SYSTEM NAME:
Quality Assurance/Risk Management (June 16, 2003, 68 FR 35657)
SYSTEM LOCATION:
Bureau of Medicine and Surgery, Navy Department, Washington, DC 20372-5300; health care treatment facilities. Official mailing addresses are published as an appendix to the Navy's compilation of record system notices.
CATEGORIES OF INDIVIDUALS COVERED BY THE SYSTEM:
Naval Military health care providers including active duty, reserve, retired, and separated personnel; Naval civilian health care providers including government employees, volunteers, and contractors.
CATEGORIES OF RECORDS IN THE SYSTEM:
Credentialing records including Individual Credentials Files, Clinical Activity Files, Clinical Performance Profiles, Performance Appraisal Reports and other records including administrative and disciplinary proceedings; records of current and past employment and/or assignment, current and past clinical privileges, qualifications and performance, peer review records, Internal Review records, statements of physical and mental health.
AUTHORITY FOR MAINTENANCE OF THE SYSTEM:
5 U.S.C. 301, Departmental Regulations; 10 U.S.C. 1102 and 5132; and E.O. 9397 (SSN).
PURPOSE(S):
This system relates to the Bureau of Medicine and Surgery's Quality Assurance/Risk Management Program. It is used to review the quality and appropriateness of are provided to patients; investigate analyze, and report accidents, injuries, and other incidents which may be related to patient care or safety; to identify health care providers with known or suspected deficiencies or impairments which may affect patient care or safety or be the subject of professional negligence claims.
ROUTINE USES OF RECORDS MAINTAINED IN THE SYSTEM, INCLUDING CATEGORIES OF USERS AND THE PURPOSES OF SUCH USES:
In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, these records or information contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows
With the exception of the subject of a quality assurance act, the identify of any person receiving health care services from the Department of Defense of the identify of any other person associated with the department for purposes of a medical quality assurance program that is disclosed in a medical quality assurance record shall be deleted from that record or document before any disclosure of such record is made outside the Department of Defense. Such requirement does not apply to the release of information pursuant to the Privacy Act of 1974, as amended (5 U.S.C. 552a).
Medical quality assurance record (10 U.S.C. 1102) described herein may not be made available to any person under the Freedom of Information Act (5 U.S.C. 552).
Quality assurance records may be disclosed
To a Federal executive agency or private organization, if such medical quality assurance record or testimony is needed by such agency or organization to perform licensing or accreditation functions related to Department of Defense health care facilities or to perform monitoring, required by law, or Department of Defense Health care facilities.
To an administrative or judicial proceeding commenced by a present or former Department of Defense health care provider concerning the termination, suspension, or limitation of clinical privileges of such health care provider.
To a governmental board or agency or to a professional health care society of organization, is such medical quality assurance record or testimony is needed by such board, agency, society, or organization to perform licensing, credentialing, or the monitoring of professional standards with respect to any health care provider who is a or was a member of an employee of the Department of Defense.
To a hospital, medical care center, or other institution that provides health care services, if such medical quality assurance record or testimony is needed by such institution to assess the professional qualifications of any health care provider who is or was a member or employee of the Department of Defense and who has applied for or been granted authority or employment to provide health care services in or on behalf of such institutions.
To an officer, employee, or contractor of the Department of Defense who has a need for such record or testimony to perform official duties.
To a criminal or civil law enforcement agency or instrumentality charged under applicable law with the protection of the public health or safety, if a qualified representative of such agency or instrumentality makes a written request that such record of testimony be provided for a purpose authorized by law.
In an administrative or judicial proceeding commenced by a criminal or civil law enforcement agency or instrumentality referred to in the above paragraph, but only with respect to the subject of such proceeding.
The DoD 'Blanket Routine Uses' that appear at the beginning of the Navy's compilation of systems notices also apply to this system.
NOTE This system of records contains individually identifiable health information. The DoD Health Information Privacy Regulation (DoD 6025.18-R) issued pursuant to the Health Insurance Portability and Accountability Act of 1996, applies to most such health information. DoD 6025.18-R may place additional procedural requirements on the uses and disclosures of such information beyond those found in the Privacy Act of 1974 or mentioned in this system of records notice.
POLICIES AND PRACTICES FOR STORING, RETRIEVING, ACCESSING, RETAINING, AND DISPOSING OF RECORDS IN THE SYSTEM:
STORAGE:
Records are maintained on hard copy forms in filing cabinets.
RETRIEVABILITY:
Records are retrieved by full name or Social Security Number of health care provider, or other alpha/numeric identifier.
SAFEGUARDS:
Files are monitored during normal working hours by authorized personnel and the room or the files are locked at all other times.
RETENTION AND DISPOSAL:
Records are retained at the command to which the health care provider is assigned and are transferred to the provider's new command upon transfer. When health care providers leave the health care system, the Individual Credentials Files are ordinarily retained at a provider's last command for 10 years and then destroyed. If the provider's Individual Credentials File contains a permanent adverse privileging action or an investigation of criminal misconduct, the original is forwarded to BUMED for the 10 year retention period and then permanently archived. Performance Appraisal Reports and associated documents are retained at each command to which a provider is assigned for 10 years after the provider leaves the facility and then destroyed.
SYSTEM MANAGER(S) AND ADDRESS:
Chief, Bureau of Medicine and Surgery, Navy Department, Washington, DC 20372-5300. Commanding officers or Officers in charge of Navy Medical Department health care treatment facilities. Official mailing addresses are published as an appendix to the Navy's compilation of systems of records notices.
NOTIFICATION PROCEDURE:
Individuals seeking to determine whether this system of records contains information about themselves should address written inquiries to the naval medical facility where the treatment was received or to the Chief, Bureau of Medicine and Surgery. Requests should contain the full name, Social Security Number, and signature of the individual. The individual may also visit BUMED or the health care treatment facility. Visitors must possess proof of identification such as I.D. card, driver's license, or other identification showing name and a recent photograph of the individual.
RECORD ACCESS PROCEDURES:
Individuals seeking access to records about themselves contained in this system of records should address written inquiries to the naval medical facility where the treatment was received or to the Chief, Bureau of Medicine and Surgery. Requests should contain the full name, Social Security Number, and signature of the individual. The individual may also visit BUMED or the health care treatment facility. Visitors must possess proof of identification such as I.D. card, driver's license, or other identification showing name and a recent photograph of the individual.
CONTESTING RECORD PROCEDURES:
The Navy's rules for accessing records, and for contesting contents and appealing initial agency determinations are published in Secretary of the Navy Instruction 5211.5; 32 CFR part 701; or may be obtained from the system manager.
RECORD SOURCE CATEGORIES:
Incident reports relating to patients, staff, and other personnel documenting accidents, injuries, and other incidents, together with supportive correspondence and statements including statistical display and summaries.
EXEMPTIONS CLAIMED FOR THE SYSTEM:
None.
FEDERAL REGISTER HISTORY: