When an organization demonstrates substantial compliance with AAAHC standards, it is granted accreditation status for what period of time?

Three years

What is the primary purpose of the self-inspection program?

To identify problems at the lowest management level, implement solutions, and provide a feedback system to track problems until they are resolved

According to IG reports, how can commanders achieve the best results?

By emphasizing critical self-assessments.

How should self-inspection programs be tailored?

They should be tailored to each unit's structure and mission and contain mechanisms that ensure adequate coverage of the organization's mission, resources, training, and people programs.

What are two examples of cross-feed items?

Inspection reports from other bases, the Inspector general's periodic analyses report, audit reports, and TIG briefs.

Who is the OPR (Office of Primary Responsiblity) for self-inspection programs?

SAF/IG

Who conducts periodic staff assistance visits to make certain all personnel understand the goals, objectives, and administrative management of the self-inspection program?

The self-inspection manager.

How frequently should self-inspections occur, and how frequently can they occur?

Annually. However, commanders may direct self-inspections to be conducted more frequently if deemed necessary

What is the database which all work centers within the MTF can log and track their inspection data?.

MICT (Management Internal Control Toolset)

Under whose authority are UEIs conducted?

MAJCOM/IGs

What does a UEI validate? (Unit Effectiveness Inspections)

A wing commander's inspection report for accuracy, adequacy and relevance, and provide an independent assessment of the wing's resource management, leadership, process improvement efforts, and ability to execute the mission

What is the UEI cycle for active duty wings?

24-30 months for active duty.

What is the highest score a wing can receive on a UEI?

Outstanding

What UEI rating is given for a score of 15 or less?

Ineffective

What types of records include all books, papers, maps, photographs, electronic media, or other documentary materials, regardless of physical form or characteristics, that the USAF makes or receives under Federal law or during the course of its public business?

Federal

What types of information are considered to be personal papers?

Papers that the individual created before entering government service; private materials that the individual brought into, created, or received in the office but are not related to government business, and work-related circumstances, work-related personal papers not used for transacting government business.

With agency approval, Air Force personnel who retire may take what types of documents?

Non-record copies of documents and copies of materials they drafted, reviewed, or otherwise acted upon.

What is records staging, and how often is it usually completed?

The process of gathering, arranging in proper order, storing, and disposing of paperwork; most staging activities are completed annually.

What is the term for "the point in time, determined by the disposition instructions, to be when your retention period begins"?

Cutoff date.

According to AFI 33-364, Records Disposition—Procedures and Responsibilities, what is the size of the tuck bottom box that you may use to package records for disposition?

14 ¾ inches by 12 inches by 9 ¾ inches.

When packing your records for disposition, how should you pack them, and what order should they be packed in?

The records packed in staging boxes should be loose enough to allow others to remove files freely or add more files later. Records are placed in boxes in an upright position in the same numerical sequence listed on SF 135, Records Transmittal and Receipt, with the label facing the numbered end of the box

When filled to capacity, what quantity of records can the standard shipping container hold?

One cubic foot of records.

How should you seal and mark your boxes when they are being shipped to a federal records center or through postal channels to any location?

With one-inch filament tape, and on the top of each box, indicate the shippers and addressee's names and addresses.

What are the purposes of the SF 135 and SF 135A?

The SF 135 is used to identify records for retirement to a federal records center or staging area (the SF 135A is used when you need a second form); as a packing list for transferred or retired records; as a medium for controlling the location, retrieval, reference, and disposition of records in staging areas and federal records centers; and to identify and account for lost, destroyed, or withheld records that personnel normally would have retired

What are the three types of outpatient prescription files?

Drugs listed as Schedule II, drugs listed as Schedules III, IV, and V, and drugs listed as non-controlled legend drugs

When should an AF Form 2380 be initiated?

For each individual batch prepared

What information is recorded on an AF Form 2380?

Manufacturer's quality control data and amounts for each product used as an ingredient in the preparation

When should an AF Form 2380 be destroyed?

After three years or when it is no longer needed, whichever is sooner.

When should an AF Form 2381 be initiated?

For all medications manufactured in bulk quantities

What is an AF Form 2381 used for?

To record the formula to be followed each time the item is compounded

When should an AF Form 2381 be destroyed?

When it is superseded, becomes obsolete, or is no longer needed

What is an AF Form 2382 used for?

To fulfill information requirements for bulk compounding of pharmaceutical products

When should an AF Form 2382 be destroyed?

After three years or when it is no longer needed, whichever is sooner

What AF form is used to track perpetual inventory for all scheduled medications or any other drugs designated as controlled by the MTF commander?

AF Form 582

When should an AF Form 582 be destroyed?

After 3 years

What is the purpose of MEPRS?

To report manpower and expense requirements for MTFs; this tri-service resource management reporting system provides a means of comparing MTF costs and productivity

What are the criteria for an activity to be considered a work center, and does the pharmacy meet those criteria?

The performance of the function must be assigned or authorized by higher medical authority; a staff must be assigned (manpower); and physical space is allocated/used, a workload is generated, and expenses are identifiable. With these elements satisfied, a work center is established and expenses are identified, collected, and reported. The pharmacy meets the criteria for a work center.

What kind of service is the pharmacy designated as in the MEPRS accounts structure, and what is its functional account code?

Ancillary service and it has a functional account code of D.

What is the fourth-level account used for in the MEPRS system?

Special identifiers.

What are the benefits to leaders at all levels of properly reported MEPRS data?

(1) They have an understanding of the costs associated with running an MTF or cost awareness.

(2) They determine if funds are being spent wisely or determine spending cost effectiveness.

(3) They make cost comparisons with other MTFs or civilian facilities.

(4) They determine aspects of manpower or personnel utilization.

Who is responsible for supporting the data collection requirements of the MEPRS program?

The MDG Commander

What Air Force system is used to document employee hours to correctly distribute salaries of assigned personnel?

Defense Medical Human Resources System-internet (DMHRSi).

What equation is used to determine the appropriate amount of full-time equivalents?

1 FTE = 168 hours.

Within an MTF, who must report their MEPRS personnel utilization data?

Military personnel, federal civilian employee, foreign national employees, personnel "borrowed" from another facility (i.e., manning assistance), medical students, contract personnel, volunteers, and reservists and Air National Guard, patient squadron personnel.

What are the three types of personnel utilization data?

Assigned, available, and non-available.

Who is responsible for ensuring that each person assigned to a work center completes his or her biweekly timesheet?

Work center MEPRS monitors.

What is the primary purpose of EASIVi?

To process the MEPRS information and its associated reports. It enables the collection of monthly data, fixes errors on-line, provides for an automatic allocation process, enables separate reporting capabilities for each MTF, and validates all manual and automated inputs prior to their acceptance into the system.

What types of activities is workload data associated with under the MEPRS workload reports?

Patient care and non-patient care activities.

In the Pharmacy Services Workload Report, what are raw values?

The number of procedures performed, or in the case of pharmacy, how many prescriptions were filled, sterile products were compounded, or clinic issues were completed

In the Pharmacy Services Workload Report, how are prescriptions weighted, and how do refills figure into the count?

Weighted as "1"; a refill is counted the same as a new prescription

What does the first portion of the Prescription Usage and Cost Report show?

The number of prescriptions broken down into schedules (CII-CV, Legend, and OTC) based on how medications are initially loaded into CHCS

What are some examples of FHPPP? (force health protection prescription products)

ATNAA (Atropine and Pralidoxime chloride) and Diazepam autoinjectors, Pyridostigmine Bromide (PB tabs), certain antimicrobials, and antimalarials.

On what two forms must dispensing of FHPPP be annotated?

SF600, Chronological Record of Medical Care, and on the deploying members DD Form 2766, Adult Preventative and Chronic Care Flowsheet.

Who can bulk FHPPP be issued to?

Troop commander.

What section is responsible for processing returns of FHPPP post-deployment?

Medical Logistics.

What are 886 AS assets referred to as?

HSMR

What AFI list the different HSMR AS teams?

AFI 41-106, Medical Readiness Program Management.

What AS is the Pharmacy Response Team under?

886E

Who is responsible for selection, training, and replacement of assigned personnel on the pharmacy team?

Pharmacy team chief

According to AFMAN 10-2608, Disease Containment, what is each AF installation required to have?

A DCP

What type of operation is set up in the event mass prophylaxis/medications need to be distributed as part of the CBRN response?

POD site

What is the purpose of a POD?

To provide the overall outpatient dispensing procedures for executing mass prophylaxis in response to one of several contingencies where medications or vaccines will need to be dispensed to a large number of people in a short period of time

How many patients and first responders can the Pharmacy Team treat during the first 48 hours following a CBRN event?

Up to 300 patients and up to 150 first responders.

What is the Strategic National Stockpile (SNS)?

A federal asset owned by both the CDC and DHS. The SNS is activated in the event of a natural or man-made disaster, epidemic or pandemic outbreak occurs, and if local and State resources are overwhelmed.

What pharmacy law required an initial inventory of all controlled substances throughout each medical facility on 1 May 1971?

CSA of 1970

Under what federal law is OTC Pseudoephedrine considered a Scheduled Listed Chemical Product?

The Combat Methamphetamine Epidemic Act of 2005.

For a facility to order controlled substances, the facility must first obtain what type of license?

DEA license

What form is issued by the DEA and is required to purchase Schedule II drugs?

DEA Form 222, Controlled Substance Ordering Form.

Upon receiving controlled substances from Medical Logistics, what document is used to ensure the correct drug and quantity was received?

Using Activity Issue List

What form or its automated equivalent is used to track the perpetual inventory (receipts, issues, and amounts on hand) for all scheduled medication and any other drugs your MTF commander has designated as controlled?

AF Form 582, Pharmacy Stock Record

How long should an AF Form 582 be retained?

Three years.

What are the requirements when completing prescription forms for drugs in Schedules II-V?

To be written in ink or typed.

A patient brings three separate AF Forms 781, Multiple Item Prescriptions, to the in-window of your pharmacy. Each of the three prescription forms has one medication written on it; why might the provider use three separate forms to write for three separate prescriptions?

Separate prescriptions must be written for controlled and non-controlled medications. Separate prescriptions must be written for drugs listed as Schedules II from those listed as Schedules III, IV, and V. The patient at the in-window may have had a prescription written for a non-controlled medication, a medication listed as a Schedule III, IV, or V medication, and a Schedule II medication.

A patient comes to the in-window of your pharmacy with an AF Form 781, Multiple Item Prescriptions. The form contains a controlled medication prescription hand-written by the provider. What number must be on the prescription for you to fill it?

The DEA number.

Who are the two individuals equally responsible for correctly prescribing and dispensing controlled substances in the MTF?

The prescribing provider and the pharmacist

Which Scheduled medication prescriptions may not be refilled?

Schedule II prescriptions.

What is a DEA number?

The prescriber's registration number with the DEA and allows him or her to write prescriptions for controlled drugs.

What does the second letter in the provider's DEA number represent?

The first letter of the last name of the provider

How long must you retain AF Forms 781, Multiple Item Prescriptions, and what must be done with them after that period of time?

Three years and then destroyed

Before releasing outpatient medication from the dispensing area, what information must be on the label?

The name and address of the pharmacy; a prescription number; the name of the provider; the name of the patient; directions for taking the medication; and the date of the filling or refilling of the prescription.

What is an AF Form 579, Controlled Substances Register and Log?

The equivalent of a prescription for the patient and is the source document for every dose administered.