FY 2016 NDAA Section 713 requires expansion of the annual Evaluation of Effectiveness of the TRICARE Program to include information on:
- Accreditation status of each military treatment facility (MTF) and
- Any policies or procedures implemented during such year by the Secretary of the military department concerned that were designed to improve patient safety, quality of care, and access to care at MTFs.
Accreditation Status
The Military Health System (MHS) is dedicated to providing quality care to all beneficiaries. One strategy utilized across the MHS to assess performance in the MTFs is accreditation by nationally-recognized healthcare accreditation organizations. The accreditation process consists of the following:
- Onsite survey by subject matter experts to access compliance of standards,
- A survey report from the accrediting body with feedback on standards compliance,
- MTF implementation of changes and documentation of standards compliance for areas identified as needing improvement in the report, and
- Final accreditation decision by the accrediting body.
This process supports the MTF leadership in identifying opportunities for improvement. Frequently, the areas identified for improvement are based on a single standard or element of performance. MTFs implement improvements and monitor for continual accreditation compliance.
Download the Report
Policies and Procedures
The following polices and procedures from across the Services are designed to improve patient safety, quality of care and access to care at MTFs.
| Date | File | Description |
| 5/19/2016 | Memorandum: Trusted Care – Patient Centeredness Vision | This memorandum from the Air Force Surgeon General describes the "Patient Centeredness Vision" which encompasses the six aims of health care: safe, effective, patient centered, timely, efficient, and equitable. |
| 4/20/2016 | Memorandum: Patient Centered Practice Hours | This memorandum encourages Air Force military treatment facilities to establish more patient-centered clinic hours. |
| 1/11/2016 | Memorandum: Prevention of Retained Surgical Items Standard Operation Procedure | The purpose of this memorandum is to provide guidance to perioperative personnel for prevention of unintended retained surgical items during operative or other invasive procedures. |
| 10/1/2015 | Guideline: Trusted Care Concept of Operations | This Trusted Care concept of operations (CONOPS) describes the transformation of the Air Force Medical Service into a high reliability healthcare system. High reliability organizations (HROs), as originally described in the nuclear power and aviation industries, consistently achieve better-than-expected outcomes despite operating in complex or high-risk environments. |
| 8/26/2015 | Memorandum: National Surgical Quality Improvement Program | This memorandum describes the American College of Surgeons (ACS) National Surgical Quality Improvements Program (NSQIP) - a risk adjusted, outcomes-based program which measures and assists in improving the quality of surgical care. |
| 6/5/2015 | Memorandum: First Call Resolution and Do Not Call Back Policy | This policy requires first call resolution for all patients requesting appointments at all Air Force medical treatment facilities. Under this policy, beneficiaries will not be asked to call back for an appointment. |
| 3/27/2015 | Instruction: #6010.03, Credentialing and Privileging Program | This instruction updates and reissue policy and procedures for the Credentialing and Privileging Program for the Department of the Navy as part of the DON Clinical Quality Management Program (CQMP). |
| 3/17/2015 | Instruction: #44-102, Medical Care Management | This instruction implements Air Force Policy Directive (AFPD) 44-1, Medical Operations, and provides guidance for the organization and delivery of medical care. It implements various publications of Department of Defense (DoD), recognized professional organizations, the Joint Commission (TJC), the Accreditation Association for Ambulatory Health Care (AAAHC) and appropriate health and safety agencies |
| 1/21/2015 | Federal Regulation: #MEDCOM Regulation 40-28, Medical Services Surgical Counts | This regulation provides guidelines for accountability of items used during operative and other invasive procedures (inclusive of minimally invasive procedures) to ensure they are not retained in a patient. This regulation addresses which items will, at a minimum, be counted, as well as when, how, and by whom the surgical count will be performed. |
| 4/2/2015 | Memorandum: #OTSG/MEDCOM Policy Memo 15-019, First call Resolution and Do Not Call Back Policy | This Army OTSG/MEDCOM policy identifies responsibilities of MTF commanders, primary care, specialty care and other stakeholders identified in the appointing process to ensure patient satisfaction for our beneficiaries; outlines use of alternative portals such as Army Medicine Secure Messaging, Nurse Advice Line and TRICARE Online; specific procedures are also identified to correctly transfer calls in accordance with existing access to care standards, referral management protocols, and proper use of managing clinic schedules to ensure appointing success the first time one of our patients seeks access. |
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Last Updated: November 03, 2025