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NASA Ball NASA
Policy
Directive
NPD 1850.1
Effective Date: February 23, 2010
Expiration Date: December 31, 2024
COMPLIANCE IS MANDATORY FOR NASA EMPLOYEES
Printable Format (PDF)

Subject: NASA Medical System Quality Assurance - Revalidated

Responsible Office: Office of the Chief Health & Medical Officer


CHANGE HISTORY

Chg#
Date
Description/Comments
1
02/2/2015
Update to comply with 1400 Compliance,with administrative changes, and update authorities documents.

1. POLICY


a. It is NASA's policy that:

(1) The Agency's medical care system shall adhere to the highest principles and requirements to maintain quality assurance by conducting a comprehensive program to systematically review and improve the quality of medical and behavioral health services and the efficiency and effectiveness of the utilization of staff and resources in the delivery of such services.

(2) All licensed medical professionals and non-licensed support health-care personnel providing health care for NASA, whether NASA civil servants, detailees to NASA, or NASA contractors, shall hold all appropriate and required credentials for their medical specialty and any such services provided.

(3) Medical privileges to provide health care in the NASA medical care system shall only be accorded to those individuals who have the appropriate and required credentials for their specialty.

(a) Medical privileges to provide health care in the NASA medical care system can be denied, restricted, reduced, or revoked as a result of any incident where provision of accepted level of medical care is not met.

(b) Any health-care provider in the NASA medical care system whose clinical privileges are denied, restricted, reduced, or revoked as a result of an adverse privileging action may request a fair hearing.

(4) Health-care providers with medical conditions that prevent or reduce the ability to safely execute their responsibilities in providing health care may be considered impaired and may be subject to a review of health status and restriction of practice.

(5) Any incident involving the NASA medical care system that results in, or has a reasonable likelihood of resulting in an unexpected occurrence involving serious physical or psychological injury or death, shall be reviewed by the Chief Health and Medical Officer (CHMO) for possible subsequent investigation.

(6) Records created by or for NASA related to medical quality assurance (i.e., proceedings, discussion, findings, recommendations, evaluations, opinions, minutes, reports, and other documents or actions that emanate from quality assurance committees, quality assurance programs, or quality assurance program activities) are confidential.

(a) NASA medical quality assurance records are within the purview of the "Privacy Act" of 1974.

(b) NASA medical quality assurance records may not be made available to any person, except in those cases described in sections 3.2 and 3.3, under the "Freedom of Information Act" (Section 552) and the "Privacy Act" (Section 552a) of Title 5, United States Code.

(c) Medical records created by or for NASA shall be retained in accordance with NASA Records Retention Schedule.


2. APPLICABILITY

This NPD is applicable to NASA Headquarters (HQ) and NASA Centers, including Component Facilities and Technical and Service Support Centers. This NPD also applies to the Jet Propulsion Laboratory (JPL), a Federally Funded Research and Development Center, other contractors, grant recipients, or parties to agreements only to the extent specified or referenced in the appropriate contracts, grants, or agreements.

b. In this directive, all mandatory actions (i.e., requirements) are denoted by statements containing the term "shall." The terms "may" or "can" denote discretionary privilege or permission, "should" denotes a good practice and is recommended but not required, "will" denotes expected outcome, and "are/is" denotes descriptive material.


3. AUTHORITY

a. 5 U.S.C. 7901, Health Service Programs.

b. 29 U.S.C. 668, Section 19 of the Occupational Safety and Health Act of 1970, as amended, Programs of Federal Agencies.

c. Executive Order 12196, dated February 26, 1980, Occupational Safety and Health Programs for Federal Employees, 3 CFR (1980 Compilation).

d. 29 CFR Part 1960, Basic Program Elements for Federal Employee Occupational Safety and Health Programs and Related Matters.


4. APPLICABLE DOCUMENTS AND FORMS

5 U.S.C. 552a, the Privacy Act of 1974, as amended.


5. RESPONSIBILITY

a. The Chief Health and Medical Officer (CHMO) shall:

(1) Implement policies to maintain quality assurance in the NASA medical care system and monitor compliance by all components of the NASA medical care system.

(2) Establish processes for the credentialing and privileging of all NASA licensed health-care providers and non-licensed support health-care personnel prior to delivery of any such services to NASA, including actions for addressing an impaired provider.

(3) Establish a process for investigating medical incidents, determining when a medical incident investigation is warranted, and assigning impartial investigating officers as required.

(4) Ensure any health-care providers under investigation are afforded a fair hearing.

(5) Convene a Medical Review Board as required to review all cases of adverse privileging actions against previously privileged health-care providers.

(6) Ensure periodic Quality Assurance (QA) audits.

b. The Center Chief Medical Officers/Medical Directors shall:

(1) Ensure appropriate medical credentials review of all civil servants and detailees to NASA who provide health care and provide the CHMO with a credentialing and privileging report on all NASA health-care providers annually.

(2) Report to the CHMO any medical incidents or questionable deviations from the medical standard of care that may warrant a formal medical incident investigation.

(3) Conduct medical incident investigations, including assignment of impartial investigating officers, according to the procedures established by the CHMO, and report the results of any medical incident investigation to the CHMO.

(4) Report to the CHMO any temporary or permanent limitation of privileges for a privileged health-care provider.

(5) Maintain medical QA records and ensure such records meet privacy requirements as described in this policy, report to the CHMO any requests for disclosure of medical QA records, and provide medical QA records only to approved recipients on a need to know basis.

c. NASA Center Occupational Health Contracting Officer Technical Representative shall ensure that all provisions and requirements of NASA medical quality assurance policies are stipulated and in affect for health-care providers in all statements of work for contracts procuring health care or human research services.


6. DELEGATION OF AUTHORITY

None.


7. MEASUREMENT/VERIFICATION

The Office of the Chief Health and Medical Officer shall provide assessments of the application of this directive.


8. CANCELLATION

NPD 1850.1, NASA Medical System Quality Assurance, dated February 23, 2010.



REVALIDATED WITH CHANGE 1 ON 2/2/15, ORIGINAL SIGNED BY:

/s/ Charles F. Bolden, Jr.
Administrator



ATTACHMENT A: REFERENCES

A.1 NPD 1000.3, The NASA Organization.

A.2 NPD 1440.6, NASA Records Management.

A.3 NPD 1800.2, NASA Occupational Health Program.

A.4 NPR 1800.1, NASA Occupational Health Program Procedures, Chapter 2.2.

A.5 NPR 8715.2, NASA Emergency Preparedness Procedural Requirements.

A.6 NASA Occupational Health Medical Quality Assurance Program Employee and Management Directed Principles, Section II, Staff Qualifications and Competency.

A.7 Health Care Quality Improvement Act, as amended, 42 U.S.C. ºº 11101 and 11111 et.seq..

A.8 45 C.F.R. Part 60, National Practitioner Data Bank for Adverse Information on Physicians and Other Health Care Practitioners.

(URL for Graphic)

None.



DISTRIBUTION:
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This document does not bind the public, except as authorized by law or as incorporated into a contract. This document is uncontrolled when printed. Check the NASA Online Directives Information System (NODIS) Library to verify that this is the correct version before use: https://nodis3.gsfc.nasa.gov.