By Col. Richard MalishMarch 19, 2019
Army Medicine had a remarkable year in 2018. Without fanfare, Army medicine quietly and deliberately achieved one of its most outstanding years in recent times in measures of quality and safety.
Less Human Error
One of the frightening things about modern medicine is the scale at which human error contributes to death rates in America. Researchers, advocacy groups, and professional societies are bringing public attention to this epidemic. In 2016, a Johns Hopkins study estimated that 250,000 patients die every year because of medical mistakes in the United States, making medical error the third leading cause of death.
In spite of this alarming nationwide trend, Army medicine has decreased the number of preventable (and therefore reportable) events. Two years after the Johns Hopkins study, the Army reduced its reportable event rate by 53 percent (from 205 in 2016 to 97 in 2018). Acknowledging that the goal is zero preventable error, the data indicates that Army's efforts to 'get to zero' is resulting in a trend in the right direction.
While poor safety is often identified by errors of commission, low-quality organizations may be defined as ones in which errors of omission are rampant. High-quality organizations minimize errors of omission by habitually following evidence-based guidelines, enforcing standards, and going to extremes to ensure corners are not cut. Measuring quality is more difficult than quantifying safety because quality issues can easily hide in the complex 'system of systems' of modern healthcare.
To discover blind spots for quality and safety, Army Medicine has worked with The Joint Commission for decades. The Joint Commission is an independent, not-for-profit organization that the Army hires to inspect its hospitals and their clinical operations. According to its website, "The Joint Commission accredits and certifies nearly 21,000 health care organizations and programs in the United States." Typically, a team of 4 to 5 Joint Commission experts descend upon a hospital to inspect it over a 3- to 5-day period.
In 2018, the Joint Commission cited Army hospitals with five fewer quality lapses, on average, than the national mean. In the last nine months of 2018, Army hospitals averaged 10 fewer findings than the mean (22.4 versus 32.7). The first two months of 2019 have seen the quality streak continue -- with fewer than 20 findings per hospital.
Another way that Army Medicine assesses quality is by comparing its performance to quality benchmarks aggregated by the National Committee for Quality Assurance (NCQA). As measured in November 2018, Army Medicine performed above the national average in 17 of 20 Health Effectiveness and Data Information Set (HEDIS) measures tracked by the Military Health System. These measures include cancer screening, diabetes tracking and treatment, and well-child visits, to name a few. Impressively, the Army was in the top 25 percent of healthcare plans in 16 of 20 measures, and in the top 10 percent in half.
Lessons from Aviation
How has Army Medicine attained these achievements in quality and safety? It turned to its colleagues in aviation for guidance. Modeling the practices of the Army Aviation Center of Excellence and the Combat Readiness Center, Army medical leaders imbued the system with the following High Reliability Organization (HRO) tenets:
1) Vigilance to vulnerability,
2) Regimented communication for key transactions,
3) Mishap investigation, analysis, and action,
4) Standardization of safety protocols, and
5) Leadership accountability for the performance and treatment of teams.
Army Medicine operationalized the tenets by focusing on "The Top 6," which are tactical protocols standardizing procedural/operative checks, information exchanges, and key aspects of hospital management. The tenet of leadership accountability was the glue that bound the HRO methodology together. Regional and Hospital Commanders were given the lead for implementation of and accountability for The Top 6. Maj. Gen. Jeffery Clark, the U.S. Army Medical Command Deputy Commander for Operations, and leader of the Quality and Safety effort, wouldn't have it any other way, summarizing the program in six words: "Quality and safety is leader business."
Quality and Safety in medicine is a journey -- not a destination. Army Medicine leaders will continue their efforts to prevent medical errors of commission and omission -- but they will redirect their focus to operational and deployed medicine in the near future.
In the next two years, as directed by the National Defense Authorization Acts of 2017 and 2019, the Army will transfer the authority, direction, and control of its hospitals to the Defense Health Agency (DHA). As a result, one thing is certain; Army Medicine's 2018 quality and safety performance should make its hospitals attractive assets for the DHA.