FORT SAM HOUSTON, TEXAS -- In an effort to improve patient safety, quality and transparency, the Army Surgeon General and Commander U.S. Army Medical Command (MEDCOM), Lt. Gen. Nadja Y. West, directed establishment of the Quality and Safety Center (QSC) and a Root Cause Analysis Event Support Engagement Team (RESET) in 2016.
The establishment of RESET was an effort to reduce patient harm across the entire MEDCOM enterprise. As part of its mission, the RESET team conducts a comprehensive non-punitive, systematic analysis to support data-driven decision making, improve health care quality and reduce the occurrence of patient harm due to wrong-site surgery, unintentionally retained foreign objects, or unanticipated death.
Lt. Gen. West said, "The delivery of safe healthcare to our beneficiaries, whether they receive that care in our health readiness platforms or on the battlefield, is our core mission."
"Ensuring that the care we provide is consistently the safest we can possibly deliver must be the daily focus of all that we do as a healthcare system, leaders, care delivery teams and individuals," added West.
The RESET deploys on order by the Deputy Commanding General - Operations or when requested by Regional Health Command and Military Treatment Facility commanders to assist Regional Health Commands and medical/dental treatment facilities to reveal causal factors and identify root causes, and develop recommendations for future actions to share knowledge across Army Medicine and the Military Health System. It is a resource for medical commanders supporting the study of adverse patient safety problems, development of solutions, and dissemination of best practices and lessons learned across the Army Medical Department.
The RESET team is comprised of experts in relevant clinical subject matter, occupational and patient safety, root cause analysis, health risk communication, and human systems integration. Upon request by a Medical Treatment Facility Commander and approval of the Army Surgeon General, the RESET team deploys to the location within a week or so to perform a detailed root cause analysis though the lens of clinical and human systems performance.
Some of the top root causes they've discovered to date include, but are not limited to; communication, personnel turnover, standards, policies, admin controls, work direction, supervision during work and crew teamwork.
Compared to U.S. civilian healthcare facilities, most of which do not report sentinel type events, Army medical facilities report them in an effort to be transparent and improve patient safety and quality care. This is just one example of how Army Medicine is striving to become a High Reliability Organization (HRO).
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