Madigan Army Medical Center is no stranger to the front line. From deploying to every conflict and humanitarian effort around the globe to researching, producing and testing innovative equipment and protocols to standing up the first military treatment facility response to COVID-19, Madigan expects to lead the way. In that vein, it has just completed the first Joint Commission survey for any MTF that has implemented the Department of Defense’s new electronic health record, MHS GENESIS, and is the second MTF to complete the survey since the outbreak of COVID-19.

MAJ Jes
1 / 2 Show Caption + Hide Caption – Maj. Monique Jesionowski, chief of Emergency Nursing Services listens as a colleague offers specifics to answer a surveyor’s question while Staff Sgt. Amanda Mihail, a medic, takes notes while touring the Emergency Department at Madigan Army Medical Center on Joint Base Lewis-McChord, Wash., during its Joint Commission accreditation survey on March 16. (Photo Credit: Kirstin Grace-Simons) VIEW ORIGINAL
A medic explains the process
2 / 2 Show Caption + Hide Caption – Staff Sgt. Aritzelt, a medic, gives a surveyor an explanation of a process while touring the Emergency Department at Madigan Army Medical Center on Joint Base Lewis-McChord, Wash., during its Joint Commission accreditation survey on March 16. (Photo Credit: Kirstin Grace-Simons) VIEW ORIGINAL

The surveyors shared a collective assessment that Madigan was meeting the standard quite well.

“All that we did is show the great work of Madigan; you create the environment for excellence to exist,” Madigan Command Sgt. Maj. Albert Harris said to Madigan’s leadership at an end-of-the-day briefing session.

A team of surveyors scoped out every corner of Madigan and its outlying clinics from Tuesday, March 16 through Friday, March 19. The doctors, nurses, specialists and engineers of the team conducted tracers in clinics in Madigan’s Medical Mall, hospital tower, South Sound Community Medical Home in Olympia, the Allen Soldier-Centered Medical Home, the McChord Clinic, embedded behavioral health clinics that are located within units around Joint Base Lewis-McChord, Wash., as well as testing all forms of environment of care and life and patient safety systems throughout the footprint.

In the freezer
1 / 2 Show Caption + Hide Caption – Tanya Porter, a registered nurse, serves as scribe and follows a surveyor into the freezer while touring the kitchen at Madigan Army Medical Center on Joint Base Lewis-McChord, Wash., during its Joint Commission accreditation survey on March 16. (Photo Credit: Kirstin Grace-Simons) VIEW ORIGINAL
Donning and doffing
2 / 2 Show Caption + Hide Caption – Jose Rodriguez-Torres, the inpatient technician supervisor, demonstrates donning and doffing personal protective equipment for a surveyor inspecting the compounding section of the Inpatient Pharmacy at Madigan Army Medical Center on Joint Base Lewis-McChord, Wash., during its Joint Commission accreditation survey on March 16. (Photo Credit: Kirstin Grace-Simons) VIEW ORIGINAL

Before they left their seats at the in-brief for the week’s survey, they wanted to know all about Madigan’s response to COVID-19.

Acting Commander Col. (Dr.) Scott Roofe explained, “Madigan really used it as a learning and innovation opportunity.”

The first cases of the novel coronavirus in the U.S. were located in the Puget Sound area of Washington state. Madigan was the first MTF to treat a COVID-positive patient. It activated its emergency operations center early on and stayed in lock step with community partners to include local and state health departments. It continues to have regular meetings with them to discuss current state and future planning on all things COVID-related.

Roofe has made frequent use of the term innovate over the course of the past year.

“Our staff helped innovate, it wasn’t all top down. Madigan was able to provide care through alternatives like virtual health,” he noted.

In clinics and offices throughout the facility, staff have come up with ways to shift processes to remote or touchless means to remove patients and staff from close contact. Providers across the organization became proficient in platforms and methods for offering virtual appointments, both teleconferencing and video-enabled. They engaged with one another through a variety of alternative means as well.

Continuing into the vaccination phase of responding to the virus, Madigan staff have still been creating new ways to address the unique challenges to providing care. For example, Rick Barnhill, the deputy chief of Informatics, developed an online vaccine appointment application with his team that has now been adopted by all of the Defense Health Agency as the vaccine appointment scheduler.

Rick Barnhill, app developer
Rick Barnhill, the deputy chief of Informatics, sits in front of a screen displaying his COVID-19 vaccination appointment scheduling application that he and his team created at Madigan Army Medical Center on Joint Base Lewis-McChord, Wash., that has been adopted as the scheduler by Defense Health Agency for all military medicine. The scheduler is one of the responses Madigan is sharing with the Joint Commission survey team as it conducts its accreditation survey on March 16 – 19. (Photo Credit: Jay Ebbeson) VIEW ORIGINAL

Some departments, like behavioral health, had already been making use of telehealth options. For others, it was brand new. But, even the veterans of such processes found their virtual workload increase significantly over the past year.

“Telehealth worked well for us,” said Col. Christopher Perry, the chief of the Department of Behavioral Health, of providing services for patients during the pandemic. “It has highlighted the great need for behavioral health.”

For encounters like surgeries that cannot be performed remotely, staff implemented virtual health options to complete as much of the process without having the patient in the clinic as possible. They did preoperative screenings over the phone and offered education remotely as well.

Also of interest to the surveyors was delayed care – whether it was determined that patients were not getting the screenings and treatments they needed, but also how providers and clinics were attempting to address any such issues.

Col. (Dr.) Thomas Rawlings, the deputy chief of the Department of Anesthesia and Operative Services, answered this query by explaining that all elective surgeries were initially canceled in deference to strictly urgent ones. As operations have slowly moved back to normal, these procedures have returned to the schedule. To ensure that patients were not being neglected, the department has been doing chart reviews to identify anyone who may be at risk and need attention.

“We identified patients who needed screens to stay ahead of disease,” said Rawlings.

Checking the records
Traci Taipale, an inpatient registered dietitian, shows a surveyor a patient’s chart at Madigan Army Medical Center on Joint Base Lewis-McChord, Wash., during its Joint Commission accreditation survey on March 18. (Photo Credit: Kirstin Grace-Simons) VIEW ORIGINAL

The pandemic has provoked constant assessment of processes and methodology. It has also brought a focus to how much work gets done through relationships.

Before coming into the DHA geographical market organization of MTFs, Madigan found itself developing close relationships with its area defense health partners through its shared experience of bringing MHS GENESIS on line.

This complex and highly capable record system integrates all health recording applications across all services into one system that is also being adopted by the Department of Veterans Affairs. With every challenge that has come along since its 2017 introduction in the Puget Sound Military Health System market, Madigan, along with its fellow PSMHS MTFs, has had to work out how what may have been a well-known process in the legacy systems would function within MHS GENESIS. Mass vaccination is one of those elements that Madigan helped determine last flu season and has carried forward into its robust COVID vaccination efforts as well.

Madigan and its PSMHS cohorts formed the test wave that implemented and honed the EHR for two years before it was rolled out to any other facility. The surveyors have been aware of it, the challenges it presented in its rollout and how transformative it has been to the delivery of health care. They were excited to see it in action.

Following up a walk-through of the Emergency Department with a record review, one of the surveyors, who was an Army nurse in her earlier career, declared in a sing-song voice, “This is the first time I get to see GENESIS!”

Though the nurse showing the surveyor the records did have to visit multiple screens to cover the subject of the fall risk of the patient – complexity added by MHS GENESIS’ data rich environment – the surveyor could easily see that the subject was well covered in the record.

Reviewing initiatives
Krista Marcum, staff nurse in leadership in the Emergency Department, shows a surveyor how she assesses fall risk for a patient in their record in MHS GENESIS, the Department of Defense’s new electronic health record, at Madigan Army Medical Center on Joint Base Lewis-McChord, Wash., during its Joint Commission accreditation survey on March 16. (Photo Credit: Kirstin Grace-Simons) VIEW ORIGINAL

The relationships formed through the trialing and refinement of MHS GENESIS have aided all market facilities during COVID through sharing resources and capabilities. Madigan has served as a main hub for testing while Naval Hospital Bremerton was able to send unused equipment to Madigan to help it stand up its COVID ward.

Many of these parts of Madigan’s experience over the last few years since its previous survey may not have been readily apparent to the survey team. What they repeatedly commented on with staff they interacted with throughout the week was the clear emphasis Madigan puts on teamwork. The surveyors were impressed with the way Madigan works together as one team, as a collection of teams and in concert with other units across the base.

They made particular comment on:  the time outs teams do in the operating room before starting a procedure; the way the behavioral health assets that are embedded within units around the base work with the unit and its leadership to build trust and accessibility to care; the ability of staff in any given clinic to explain a process because they have been included in its understanding and use; and how the Pediatrics Hematology/Oncology specialty clinic partners so fully with families as they shepherd their kids through cancer treatment.

The lead surveyor noted in the out-brief, “Everywhere we went, it was a big team effort. You’ve inspired me a number of times; thank you for that.”

Those kudos found company in other surveyors’ remarks.

A quality review
1 / 2 Show Caption + Hide Caption – Vicki Odegaard, the chief of the Quality Services Division, and Becky Lee, the Joint Commission/Performance Improvement registered nurse, relax before the exit brief of the Joint Commission accreditation survey at Madigan Army Medical Center on Joint Base Lewis-McChord, Wash., on March 19. (Photo Credit: Kirstin Grace-Simons) VIEW ORIGINAL
The kitchen
2 / 2 Show Caption + Hide Caption – Capt. Vladislava Ivanova, the chief of Production and Service in the Nutrition Care Division, listens as Sgt. 1st Class Jonathan Williams, the NCD noncommissioned officer, explains a process to a surveyor while touring the kitchen at Madigan Army Medical Center on Joint Base Lewis-McChord, Wash., during its Joint Commission accreditation survey on March 18. (Photo Credit: Kirstin Grace-Simons) VIEW ORIGINAL

The Reproductive Endocrinology & Infertility Clinic’s efforts in providing fertility services for patients as well as Madigan and the ED’s help in pushing forward on improved fall assessments were just two specific examples of efforts and services for which the surveyors expressed gratitude.

The survey team echoed what has come to the fore repeatedly this past year. In every clinic and office, the pandemic has brought into stark relief how each member of the team contributes to the whole and how their collective efforts are appreciated by patients.

Continuously, comments of thanks have been added to Madigan’s Facebook page posts. Even when the line has been hours-long at the Pharmacy because the pandemic closed the waiting room and shunted 10 windows through 2 drive-thru lanes, or appointments were rescheduled, patients have expressed appreciation for the team’s efforts to find a way to make it work.

For Madigan, survey week was just a chance to show that it rises to a good challenge.

Editor’s Note: The survey team prefers to not be photographed as they assess a facility and is not be named here either.

Commander hears the out-brief
1 / 7 Show Caption + Hide Caption – Col. Scott Roofe, the acting commander, listens to the Joint Commission exit brief at the close of the weeklong accreditation survey at Madigan Army Medical Center on Joint Base Lewis-McChord, Wash., on March 19. (Photo Credit: Kirstin Grace-Simons) VIEW ORIGINAL
Out-brief
2 / 7 Show Caption + Hide Caption – Col. Scott Roofe, the acting commander, along with other leaders, listens to the Joint Commission exit brief at the close of the weeklong accreditation survey at Madigan Army Medical Center on Joint Base Lewis-McChord, Wash., on March 19. (Photo Credit: Kirstin Grace-Simons) VIEW ORIGINAL
Finding the records
3 / 7 Show Caption + Hide Caption – Jose Rodriguez-Torres, inpatient technician supervisor, searches records to help show a surveyor a process in Inpatient Pharmacy at Madigan Army Medical Center on Joint Base Lewis-McChord, Wash., during its Joint Commission accreditation survey on March 16. (Photo Credit: Kirstin Grace-Simons) VIEW ORIGINAL
Pharmacy logs
4 / 7 Show Caption + Hide Caption – April Azzarello, a medication safety pharmacist, talks to Dr. Hee-Won Patten, the chief of the Inpatient Pharmacy, about a reference a surveyor has asked about in a records review in the Inpatient Pharmacy at Madigan Army Medical Center on Joint Base Lewis-McChord, Wash., during its Joint Commission accreditation survey on March 16. (Photo Credit: Kirstin Grace-Simons) VIEW ORIGINAL
Watching the hot line
5 / 7 Show Caption + Hide Caption – Capt. Vladislava Ivanova and Sgt. 1st Class Zachariah Bridgeman, the chief and noncommissioned officer-in-charge, respectively, of the Production and Service in the Nutrition Care Division, look on as an NCD teammate completes a task while touring the kitchen at Madigan Army Medical Center on Joint Base Lewis-McChord, Wash., during its Joint Commission accreditation survey on March 18. (Photo Credit: Kirstin Grace-Simons) VIEW ORIGINAL
Hot line
6 / 7 Show Caption + Hide Caption – Gwendolyn Wyatt, patient tray service leader, and Phil Madarang, patient tray service cook, prepare lunch for inpatients while a surveyor tours the kitchen at Madigan Army Medical Center on Joint Base Lewis-McChord, Wash., during its Joint Commission accreditation survey on March 18. (Photo Credit: Kirstin Grace-Simons) VIEW ORIGINAL
The SAFER matrix
7 / 7 Show Caption + Hide Caption – Lt. Col. (Dr.) Melissa Grant, the deputy commander for Surgical Services, looks through the preliminary report at the Joint Commission exit brief at the close of the weeklong accreditation survey at Madigan Army Medical Center on Joint Base Lewis-McChord, Wash., on March 19. (Photo Credit: Kirstin Grace-Simons) VIEW ORIGINAL

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