a. The Quality Assurance (QA) Committee. The QA Committee (the executive
committee of the clinical staff) will actively participate in the QAP, assuring that quality care
is being delivered within the MTF and by the separate activities under its command.
(1) This committee will consist of a majority of physicians; the chief, department
of nursing; the chief, patient administration division (PAD), and/or the medical record
administrator; and the quality assurance coordinator (QAC).
(2) Copies of all minutes and reports for all QAP activities will be submitted to
the Quality Assurance Committee for review, analysis, and further action. These minutes
will contain findings from ongoing monitoring and evaluation of the appropriateness of care
and treatment provided to patients.
(3) The one exception to the above reporting requirements is the Credentials
Committee which reports directly to the commander.
b. Credentials Committee. The role of this committee is to review the credentials
of healthcare professionals and recommend to the commander the clinical privileges of
practitioners serving within the MEDDAC or MEDCEN and subordinate clinics and
facilities. This will include Army National Guard (ARNG) and Reserve Component (USAR)
(1) This committee should normally be composed of at least the chief of
medicine; the chief of surgery; the chief of primary care and/or community medicine or the
chief, family practice, as appropriate; and the Deputy Commander for Clinical Services
(2) The committee meets formally or on call. Meetings must be timed to permit
thorough appraisal of the practitioners' credentials and prevent expiration of privileges.
c. Utilization Management (UM) Committee. A written plan for utilization
management will be prepared which defines goals for the year. The plan will include the
authority and responsibility of those involved in the performance of UM activities,
procedures for monitoring, required reporting to the QA committee, and corrective action.
Some of the functions of the UM committee are:
(1) Review of care received by inpatients with excessive lengths of stay for
diagnoses, diagnostic-related groups (DRGs), or procedures.
(2) Review of accessibility or availability and alternate use of ambulatory
(3) Effective use of discharge planning.