DoDI 6025.13 Medical Quality Assurance and Clinical Quality Management in the MHS

DOD INSTRUCTION 6025.13
MEDICAL QUALITY ASSURANCE AND CLINICAL QUALITY
MANAGEMENT IN THE MILITARY HEALTH SYSTEM
Originating Component:

Office of the Under Secretary of Defense for Personnel and Readiness

Effective:

July 26, 2023

Releasability:

Cleared for public release. Available on the Directives Division Website
at https://www.esd.whs.mil/DD/.

Reissues and Cancels:

DoD Instruction 6025.13, “Medical Quality Assurance and Clinical
Quality Management in the Military Health System,” February 17, 2011,
as amended

Cancels:

See Paragraph 1.3.

Approved by:

Gilbert R. Cisneros, Jr., Under Secretary of Defense for Personnel and
Readiness

Purpose: In accordance with the authority of DoD Directive 5124.02, this issuance:
• Establishes policy, assigns responsibilities, and provides procedures for medical quality assurance
and clinical quality management (CQM), consistent with the requirements of Section 744 of the William
M. (Mac) Thornberry National Defense Authorization Act for Fiscal Year 2021.
• Authorizes the Defense Health Agency (DHA) to issue further guidance involving medical quality
assurance, CQM programs, activities for all military medical treatment facilities (MTFs), and all
operational clinical services to the extent practicable, in the Military Health System (MHS).
• Supersedes the February 13, 2012 Assistant Secretary of Defense for Health Affairs Memorandum
but only with respect to the reporting of sentinel events.

DoDI 6025.13, July 26, 2023

TABLE OF CONTENTS
SECTION 1: GENERAL ISSUANCE INFORMATION .............................................................................. 3
1.1. Applicability. .................................................................................................................... 3
1.2. Policy. ............................................................................................................................... 3
1.3. Cancelled Documents. ...................................................................................................... 4
SECTION 2: RESPONSIBILITIES ......................................................................................................... 6
2.1. ASD(HA). ......................................................................................................................... 6
2.2. Director, DHA................................................................................................................... 6
2.3. Secretaries of the MILDEPS............................................................................................. 9
SECTION 3: MILDEP SG SUPPORT OF MHS CQM ....................................................................... 11
3.1. Establishing CQM Capability. ........................................................................................ 11
3.2. Establishing Off-Duty Employment Procedures. ........................................................... 12
3.3. Exercising Privileging Authority. ................................................................................... 12
SECTION 4: CQM PROGRAMS ....................................................................................................... 13
4.1. CQM. .............................................................................................................................. 13
4.2. PS. ................................................................................................................................... 17
4.3. HRM. .............................................................................................................................. 18
4.4. CP.................................................................................................................................... 22
4.5. AC. .................................................................................................................................. 25
4.6. CM. ................................................................................................................................. 26
4.7. CQI. ................................................................................................................................. 27
SECTION 5: MHS HRM WORKING GROUP .................................................................................... 29
5.1. Mission............................................................................................................................ 29
5.2. Organization. ................................................................................................................... 29
5.3. Reporting......................................................................................................................... 29
GLOSSARY ..................................................................................................................................... 31
G.1. Acronyms. ...................................................................................................................... 31
G.2. Definitions. ..................................................................................................................... 32
REFERENCES .................................................................................................................................. 38

TABLE OF CONTENTS

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DoDI 6025.13, July 26, 2023

SECTION 1: GENERAL ISSUANCE INFORMATION
1.1. APPLICABILITY.
This issuance applies to:
a. OSD, the Military Departments (MILDEPs), the Office of the Chairman of the Joint
Chiefs of Staff and the Joint Staff, the Combatant Commands, the Office of Inspector General of
the Department of Defense, the Defense Agencies, the DoD Field Activities, and all other
organizational entities within the DoD (referred to collectively in this issuance as the “DoD
Components”).
b. All MTFs.
c. Operational clinical services.
d. Service members of the Active and Reserve Components (including National Guard
personnel in a Title 10 or Title 32 duty status), civilian, contract, volunteer, and other medical or
dental health care providers who deliver health care or operational clinical services in the DoD.
e. Managed care support contractors, designated providers, and overseas contractors,
consistent with their respective contracts awarded by the DoD.
1.2. POLICY.
a. DoD ensures safety and quality in all aspects of the MHS under a comprehensive Military
Health System Clinical Quality Management Program pursuant to Section 744 of the William M.
(Mac) Thornberry National Defense Authorization Act for Fiscal Year 2021.
b. MHS CQM programs are implemented with a focus on accountability, transparency, and
standardization throughout the MHS; and include, but are not limited to:
(1) Patient safety (PS).
(2) Health care risk management (HRM).
(3) Credentialing and privileging (CP).
(4) Accreditation and compliance (AC).
(5) Clinical measurement (CM).
(6) Clinical quality improvement (CQI).
c. DoD develops and implements those organizational structures, education and training
requirements, policies, and means to engage external stakeholders to ensure the MHS adheres to

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DoDI 6025.13, July 26, 2023
high reliability organization (HRO) principles when delivering health care and operational
clinical services.
d. DoD implements a full range of procedures for productive communication between
patients and health care providers regarding actual or perceived adverse clinical events.
(1) Procedures for full disclosure of such events (respecting the confidentiality of medical
quality assurance (MQA) records).
(2) Procedures to resolve patient concerns by independent, neutral health care resolutions
specialists under Defense Health Agency Procedural Instruction 6025.17.
(3) Patients and their families, including Service members and their dependents, have a
right to have their thoughts, opinions, and complaints heard regarding care provided by the
MHS. If any patient believes they have suffered personal harm due to a perceived failure to
provide quality medical care, they have the right to submit their concerns in writing as part of the
MQA review of the care provided. The requirement for written concerns will ensure inclusion of
these submissions throughout the MQA review procedures. This written requirement does not
extend to complaints, concerns, or grievances presented to health care resolutions and patient
experience staff (e.g., patient advocacy or patient relations) when not associated with an MQA
review.
e. MQA records and information created by or for the DoD as part of the MQA program are
confidential and privileged in accordance with Section 1102 of Title 10, United States Code
(U.S.C.). Disclosures of such records and information, other than aggregate statistical
information, will occur only as authorized by Section 1102 of Title 10, U.S.C.
f. DoD implements medical management procedures in accordance with DoD
Instruction 6025.20 to ensure that health care services provided in MTFs or by non-DoD
providers at DoD expense are necessary and appropriate.
1.3. CANCELLED DOCUMENTS.
This issuance cancels the following documents:
a. Assistant Secretary of Defense for Health Affairs (ASD(HA) Memorandums:
(1) “Medical Quality Assurance and Clinical Quality Management in the Military Health
System Sentinel Event and Root Cause Analysis Process Improvements,” March 12, 2015
(2) “Military Health System Definition of Quality in Health Care,” May 9, 2002
(3) “Policy Memorandum for Military Health System Health Care Quality Assurance
Data Transparency,” October 20, 2010
(4) “Policy on Reporting Joint Commission on Accreditation of Healthcare
Organizations-Reviewable Sentinel Events in the Military Health System,” July 13, 2004

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DoDI 6025.13, July 26, 2023
(5) “Reporting Sentinel Events to the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO),” September 24, 1998
b. DoD Manual 6025.13, “Medical Quality Assurance and Clinical Quality Management in
the Military Health System,” October 29, 2013
c. Under Secretary of Defense for Personnel and Readiness Memorandum, “Strengthening
Clinical Quality Management in the Military Health System,” April 1, 2019

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DoDI 6025.13, July 26, 2023

SECTION 2: RESPONSIBILITIES
2.1. ASD(HA).
Under the authority, direction, and control of the Under Secretary of Defense for Personnel and
Readiness, and in accordance with DoD Directive 5136.01, the ASD(HA):
a. Is accountable for the success of CQM in the MHS.
b. Oversees the implementation of this issuance, ensuring consistent application across the
MHS.
c. Develops supporting guidance, as necessary, to implement this issuance.
d. Exercises any authority:
(1) Of the Secretary of a MILDEP, a MILDEP Surgeon General (SG), or the Director,
DHA, including authority pertaining to clinical adverse actions and reports to the National
Practitioner Data Bank (NPDB) pursuant to this issuance, to the extent the ASD(HA) determines
necessary in the implementation of this issuance.
(2) To approve MHS participation in systematic measurement of indicators of health
care quality and comparison of such indicators with benchmarks from other health care systems
and promotion of transparency regarding MHS CQM. The participation of DoD Components in
such compilations for disclosure is subject to ASD(HA) approval.
(3) To grant waivers or exceptions to this issuance in exceptional circumstances, in
accordance with law.
e. Develops measures for appropriate oversight of MHS CQM programs.
2.2. DIRECTOR, DHA.
Under the authority, direction, and control of the Under Secretary of Defense for Personnel and
Readiness, through the ASD(HA), the Director, DHA:
a. Is accountable for the success of CQM in the DHA.
(1) Provides a CQM strategy and plan to the ASD(HA), or designee, annually.
(2) Establishes in TRICARE:
(a) Regulations, contracts, and regulatory guidance to implement this instruction.
(b) Appropriate standards for quality assurance and PS in TRICARE provider
networks and other TRICARE-authorized providers.

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DoDI 6025.13, July 26, 2023
b. Develops procedures to satisfy the requirements of each of the six CQM programs
outlined in this issuance, and implements them within all MTFs under the authority, direction,
and control of the DHA. Ensures quality programs are in place for health care in private sector
care purchased through managed care support contracts.
(1) Includes procedures pertaining to standard of care (SOC) determinations and the
reporting of those determinations to:
(a) The ASD(HA).
(b) The respective MILDEP SG when the determination involves a provider who is a
Service member.
(c) The NPDB, State(s) of licensure, and applicable certifying or regulatory agencies
as appropriate.
(2) Includes procedures to:
(a) Assess potentially compensable events (PCE).
(b) Identify significantly involved providers (SIPs).
(c) Determine whether or not SOC was met.
(d) Learn from system and human factors issues causing or contributing to PCEs.
(e) Provide for appropriate accountability for SIPs in PCEs.
(f) Develop and implement process improvement activities with follow-up
reassessment for effectiveness of risk mitigation and harm prevention.
(3) Includes procedures to establish support within the MHS for all activities under this
issuance, including support for such activities for operational clinical services. At the
installation level, on installations where there is an MTF, such support may take the form of
integrating some or all CQM and related activities of MTFs and operational clinical services
under arrangements agreed to by the MTF Director and MILDEP Medical Commander.
c. Exercises authority:
(1) To report those providers, suppliers, and practitioners under the Director’s
privileging authority to the NPDB, State(s) of licensure, and applicable certifying or regulatory
agencies, as appropriate. The Director, DHA:
(a) Will not delegate this report authority below the Assistant Director for Health
Care Administration, DHA, except for reports where there is no discretion on filing the report.
(b) For action involving individuals under administrative control of a MILDEP, will
notify the respective MILDEP SG within 24 hours of the report.

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DoDI 6025.13, July 26, 2023
(2) In cases in which a health care provider is practicing or privileged under more than
one report authority (among any combination of the DHA Director or MILDEP SGs), and it is
uncertain whose responsibility applies to the privileging authority most responsible for the
matters under review, to designate the report authority responsible for a comprehensive review of
the entire matter.
(3) To establish procedures for off-duty employment of health care personnel under their
administrative control. For health care providers, notifies any privileging authority, military or
civilian, under whose authority the individual is practicing, or has been granted privileges, the
nature of any off-duty employment and any noncompliance with these procedures. The
privileging authority may disallow or limit any off-duty employment the privileging authority
determines would interfere with delivery of health care services for which the privileging
authority is responsible.
d. Manages the ASD(HA)-approved repository for provider credential and privileging
records and HRM activities (e.g., NPDB reports, status and outcome of QAIs, PCE procedures,
and clinical adverse actions). Management of this repository includes management and
administration of all unit identification codes and controlling access appropriately.
(1) Coordinates with the MILDEP SGs for management of this repository and its
associated functions for operational clinical services, to include authorizing MILDEP
management of unit identification codes within the database in compliance with DHA
procedures.
(2) Maintains records within this repository to at least 50 years post record inactivity.
(3) Manages any such repository that creates, ingests, exports, or stores records in
accordance with DoDI 5015.02.
e. Requests and sustains access to Under Secretary of Defense for Personnel and Readiness
casualty reports for the HRM Program within the Office of the Deputy Assistant Director for
Medical Affairs (DAD MA), DHA.
f. Develops and implements telemedicine initiatives, including privileging by proxy.
g. Develops appropriate metrics to monitor, evaluate, and improve DHA CQM programs.
h. Reports to ASD(HA) any non-concurrence with external peer review, through the MHS
HRM Working Group:
(1) Any paid medical tort or active duty claim in which the DHA Director non-concurs
with the external peer review determination of SOC not met, regardless of determination of
causation.
(2) Any active duty death or disability payment, or imminent payment as in active duty
health care, other adjudicated action, or decision, in which the DHA Director non-concurs with
the external peer review determination of SOC not met, and the care delivered by the SIP caused
or contributed to the patient harm.
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DoDI 6025.13, July 26, 2023
2.3. SECRETARIES OF THE MILDEPS.
The Secretaries of the MILDEPs:
a. Designate their respective SGs to serve as chief medical advisor to the Director, DHA.
b. Hold the SG appropriately accountable for the success of CQM in accordance with this
issuance in their respective Department, with respect to all health care provided under the
authority of the Department.
c. Ensure Departmental legal offices conducting adjudication of medical tort and active duty
claims (including claims under Section 2733a of Title 10, U.S.C., and Part 45 of Title 32, Code
of Federal Regulations (CFR)) promptly notify the HRM program in the respective MTF and the
HRM program in the Office of the DHA DAD MA concerning the amount of a medical tort or
active duty claim filing, settlement, judgment, or any other change in status. Data fields will
include any factual information discovered during the claims process that bore on the decision to
deny or settle or was relevant for any judgment, and at least:
(1) Unique claim identification number.
(2) Claimant last and first names and middle initial.
(3) Incident date.
(4) Claim filing date.
(5) Type of claim (Federal Tort Claims Act, Military Claims Act, active duty claim).
(6) Base of origin (MTF) of claim (and incident location if different than base of origin).
(7) Claim status (open or closed).
(8) Claim allegation.
(9) Claim amount.
(10) Date claim closed.
(11) Disposition of claim when closed (e.g., was appeal filed with Department of
Justice).
(12) Other data fields as determined appropriate by the ASD(HA).
d. Through their respective military criminal investigative or personnel organizations, ensure
completed DoD health care provider criminal, disciplinary, and government administrative
actions be forwarded to privileging authorities, or designees, and the HRM Program in the office
of the DHA DAD MA or respective Service HRM representative, as appropriate, for action and
reporting purposes as required. Actions to be forwarded might include judicial or non-judicial

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DoDI 6025.13, July 26, 2023
punishment, disability retirement or separation from Service, and reprimands or terminations for
civilian health care providers.
e. Ensure Departmental personnel facilitate the exchange of information needed by the DHA
Director for clinical reviews of active duty death and disability cases.
f. Ensure their respective SG reports to ASD(HA) any non-concurrence with external peer
review, through the MHS HRM Working Group:
(1) Any paid medical tort or active duty claim in which the MILEP SG non-concurs with
the external peer review determination of SOC not met, regardless of determination of causation.
(2) Any active duty death or disability payment, or imminent payment as in active duty
health care, other adjudicated action, or decision, in which the MILDEP non-concurs with the
external peer review determination of SOC not met, and the care delivered by the SIP caused or
contributed to the patient harm.

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DoDI 6025.13, July 26, 2023

SECTION 3: MILDEP SG SUPPORT OF MHS CQM
3.1. ESTABLISHING CQM CAPABILITY.
Each SG:
a. Is accountable for the success of CQM in accordance with this issuance in their respective
Department with respect to all health care provided under the authority of the Department.
b. Establishes, consistent with this issuance, in relation to operational clinical services
provided under the authority of the MILDEP, CQM capability within their respective MILDEP
to satisfy the requirements of each of the six CQM programs outlined in this issuance, all
volumes of the Defense Health Agency-Procedures Manual (DHA-PM) 6025.13, and other
activities under this issuance. Such capability may include support from DHA and may, at the
installation level where an MTF is located, rely on integrated implementation of some or all such
programs and activities under arrangements agreed to by the MTF Director and MILDEP
Medical Commander.
c. Will establish guidance for operational clinical services:
(1) Consistent with DHA-PM 6025.13, for SOC determinations and all reportable actions
and resulting reporting of determinations to ASD(HA), the NPDB, State(s) of licensure, and
applicable certifying or regulatory agencies.
(2) Consistent with DHA-PM 6025.13, to:
(a) Assess PCEs.
(b) Identify SIPs.
(c) Determine whether or not SOC was met.
(d) Learn from system and human factors issues causing or contributing to PCEs.
(e) Provide for appropriate accountability for SIPs in PCEs.
(f) Develop and implement process improvement activities with follow-up
reassessment for effectiveness of risk mitigation and harm prevention.
(3) Consistent with DHA Procedural Instruction 6025.17 for health care resolutions and
peer support programs, and DHA-PM 6025.13 for impaired health care provider programs.
(4) Consistent with DHA-PM 6025.13 for CP, to include:
(a) Supervision and competency review of health care providers.
(b) Maintenance of active privileges for members of the Reserve forces.

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DoDI 6025.13, July 26, 2023
(c) Standards for health care provider competencies commensurate with duty
assignment and required operational clinical skills.
(d) Standards to ensure health care provider new accessions’ competencies are
commensurate with duty assignment and required operational clinical skills.
(5) Consistent with this issuance and DHA-PM 6025.13, for AC.
(6) Consistent with DHA-PM 6025.13, for the continuous monitoring, evaluating, and
improvement of CQM programs. Guidance must incorporate MHS HRO guiding principles,
with emphasis on promoting a strong culture of safety, eliminate preventable patient harm, and
improve patient outcomes and experience.
d. Will provide a CQM strategy and plan, consistent with this issuance, to the ASD(HA), or
designee, annually.
3.2. ESTABLISHING OFF-DUTY EMPLOYMENT PROCEDURES.
Each SG establishes procedures for off-duty employment of health care personnel under their
administrative control. For health care providers, notifies any privileging authority, military or
civilian, under whose authority the individual is practicing or has been granted privileges, the
nature of any off-duty employment, and any noncompliance with these procedures. The
privileging authority may disallow or limit any off-duty employment the privileging authority
determines would interfere with delivery of health care services for which the privileging
authority is responsible.
3.3. EXERCISING PRIVILEGING AUTHORITY.
Each SG exercises authority for the following in relation to operational clinical services provided
under the privileging authority of the MILDEP, and will notify the Director, DHA, or designee,
in the case of any action or decision involving a health care provider:
a. Report providers under their privileging authority to the NPDB, State(s) of licensure, and
applicable certifying or regulatory agencies, as appropriate.
b. For clinical adverse actions under their privileging authority.
c. For any criminal convictions or for other adjudicated actions or decisions related to the
delivery of health care reported under their privileging authority.

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DoDI 6025.13, July 26, 2023

SECTION 4: CQM PROGRAMS
4.1. CQM.
a. Clinical quality strategy and plans will be developed, communicated, and implemented at
the MHS, MILDEP SG, DHA, DHA market, and MTF leadership levels, and in operational
clinical services, to ensure:
aim.

(1) Support of the MHS mission, vision, core values, strategy, and the MHS quadruple

(2) Delivery of safe, timely, effective, efficient, equitable, and patient-centered health
care, as adopted from the Institute of Medicine’s “Crossing the Quality Chasm: A New Health
System for the 21st Century,” across all DHA markets and their MTFs, in the MILDEPS and
their operational clinical services, and in the TRICARE Health Plan network.
(3) Consideration of social determinants, community factors, and care coordination
factors that impact health outcomes.
(4) Incorporation of the MHS HRO guiding principles:
(a) Preoccupation with failure.
(b) Sensitivity to operations.
(c) Deference to expertise.
(d) Reluctance to simplify.
(e) Commitment to resilience.
(f) Constancy of purpose.
(g) Respect for people.
b. Clinical quality planning to implement the MHS clinical quality strategy will set clear
priorities for clinical quality control and assurance, and CQI. It requires leadership engagement
and a learning system with standardized approaches to control, assurance, improvement, and
transparency. It also requires engaging those requiring and receiving the services provided, as
well as those front line staff who provide those services.
(1) Leadership engagement for effective CQM must be demonstrated through:
(a) Established committee infrastructure in support of all CQM programs to define
accountability and support improvement over time.
1. The MHS HRM Working Group in accordance with Section 5 of this issuance.

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DoDI 6025.13, July 26, 2023
2. Additional infrastructure will be established, as appropriate, to support CQM
at all levels throughout the MHS.
(b) Established organizational expectations and training for leadership behaviors, and
a structured means to identify, prioritize, and address daily management concerns and barriers
impacting clinical operations (e.g., visual management, leader standard work at all levels, and
accountability).
1. Relationships inherent in such a system require trust, respect, and inclusion.
MHS leadership at all levels must strive for a just culture that rewards reporting actual or
potential harm, yet addresses reckless or malicious behavior appropriately.
2. Contextual excellence (e.g., how well a service helps someone or performs) in
daily management of clinical operations should be sought and encouraged over simply
compliance excellence (e.g., whether or not a service was performed). MHS leadership must
actively promote and encourage health care workforce development in CQM skills, and support
sustainment of CQM capability and capacity.
(2) Transparency for effective CQM will be demonstrated in four domains:
(a) Transparency Between Clinicians and Patients.
Clinicians will practice honesty with patients and their families about all aspects of
care, provide disclosure for adverse outcomes, and continue to strive to improve care to prevent
future adverse outcomes.
(b) Transparency Between Clinicians Themselves.
Clinicians will communicate with other clinicians about the care delivered to improve
coordination and consistency of care and to prevent errors.
(c) Transparency Between Health Care Organizations.
As a learning organization, each health care organization will continue to strive to
improve patient care by sharing information among organizations and learning from their peers.
(d) Transparency Between Health Care Organizations, Clinicians, and the Public.
Health care organizations and their clinicians will be committed to sharing timely,
accurate information about the care provided, in a way that is useful to patients.
(3) Standardized approaches for effective CQM will be established for each MHS HRO
domain of change:
(a) Leadership Commitment.
principles.

Leaders will engage at every level, committed to and fostering MHS HRO guiding

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DoDI 6025.13, July 26, 2023
(b) Culture of Safety.
Leaders will encourage a system-wide culture of advancing toward zero harm.
(c) Continuous Process Improvement.
Leaders will promote an integrated system in which every member is a problem
solver capable of leveraging improvement science to include at least:
1. Identification, communication, and management of priorities for both clinical
quality control and improvement, with clear depiction of drivers, associated measures, metrics,
and respective data sources.
2. Daily management of concerns with, barriers to, or sustainment of success in
priorities, leveraging a health care workforce trained on CQM and MHS-wide standard processes
and tools.
(d) Patient-centeredness.
Leaders will establish partnerships with empowered patients and families in
communities to optimize safety, quality, and the care experience. Patient-centeredness should
involve:
1. Co-design of health care and health outcomes with patients as equal partners in
defining and creating value.
2. Co-production with frontline health care staff for those health care services
that directly impact patient health care experience and health outcomes (e.g., using the MHS
HRO model involving clinical communities, clinical support services, and enabling expertise,
integrating both co-design with patients and clinical decision support into care pathways and PS
processes).
c. MQA records and information created by or for the DoD as part of an MQA program are
confidential and privileged in accordance with Section 1102 of Title 10, U.S.C. Disclosures of
such records and information (other than aggregate statistical information) will occur only as
authorized by Section 1102 of Title 10, U.S.C.
(1) DHA will use electronic databases to collect, track, and report:
(a) PS surveillance and reporting.
(b) HRM documentation.
(c) Required health care provider data for credentials, clinical performance, and
granting of clinical privileges.
(d) AC findings.

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DoDI 6025.13, July 26, 2023
(e) Clinical measures and metrics reported internally to the MHS or reported
transparently to the public (e.g., as part of a Federal, commercial, or professional organization
quality improvement effort), and relationship of such metrics and measures to MHS strategic
objectives and initiatives.
learning.

(f) CQI priorities, plans, and progress, as well as leading practices for sharing and
(g) Strategy, plans, and performance of CQM itself.
(h) Additional information as needed.

(2) All required data will be promptly documented and available in respective databases
for review by the ASD(HA) or designee.
d. The DHA and each MILDEP will ensure their respective clinical standards issuances will
be reviewed or coordinated through their respective CQM programs.
e. The DHA and each MILDEP will provide their respective CQM strategy and plan to the
ASD(HA), or designee, annually.
(1) The DHA CQM strategy and plan will be coordinated across the direct care and
TRICARE Health Plan CQM programs, through regular meetings throughout the year, for an
integrated approach across the system that is under DHA authority.
(2) DHA and MILDEP submitted CQM strategies and plans will address each of the six
CQM programs and will be accompanied by an annual assessment of the respective
Component’s previous year strategy and plan.
(a) The DHA will provide an annual assessment of the CQM programs and program
outcomes for both direct care and the TRICARE health plan to the ASD(HA) or designee; this
requirement may be met through the annual TRICARE program evaluation report to Congress.
(b) Each MILDEP will provide an annual assessment to the ASD(HA), or designee,
of their respective CQM program and program outcomes.
(c) DHA and MILDEP annual CQM strategies, plans, and assessments should be
submitted to ASD(HA), or designee, no later than the publication date of the DHA annual
TRICARE program evaluation report to Congress.
f. Operational clinical services are delivered under the authority, direction and control of a
MILDEP Medical Commander designated by the SG concerned.
(1) The MILDEP Medical Commander is responsible for implementing CQM programs
in relation to operational clinical services with standards and procedures comparable, to the
extent practicable, to those in MTFs. This requirement applies to all provisions of this issuance
and all CQM-related issuances of DHA. The MILDEP Medical Commander will maintain

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written documentation of any deviations in standards and procedures determined to be not
practicable.
(2) On a military installation in or outside the United States where there is an MTF, the
MTF Service Commander, who is under DoD Directive 5136.13 dual-hatted as the MTF
Director (unless dual hatting was waived by ASD(HA)), is deemed to be the MILDEP Medical
Commander unless a different MILDEP Medical Commander is designated by the SG
concerned. The MILDEP Medical Commander may provide for integrated implementation of
some or all CQM programs for MTF services and operational clinical services on the installation,
either through action of the dual-hatted MTF Director/Commander or other arrangements agreed
to by the MTF Director.
4.2. PS.
a. MHS PS programs incorporate the MHS HRO guiding principles, with emphasis on
promoting a strong culture of safety to eliminate preventable patient harm MHS-wide.
(1) MHS PS programs support elimination of harm through identification, investigation,
mitigation, and analysis of PS events.
(2) MHS PS programs support learning through a focus on systems, procedures, and
teamwork. They integrate and complement other CQM activities, as appropriate, for local or
MHS-wide standardized safe practices.
(3) MHS PS programs foster a culture of safety in which:
(a) Mistakes are acknowledged and lead to sustainable, positive change.
(b) Respectful and inclusive behaviors serve as behavioral norms for the
organization.
(c) The physical and psychological safety of patients and the workforce are both
highly valued and ardently protected.
(d) Reporting of near miss and no harm patient safety events is encouraged to correct
systems and process failures before they cause a reportable event.
(4) As required by Section 744(b)(1) of the William M. Thornberry National Defense
Authorization Act for Fiscal Year 2021, MHS PS programs include the implementation of
systematic procedures to eliminate, to the extent feasible, risk of harm to patients at MTFs,
including through identification, investigation, and analysis of events indicating a risk of patient
harm and corrective action plans to mitigate such risks.
b. PS event reporting to the ASD(HA) will be through the DHA Patient Safety Program
(DHA PSP) pursuant to DHA-PM 6025.13.

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DoDI 6025.13, July 26, 2023
(1) DoD Reportable Events (REs) occurring in MTFs will be reported to the ASD(HA),
or designee, and to the Director and DAD MA, DHA, through the DHA PSP.
(2) DoD REs occurring in operational clinical services will be reported to the ASD(HA),
or designee, by the respective MILDEP SG, through the DHA PSP.
4.3. HRM.
a. HRM programs incorporate the MHS HRO guiding principles, with emphasis on
promoting safe patient care and health care environments, and to identify, assess, and mitigate
risks contributing to harm and financial loss to the Federal Government.
(1) HRM programs support development, implementation, and assessment of
effectiveness of prioritized, systematic risk reduction strategies, and process improvement
activities to mitigate risk of harm to patients, family members or caregivers, facility visitors, and
health care staff.
(2) HRM programs work in collaboration with the rest of the organization’s CQM team,
its organizational leadership, and other relevant process owners throughout the organization.
b. The MHS provides safe and effective health care by requiring that its health care
providers are properly qualified, trained, and competent to perform their clinical duties, and by
taking appropriate action when there are allegations or concerns for misconduct, incompetence,
or any conduct which adversely affects, or could adversely affect, the health or welfare of a
patient or staff member.
(1) The MHS electronic database for HRM data is managed by the DHA. MTF and
operational clinical services HRM data, to include reports to the NPDB, State(s) of licensure, or
other applicable certifying or regulatory agencies, will be promptly documented in the MHS
electronic database designated by the ASD(HA), reported to the MHS HRM Working Group;
and available for review by the ASD(HA) or designee.
(2) Paid medical tort claims may require a report to the NPDB. In accordance with
Sections 11131 through 11152 and Sections 1320a-7 through 1320a-7e of Title 42, U.S.C., the
September 1987 Memorandum of Understanding between the Department of Health and Human
Services and the DoD, and the November 9, 1992 follow-up letter from ASD(HA) to the
Assistant Secretary for Health for the Department of Health and Human Services, reports to the
NPDB will be made in the name of a health care provider each time a medical tort claim
payment is made, and for which a determination of SOC not met for that SIP is made, after a
thorough peer review of the facts of the health care provided.
(a) A report to the NPDB for each SIP will be made unless, within 180 days after
receipt of notice of such payment, the report authority makes a final determination, following
external peer review of the case, that SOC was met. The external peer review will consider all
relevant information available to the HRM program regarding the patient care involved,
including in paid malpractice cases input from DoD legal counsel involved in adjudication or
litigation of the claim regarding factual information developed in the process pertinent to the
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DoDI 6025.13, July 26, 2023
final settlement or judgment. Special emphasis is given to the results of external peer reviews,
which are accepted by the report authority unless the report authority makes a specific, nondelegable determination that the results are contradicted by clear and convincing evidence.
(b) If no final decision has been made by the report authority by the end of this 180day period, all SIPs identified for the medical tort claim payment must be reported to the NPDB
immediately. A report by the report authority is not discretionary. A voidance or modification
of such a report, consistent with NPDB procedures, will be made if appropriate based on
subsequent decisions (e.g., reduction in the number of SIPs, narrative notation regarding a
determination of SOC met). The ASD(HA) has waiver approval authority in exceptional
circumstances for any exceptions to this 180-day limit.
(c) Except for any NPDB report of an “active duty health care adjudicated action or
decision” under this section, SOC determinations for purposes of medical tort claim NPDB
reports are not adverse actions and thus are not subject to due process procedures.
(d) If a claim is filed and adjudicated against the United States or Department of
Defense for medical malpractice affecting a member of the uniformed services under Section
2733a of Title 10, U.S.C., and Part 45 of Title 32, CFR, follow the processes, procedures, and
reporting criteria for medical tort claims.
(3) Payments made for active duty death or disability arising from PS events may require
a report to the NPDB. This is independent of whether a claim was filed under Section 2733a of
Title 10, U.S.C., and Part 45 of Title 32, CFR. For active duty death or disability benefits arising
from PS events, HRM programs support their respective organizations with assessments for
potential risk of liability, done in consultation with appropriate servicing health care legal
counsel.
(a) Every case in which a medical evaluation board makes a referral to a physical
evaluation board, the medical evaluation board approving official will identify and report to the
respective HRM programs (operational clinical services, DHA, or both) every instance in which
the condition that is the subject of the referral may have been incurred or aggravated as a result
of MHS-provided medical care.
(b) Every active duty death or disability payment for which the delivery of health
care within the MHS may have been the cause or a contributing factor will have an objective
peer review. The peer review will make a determination for each SIP as to whether or not a
deviation in the SOC occurred, and if the deviation caused or contributed to the active duty death
or disability.
(c) All SIPs in active duty death and disability payments with a SOC determination
of “not met” and that the deviation in SOC caused or contributed to the death or disability will be
reported to the NPDB, State(s) of licensure, or other applicable certifying or regulatory agencies.
In any case in which peer review determines with respect to a SIP that SOC was met or that a
deviation from SOC did not cause or contribute to the death or disability, the case will receive
external peer review under the same procedures applicable to paid medical tort claims.

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DoDI 6025.13, July 26, 2023
1. This includes the 180-day review period process described in Paragraph
4.3.b.(2)(b), with the 180-day period beginning on the day the medical evaluation board
approving official reports that the condition that is the subject of the referral may have been
incurred or aggravated as a result of MHS-provided medical care.
2. In any case in which a SOC review of care provided to a member of the
uniformed services is triggered by both a report from the medical evaluation board approving
official and the adjudication of a claim under Section 2733a of Title 10, U.S.C., and Part 45 of
Title 32, CFR, the SOC reviews will be merged to produce a final outcome properly accounting
for all evidence relating to the care provided.
(d) For any DoD RE or PCE involving a patient who is an active duty Service
member that is at high risk for becoming a disability or death payment, but there is expected to
be a significant time lapse prior to such payment being made, due process with appeal rights
must be afforded prior to an NPDB report of an “active duty health care adjudicated action or
decision.”
1. A SIP determined in the PCE review process to have deviated from SOC,
and the deviation caused or contributed to the Service member’s harm, will be afforded due
process with appeal rights.
2. The SIP will also be afforded a timely resolution in the deliberation by the
report authority for a potential report to the NPDB, State(s) of licensure, or other applicable
certifying or regulatory agencies.
3. These reports are submitted to the NPDB under “active duty health care
adjudicated actions or decisions.”
(4) A legal sufficiency review is required prior to completing SOC reviews for potential
NPDB reporting under Paragraphs 4.3.b.(2) and 4.3.b.(3) in the following cases:
(a) Any case of a paid malpractice claim in which no SIP will be reported.
(b) Any case in which the report authority decides not to report a SIP for whom
external peer review determined the criteria for reporting was met.
(5) Every PCE in MTFs or those associated with operational clinical services will be:
(a) Reviewed and promptly documented in the MHS electronic database designated
by the ASD(HA).
(b) Reported to the MHS HRM Working Group.
(c) Available for review by the ASD(HA) or designee.
(6) Professional review activities are indicated when there are allegations or concerns for
misconduct, incompetence, or any conduct which adversely affects, or could adversely affect, the
health or welfare of a patient. Criminal convictions, civil judgments, or government
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DoDI 6025.13, July 26, 2023
administrative actions related to conduct in, or conduct that could adversely affect the delivery of
health care, are subject to professional review activities. Also subject to professional review
activities is improper conduct in interactions with other staff when such conduct could adversely
affect the delivery of health care. Professional review activities will be conducted in accordance
with Section 11112 of Title 42, U.S.C.
(a) Professional review activities have the potential for a health care provider to be
reported to the NPDB, State(s) of licensure, and other applicable certifying or regulatory
agencies. Final adverse actions are reportable to these entities.
(b) Due process with appeal rights as well as procedures to require a timely
resolution will be included in MHS professional review activities for potential clinical adverse
actions.
(c) Summary suspensions of privileged providers that last longer than 30 calendar
days, clinical adverse actions, and criminal convictions related to health care are reported to the
NPDB, State(s) of licensure, and other applicable certifying or regulatory agencies.
(7) Impaired health provider programs (IHPP) are designed to provide support,
assistance, and coordination or advocacy for wellness of health care providers who suffer from a
condition that adversely affects, or could adversely affect, the safety or welfare of a patient.
(a) Notwithstanding the emphasis on wellness, clinical adverse action due process
may need to be initiated in cases in which a health care provider who is, or may be, impaired
does not self-refer, lacks insight or willingness to address their condition or be compliant with
treatment, fails to complete a treatment program, or relapses after treatment.
(b) If a clinical adverse action is taken against a provider for misconduct or
incompetence related to impaired health, it must be reported to the NPDB, State(s) of licensure,
or other applicable certifying or regulatory agencies as appropriate.
(c) Reports to State(s) of licensure or other applicable certifying or regulatory
agencies should be considered as appropriate, e.g., ending affiliation with the MHS while in
continued monitoring by the IHPP, separation from Service as a result of the disability
evaluation system decision, State(s) licensing board, or other applicable certifying or regulatory
agency requiring a notification of enrollment in the IHPP, or failure to successfully complete the
IHPP.
(d) Privileging authorities without the resources to have an IHPP of their own, will
require affiliation with such a program to support their providers, consistent with applicable
laws, regulations and contract provisions.
(8) DoD also reports to the NPDB, State(s) of licensure, and other applicable certifying
or regulatory agencies health care practitioners, providers, or suppliers who engage in certain
criminal or adverse administrative actions related to the delivery of health care items or services.
Reportable actions include:

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DoDI 6025.13, July 26, 2023
(a) Uniform Code of Military Justice (UCMJ) Actions. Convictions under chapter 47
of Title 10, United States Code, also known and referred to as “the UCMJ,” as approved
contained in the entry of judgment, or final non-judicial punishment under the UCMJ, regardless
of whether the conviction or punishment is the subject of a pending appeal.
(b) Other Adjudicated Actions or Decisions. The following actions are reportable if
they are against a health care provider, supplier, or provider based on acts or omissions that
affect the payment, provision, or delivery of a health care item or service:
1. Adverse Personnel Actions Affecting Uniformed Services Members. Any
administrative action resulting in separation, reduction in grade, involuntary military
occupational specialty reclassification, ending affiliation with the MHS while in continued
monitoring by the IHPP, or other adverse administrative action.
2. Adverse Civilian Personnel Actions. Any adverse personnel action as
described in chapter 75 (Sections 7501 through 7543) of Title 5, U.S.C., as well as actions under
chapter 43 of Title 5, U.S.C., when there is a due process proceeding.
3. Contract Termination for Default. A contract termination for default taken by
an MTF or medical command against a personal services or non-personal services contractor.
4.4. CP.
a. CP programs incorporate the MHS HRO guiding principles, with emphasis on full
evaluation of individual health care provider credentials and qualifications before allowing
involvement in patient care.
(1) All MHS health care providers who are licensed, certified, or registered will be
entered and tracked in the MHS electronic database designated by the ASD(HA), and available
for review by the ASD(HA) or designee.
(2) All CP data and information will be promptly documented in the MHS electronic
database designated by the ASD(HA), and available for review by the ASD(HA) or designee.
(3) CP processes will be standardized in DHA-PM 6025.13 and streamlined across the
MHS to require that health care providers are fully functional as quickly as possible with limited
downtime. Standardized CP processes will be implemented to the extent practicable in
operational clinical services per Service guidance.
(4) CP will be performed on initial appointments, renewals, and modifications.
(a) The inter-facility credentials transfer brief (ICTB) documents a health care
provider’s credentials and is the means by which information is shared between privileging
authorities. The expiration date of the professional privileges on which it is based results in
expiration of the ICTB on the same day.

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DoDI 6025.13, July 26, 2023
1. ICTB documentation will be accurate, complete, primary source verified,
include documentation of expiration of time-limited credentials, and for privileged providers it
will include a complete list a provider’s privileges.
2. Privileges granted using an ICTB that are used to support a complete
privileging application request, require at least primary source verification of time-limited
credentials and query of the NPDB.
(b) Privileging by proxy is a process which may be used when privileges and the
credentials supporting those privileges are not altered in a provider’s transfer to new clinical
duties. The ICTB used for privileging by proxy does not require repeat primary source
verification, and query of the NPDB is optional.
(5) For MTFs, privileging authority resides with the Director, DHA and may be
delegated. At the MTF level, MTF directors may delegate privileging authority to the MTF
deputy director or similarly appropriate senior leadership member. The delegation is made and
maintained in writing. Further redelegation is not authorized.
(6) For operational clinical services, privileging authority is delegated from the Secretary
concerned to the respective SG. SGs may further delegate privileging authority to appropriate
medical unit commanders or other appropriate medical command level entities (e.g., SGs of
MILDEP subordinate commands).
(7) For telemedicine, MHS providers who are authorized and providing virtual health
care within the scope of their assigned duties pursuant to licensure portability under Section
1094(d) of Title 10, U.S.C., are authorized to provide this virtual health care (telephonic or
video) from any U.S. location, to any U.S. location. (Licensure portability does not extend to
non-personal services contract health care providers.) Clinical concerns for the health care
provided at the originating site will be reported to the distant site, to include a portion of patient
health care records to be incorporated in the distant site peer review process. The distant site will
also provide to the originating site privileging authority any identified clinical concerns for the
health care provided. In the case of health care in foreign countries, such virtual services are
authorized from any U.S. location to any location on a U.S. installation or U.S. operational
location with the approval of the responsible medical authority at the originating site, who is
responsible for confirming that no local requirements preclude the arrangement. That authority
is the MTF Director, if applicable, or if no MTF, the senior medical officer or command surgeon
responsible.
b. Pursuant to requirements in Section 1094 of Title 10, U.S.C., health care providers in the
MHS must have and maintain an active, current, valid, and unrestricted license or other
authorizing documents to practice independently within the defined scope of practice for their
specialties. Additional licenses held by a provider must be in good standing whether they are
inactive, expired, or limit the provider’s practice to a military setting. Providers in the MHS may
not have one active license and another currently suspended or probationary license. For
example, if a provider is licensed in both Texas and Tennessee, and the provider’s Texas license
is active, but the provider’s Tennessee license is on probation, restricted, or is temporarily
suspended, the provider would not meet requirements for clinical practice in the MHS.

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DoDI 6025.13, July 26, 2023
(1) Section 1094(d) of Title 10, U.S.C. provides portability of State licensure for DoD
health care providers as long as their practice is within the scope of authorized Federal duties.
(2) For health care providers in the MHS, an unrestricted license is one that is not subject
to any limitation on the scope of practice and would allow the health care provider to fully
practice within the State of issuance.
(a) Maintenance of an unrestricted license requires the military health care provider
to fulfill all licensure requirements necessary to allow unabridged permission to practice in any
civilian community in the jurisdiction of licensure without having to take any additional action
on the license.
(b) An unrestricted license does not waive the standard license fee solely on the basis
of the member being in the military. For those instances in which a state may waive standard
license fees solely on the basis that the licensee is in the military, the DHA DAD MA must make
a determination as to whether that fee waiver would have the appearance of a license not fully
comparable in all respects to a full fee license.
(3) Authority to waive the license requirement is vested with the ASD(HA) and will be
used only to address extraordinary circumstances and in accordance with Section 1094 of Title
10, U.S.C. Such extraordinary circumstances include circumstances in which a state of licensure
establishes a requirement or takes an action the ASD(HA) determines would have the effect of
interfering with the effective implementation of MHS policy or accomplishment of an MHS
mission. This authority is not delegable.
c. Clinical quality of health care delivery is the responsibility of the medical staff, and will
be reflected as such in respective medical staff bylaws.
(1) Peer review is required to ensure individual health care providers deliver safe and
effective health care and practice within the scope of their clinical privileges or clinical practice,
and will be implemented in both MTFs and operational clinical services to require the ongoing
capability and competency of health care providers.
(2) Peer review processes will incorporate ongoing professional practice evaluation and
focused professional practice evaluation. Ongoing professional practice evaluations and focused
professional practice evaluations (with accompanying monitoring and evaluation plans), and any
other clinical performance assessments, will be documented in the respective provider’s provider
activity file, securely maintained training records (e.g., graduate medical education programs), or
competency or training record (e.g., enlisted training programs), as appropriate.
d. Health care providers approved for and participating in off-duty employment will submit
reports to MTF directors and their MILDEP chain of command on the number of patients seen
and the case mix of care provided.
e. Foreign national local hires (FNLH) health care providers will meet the same
credentialing and privileging requirements of U.S. health care providers within the same
specialty, with the exception of U.S. licensure. This applies only to DoD care delivered in
foreign countries by foreign nationals that are hired to work in accordance with the Status of
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DoDI 6025.13, July 26, 2023
Forces Agreement and the DHA-PM 6025.13. FNLH physicians employed within the DoD
before January 1, 2017 that were previously granted an Educational Commission for Foreign
Medical Graduates waiver are exempt from the Educational Commission for Foreign Medical
Graduates requirement.
(1) FNLH non-privileged providers may be credentialed on a case-by-case basis
contingent upon MHS requirements and validated clinical competency for the scope of practice
assigned. They will meet the same credentials requirements of other providers within the same
specialty with the exception of U.S. licensure. This applies only to DoD care delivered in
foreign countries.
(2) FNLH health care providers from jurisdictions other than the United States and its
territories who care for DoD beneficiaries are required to have documented proof of
comprehension and proficiency in oral and written use of the English language provided by an
external agency and current clinical skills.
4.5. AC.
a. AC programs incorporate the MHS HRO guiding principles, with emphasis on requiring
adherence to nationally recognized, evidence-based standards for quality and PS.
b. MTFs must maintain accreditation through an accreditation source recognized by the
Centers for Medicare and Medicaid Services or approved by the ASD(HA). On a military
installation in or outside the United States, if operational clinical services are provided in a fixed
facility, the facility is subject to accreditation unless a waiver is granted by ASD(HA).
(1) ASD(HA) will consider accreditation waivers on a case-by-case basis. All
accreditation waivers must be reviewed annually and renewed at least every 3 years.
(2) Waived facilities must demonstrate use of the same evidence-based standards for
quality and PS as required for accredited MTFs, and implement them to the extent practicable.
(3) Waived facilities will undergo a comprehensive on-site assessment at a minimum of
every 3 years. This assessment will be led by DHA or by another authority designated by DHA
for this purpose.
c. Managed care support contractors, designated providers, and overseas contractors,
maintain accreditation, or manage accreditation requirements within their respective networks, in
compliance with Section 199.6(b)(3)(i) of Title 32, Code of Federal Regulations, and their
respective contracts awarded by the DoD.
d. Operational clinical services, while under separate rules with respect to accreditation, are
provided under standards and procedures comparable to the extent practicable to those applicable
to clinical services provided in accredited MTFs.
(1) On a military installation in or outside the United States where there is an MTF,
operational clinical services are delivered under the authority, direction and control of a
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DoDI 6025.13, July 26, 2023
MILDEP Medical Commander. With respect to operational clinical services provided in a fixed
facility on the installation, unless the accreditation requirement is waived by ASD(HA), the
MILDEP Medical Commander is responsible for either including those operational clinical
services under the MTF’s accreditation, by agreement with the MTF Director, or for advising the
DHA Director and their respective MILDEP SG of the separate accreditation obtained.
(2) With respect to operational clinical services provided in fixed facilities other than on
a military installation where there is an MTF, the applicable privileging authority is responsible
for obtaining accreditation, unless waived by the ASD(HA).
(3) Operational clinical services are documented in the ASD(HA) approved electronic
medical record, or uploaded when practicable and in accordance with Military Service guidance.
(4) Operational clinical services not associated with an MTF AC program will undergo
comprehensive Military Service-led assessments of CQM every 3 years for issues in
implementation of applicable standards (i.e., DHA PM 6025.13 standards to the extent
practicable), with special attention to:
(a) Assessment of PCEs, identification of SIPs, and determinations of whether or not
SOC was met.
(b) Assessment of learning from system and human factors issues causing or
contributing to PCEs.
(c) Assessment of development and implementation of process improvement
activities with follow-up reassessment for effectiveness of risk mitigation and harm prevention.
e. DHA or MILDEP comprehensive on-site assessments waived from accreditation
requirements will be submitted to ASD(HA), or designee, within 30 days of completion of the
assessment visit.
4.6. CM.
a. CM programs incorporate the MHS HRO guiding principles, with emphasis on
assessment of quality of care delivered and alignment of CQI efforts with clinical quality
strategy and plans, identification of trends, and facilitate transparency strategy (particularly
transparency with the public).
(1) They help participation in local, State, and national quality programs and incorporate
comparative analysis of benchmarks from these organizations in MHS quality assessments.
(2) They advance the use of electronic measurement for increased efficiency and
availability of data and information needed to assess clinical quality processes, outcomes,
experience, and organizational structure and systems.

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DoDI 6025.13, July 26, 2023
(3) CM must be incorporated in every level of performance management to objectively
measure the quality of health care delivered; confirm effectiveness of quality control; and
identify opportunities for improvement.
(4) Clinical quality metrics will be defined by clinical leadership, be evidence-based to
the extent possible, and focus on quality outcomes.
b. The MHS participates with, and monitors quality assessment activities in, local, State, and
Federal programs and in external CQM and improvement organizations. MTF’s participation in
such programs should be aligned with MHS and DHA strategy. All MTF participation in these
programs must be approved by the Director, DHA. CM programs will monitor and evaluate
participation in these programs, to include protection of MQA records and information created
by or for the DoD as part of an MQA program. Disclosures of these records and information
(other than aggregate statistical information) will occur only as authorized by Section 1102 of
Title 10, U.S.C.
c. The force health protection quality assurance program provides another aspect of clinical
quality performance measurement for DoD readiness health care issues, and is conducted in
accordance with DoD Instruction 6200.05.
4.7. CQI.
a. CQI programs incorporate the MHS HRO guiding principles, with emphasis on frontline
staff driving MHS-wide CQI. CQI produces measurable and sustained improvement in the
processes and outcomes of care through elimination of unwarranted variance, increased systemwide efficiency, improved patient-centered care and experience, and may decrease the cost of
health care delivery.
(1) CQI takes place across all environments of health care delivery, and demonstrates
leadership commitment to zero harm, a culture of safety, and leading practice standardized tools
and approaches for data driven improvement of patient-centered care.
(2) The MHS demonstrates CQI primarily through the MHS HRO model which depends
on clinical communities to assess key clinical processes, identify priorities for improvement that
align with strategy, and create conditions for high reliability at the point of care (processes,
standards, and metrics). The MHS HRO model is a formalized mechanism to defer to expertise
for:
(a) Innovation in improving patient-centered outcomes.
(b) Eliminating preventable harm and waste.
(c) Maximizing value.
(d) Establishing evidence-based MHS clinical process standards.
(e) Reducing unnecessary variability.
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DoDI 6025.13, July 26, 2023
(f) Embedding learning and safety culture across all care sites.
(3) CQI programs recommend (based on gaps in clinical performance measurement),
help prioritize, and facilitate specific opportunities for improvement.
(4) CQI programs support advancement of CQM capability through coordination of the
development of standardized CQM training and education.
b. Mechanisms for the reporting, sharing and sustainment of lessons learned from process
improvement projects across the MHS will be developed.

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DoDI 6025.13, July 26, 2023

SECTION 5: MHS HRM WORKING GROUP
5.1. MISSION.
The MHS HRM Working Group supports the ASD(HA) in oversight of HRM programs in all
DoD Components. Responsibilities include:
a. Review of the management, processing, and reporting of providers (as appropriate) to the
NPDB, states(s) of licensure, and other applicable regulatory or certifying organizations, of
medical tort claims, active duty death or disability cases associated with the delivery of health
care, PCE, adverse privileging actions, or other adjudicated actions.
b. Review of reporting of providers (as appropriate) to the NPDB, States(s) of licensure, and
other applicable regulatory or certifying organizations, of judgments and convictions, or
government administrative actions.
c. Review and analysis of cases when there is nonconcurrence by the report authority with an
external SOC review.
d. Monitoring and analysis of trends in payments associated with the delivery of health care
in the MHS, of trends in clinical adverse actions, and of trends in judgments and convictions, or
government administrative actions.
e. Monitoring and analysis of trends in the types of compensated events, contributing factors
and human factors involved, and what risk mitigation and CQI activities resulted from event
analysis.
5.2. ORGANIZATION.
a. The MHS HRM Working Group is chaired by the Deputy Assistant Secretary of Defense
for Health Services Policy and Oversight.
b. Principal members will be representatives from the HRM programs, and their respective
supporting legal counsel, of the Military Services and the DHA. Others attend as designated by
the Chair or principal members, e.g., the DHA TRICARE Health Plan Medical Director, or PS or
CP program leads or subject matter experts.
5.3. REPORTING.
The MHS HRM Working Group provides to the Deputy Assistant Secretary of Defense for
Health Services Policy and Oversight:
a. HRM data, trends, and analysis.

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DoDI 6025.13, July 26, 2023
b. Review and analysis of cases when there is nonconcurrence by the report authority with
an external SOC review. Report memoranda, format as determined by the MHS HRM Working
Group, must explain the findings and the rationale for variance in SOC determinations.

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DoDI 6025.13, July 26, 2023

GLOSSARY
G.1. ACRONYMS.
ACRONYM

MEANING

AC
ASD(HA)

accreditation and compliance
Assistant Secretary of Defense for Health Affairs

CFR
CM
CP
CQI
CQM

Code of Federal Regulations
clinical measurement
credentialing and privileging
clinical quality improvement
clinical quality management

DAD MA
DHA
DHA-PM
DHA PSP
DoD RE

Deputy Assistant Director for Medical Affairs
Defense Health Agency
Defense Health Agency procedures manual
Defense Health Agency Patient Safety Program
Department of Defense Reportable Event

FNLH

foreign national local hires

HRM
HRO

health care risk management
high reliability organization

ICTB
IHPP

inter-facility credentials transfer brief
impaired health provider programs

MILDEP
MHS
MQA
MTF

Military Department
military health system
medical quality assurance
military medical treatment facility

NPDB

National Practitioner Data Bank

PCE
PS

potentially compensable events
patient safety

RE

reportable event

SG
SIP
SOC

surgeon general
significantly involved provider
standard of care

U.S.C.

United States Code

GLOSSARY

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DoDI 6025.13, July 26, 2023
G.2. DEFINITIONS.
Unless otherwise noted, these terms and their definitions are for the purpose of this issuance.
TERM

DEFINITION

Accreditation

Process of review that allows health care organizations to
demonstrate their ability to meet regulatory requirements and
standards established by a recognized accrediting organization.

adverse event

See definition for PS event.

aggregate statistical
information

Statistical information relating to medical quality assurance records
under Section 1102 of Title 10, U.S.C., that are at a sufficient level of
aggregation, under criteria established by the Director, DHA, as to
avoid disclosure of particular patients, events, or circumstances
relating to such records.

clinical adverse
action

Action invoked against a health care provider, privileged or not, with
the result that the authority to practice clinically is adversely affected.
Adversely affected privilege(s) or practice are the result of a due
process professional review action based on evidence of misconduct,
or incompetence, or any conduct that adversely affects, or could
adversely affect, the health or welfare of a patient, and that leads to
the inability of a provider to exercise their privilege(s) or practice
with their own independent judgment. This is the collective term
used in this manual that encompasses both an adverse practice action
and an adverse privileging action.

clinical privileges

Permission granted by the privileging authority to provide medical
and other patient care services. Clinical privileges define the scope
and limits of practice for privileged providers and are based on the
capability of the health care facility, licensure, relevant training and
experience, current competence, health status, judgment, and peer
and department head recommendations.

clinical privileging

The granting of permission and responsibility of a health care
provider to provide specified or delineated health care within the
scope of the provider’s license, certification, or registration.

clinical quality
assurance

A program for the systematic monitoring and evaluation of the
various aspects of a project, service, or facility to ensure that
standards of quality are being met. Clinical quality assurance’s main
purpose is to verify that clinical quality control is being maintained.

GLOSSARY

32

DoDI 6025.13, July 26, 2023
TERM

DEFINITION

clinical quality
control

Monitoring clinical services for stability, detecting emerging process
problems (special causes), and taking steps to address them. Clinical
quality control is about ensuring that a process remains stable (“in
control”) over time, that its performance remains within the upper
and lower control limits. It is usually performed by those closest to
the process.

CM

CM uses tools to help evaluate and track the quality of health care
services provided to beneficiaries in the MHS. Analyzing CM data
and acting on identified trends for improvement helps ensure the
MHS delivers safe, timely, effective, efficient, equitable, and patientcentered care.

compliance

The ongoing process of meeting the legal, ethical, regulatory, and
professional standards applicable to a particular health care
organization or provider.

CQI

CQI consists of systematic and continuous actions that lead to
measurable improvement in health care services and the health status
of targeted patient groups. Focuses on the application of several
widely accepted process improvement methodologies to improve
clinical performance and desired outcomes.

CQM

The integrated processes, both clinical and administrative, that
provide the framework to objectively define, measure, assure, and
improve the quality and safety of care received by beneficiaries. The
CQM functional capability includes the following programs: PS;
HRM; CP; AC; CM; and CQI.

credentialing

The process of obtaining, verifying, and assessing the qualifications
of both privileged and non-privileged providers to provide safe
patient care services. This assessment serves as the basis for
decisions regarding delineation of clinical privileges, as well as
appointments and reappointments to the medical staff. The required
information should include qualification data such as relevant
education, training, and experience; current licensure; and specialty
certification (if applicable), as well as performance data such as
current competency and the ability to perform the selected privileges.
This data is collected, verified, and assessed initially and on an
ongoing basis.

credentials

The documents that constitute evidence of appropriate education,
training, licensure, experience, and expertise of a health care
provider.

GLOSSARY

33

DoDI 6025.13, July 26, 2023
TERM

DEFINITION

DoD reportable event Any PS event resulting in death, permanent harm, or severe
temporary harm, as per the Agency for Healthcare Research and
Quality Harm Scale; or meeting The Joint Commission’s sentinel
event or the National Quality Forum’s serious reportable event
definitions. DoD REs require a comprehensive systematic analysis
and follow-up corrective action implementation plan report. This
term encompasses sentinel events referred to in Section 744 of the
William M. (Mac) Thornberry National Defense Authorization Act
for Fiscal Year 2021.
health care provider

Any Service member, civilian employee of the DoD, or contract
employee authorized by the DoD to perform health care services.

health care risk
management

Includes clinical and administrative activities, processes, and policies
to identify, monitor, assess, mitigate, and prevent risks to the health
care organization, patients, and staff. By employing risk
management, the health care organization proactively and
systemically safeguards PS and the organization’s resources,
accreditations, legal or regulatory compliance, assets, and customer
confidence (integrity).

legal sufficiency
review

A determination by the Office of General Counsel, Staff Judge
Advocate or other servicing legal office providing legal services to a
deciding official that a proposed action meets applicable legal
requirements.

MHS

Defined in DoD Directive 5136.01.

MQA

Consistent with Section 1102 of Title 10, U.S.C., any peer review
activity carried out before, on, or after November 14, 1986 by, or for,
the DoD to assess the quality of medical care, including activities
conducted by individuals, military medical or dental treatment
facility committees, or other review bodies responsible for quality
assurance, credentials, infection control, patient care assessment
(including treatment procedures, blood, drugs, and therapeutics),
medical records, health resources management review and
identification and prevention of medical or dental incidents and risks.

MQA records

The proceedings, records, minutes, and reports that emanate from
quality assurance program activities and are produced or compiled by
the DoD as part of MQA as defined in Section 1102 of Title 10,
U.S.C..

GLOSSARY

34

DoDI 6025.13, July 26, 2023
TERM

DEFINITION

MTF

Consistent with 10 U.S.C. 1073c and DoD Directive 5136.13, any
fixed facility of the Department of Defense that is outside of a
deployed environment and used primarily for health care, including
dental care; and any other location used for purposes of providing
health care services as designated by the Secretary of Defense or
USD(P&R).

NPDB

The NPDB is a web-based repository of reports containing
information on medical malpractice payments and certain adverse
actions related to health care practitioners, providers, and suppliers.
The NPDB is managed by the Department of Health and Human
Services in accordance with Section 11101 of Title 42, U.S.C.

near-miss event

See definition for PS event.

no-harm event

See definition for PS event.

operational clinical
services

Clinical and clinical support services on ships and planes, in
deployed settings, and in all other circumstances outside an MTF.

peer review

Any assessment of the quality of medical care carried out by a health
care provider, including any such assessment of professional
performance, any PS program comprehensive systematic analysis or
report, or any other such assessment carried out by a health care
provider under the provisions of this issuance.

potentially
compensable event

Any PS event that both reaches the patient (i.e., adverse events and
no-harm events) and has an HRM assessment that determines that the
event is likely to present a possible financial loss to the Federal
Government. All DoD RE are PCEs. All events that trigger a PCE
will also be referred to the PS manager to ensure capture in the joint
PS reporting system and investigation or analysis as defined in
Volume 2 of DHA-PM 6025.13.

privileging authority

The privileging authority is a designated official who grants
permission to individuals to provide specific care, treatment, or
services within well-defined limits. The privileging authority also
initiates and makes determinations on clinical adverse actions.

GLOSSARY

35

DoDI 6025.13, July 26, 2023
TERM

DEFINITION

PS event

A PS event is an incident or condition that could have resulted, or did
result, in harm to a patient. A PS event can be, but is not necessarily
the result of, a defective system or process design, a system or
process breakdown, equipment failure or malfunction, or human
error. PS events include adverse events, no-harm events, near-miss
events, and unsafe or hazardous conditions defined as:
An adverse event. A PS event that resulted in harm to the patient.
The event may occur by the omission or commission of medical care.
A no-harm event. A PS event that reached the patient but did not
cause harm
A near-miss event. A PS event that did not reach the patient (also
known as “close call” or “good catch”) unsafe or hazardous
condition. A condition or a circumstance (other than a patient’s own
disease process or condition) that increases the probability of an
adverse event.

quality health care

The degree to which health care services for individuals and
populations increase the likelihood of desired health outcomes and
are consistent with current professional knowledge. Care that is
evidence-based and provided in a technically and culturally
competent manner with good communication and shared decision
making.

report authority

The official with the responsibility to report to the NPDB, State(s) of
licensure, and other applicable certifying or regulatory agencies
following appropriate due process proceedings. The report authority
is: the Director, DHA with respect to matters arising from acts or
omissions of health care providers practicing under or privileged by a
privileging authority under the responsibility of the DHA; or the SG
of the Army, Navy, or Air Force, respectively, with respect to matters
arising from acts or omissions of health care providers practicing
under or privileged by a privileging authority under the responsibility
of the Departments of the Army, Navy, or Air Force, respectively.
Designated report authorities ensure there is a comprehensive review
of the entirety of such matters.

GLOSSARY

36

DoDI 6025.13, July 26, 2023
TERM

DEFINITION

SIP

A SIP is one who actively delivered care (based on clinical record
entries) in either primary or consultative roles during the episodes of
care that gave rise to the allegation, regardless of standard of care
(SOC) determination. Additional defining characteristics include
providers that: have the authority to start, stop or alter a course of
treatment; have the authority to recommend to start, stop, or alter a
course of treatment; or have the responsibility to implement a plan of
evaluation or treatment. Authority to recommend means that input
was solicited and legitimate (i.e., the individual making the
recommendation was acknowledged to have special expertise or
other specific standing in the clinical issues). This term is not meant
to include the providers who had only peripheral, yet appropriate,
patient interaction, nor those providers whose patient involvement
was not reasonably related to the specific indications or allegations of
sub-standard care and injury.

telemedicine

Telemedicine, also known as telehealth or virtual health, is the use of
telecommunications and information technologies to provide health
assessment, treatment, diagnosis, intervention, consultation, clinical
supervision, education, and information across distances. This term
includes:
Distant site. The distant site is where the health care provider
providing the medical service is located at the time the service is
provided via telemedicine.
Originating site. The originating site is the location of a patient at
the time the service is provided via telemedicine.

unsafe or hazardous
conditions

GLOSSARY

See definition for PS event.

37

DoDI 6025.13, July 26, 2023

REFERENCES
Assistant Secretary of Defense for Health Affairs Memorandum, “Amplifying Guidance Relating
to the Reporting of Sentinel Events and Personally Identifiable Information Breaches to the
Office of the Assistant Secretary of Defense (Health Affairs),” February 13, 2012
Code of Federal Regulations, Title 32, Parts 45 and 199
Defense Health Agency Procedures Manual 6025.13, “Clinical Quality Management in the
Military Health System,” August 29, 2019
Defense Health Agency Procedural Instruction 6025.17, “Healthcare Resolutions, Disclosure,
Clinical Conflict Management and Healthcare Provider (HCP) Resiliency and Support in the
Military Health System (MHS),” June 18, 2019
DoD Directive 5124.02, “Under Secretary of Defense for Personnel and Readiness
(USD(P&R)),” June 23, 2008
DoD Directive 5136.01, “Assistant Secretary of Defense for Health Affairs (ASD(HA)),”
September 30, 2013, as amended
DoD Directive 5136.13, “Defense Health Agency,” September 30, 2013, as amended
DoD Instruction 5015.02, “DoD Records Management Program,” February 24, 2015, as
amended
DoD Instruction 6025.20, “Medical Management (MM) Programs in the Direct Care System
(DCS) and Remote Areas,” April 9, 2013, as amended
DoD Instruction 6200.05, “Force Health Protection Quality Assurance (FHPQA) Program,”
June 16, 2016, as amended
DoD Manual 8910.01, Volume 2, “DoD Information Collections Manual: Procedures for DoD
Public Information Collections,” June 30, 2014, as amended
Institute of Medicine, Committee on Quality of Health Care in America, “Crossing the Quality
Chasm: A New Health System for the 21st Century,” Washington, D.C: National Academy
Press; 2001
Memorandum of Understanding between the Department of Health and Human Services and the
Department of Defense, November 9, 1992
Office of the Assistant Secretary of Defense for Health Affairs (OASD(HA)) Research
Regulatory Oversight Office Guidance, GD-20-003, “Research Determinations for Process
Improvement, Quality Improvement, and Evidence-Based Practice Projects,” March 2, 2020
Public Law 116-57, Section 744, “William M. (Mac) Thornberry National Defense
Authorization Act for Fiscal Year 2021,” January 1, 2021
United States Code, Title 10
United States Code, Title 42

REFERENCES

38