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“…I tell the squad Sweet’s got a good shot. You make it to

surgical with a pulse; you’ll probably leave with one.”

- “Redeployment” by Phil Klay

In December 2014, Phil Klay—a Marine veteran—won the National Book Award for his riveting series of short stories about life in the combat zone and life back at home after deployment.

We are proud of the combat medical system we developed, honed and continu-ously improved over 13 years of war. And it is powerful to see that success captured through the eyes of a warfighter, a keen observer of life on the front lines. It is mov-ing to be reminded that these battlefield medicine successes are understood—and appreciated—by those we serve.

The stories in Klay’s book capture the broad diversity of experiences our

servicemembers—and their families—face in combat and here at home, depicting both the physical and hidden wounds of these wars.

Just like the characters in “Redeploy-ment,” the Military Health System has its feet planted in both worlds—the deployed environment and the world at home.

Some people would like to separate these two worlds—the deployed and gar-rison environments. They imagine that they are distinct entities that can be separately organized and budgeted.

In the Military Heath System, we don’t have the luxury of operating as if this distinction exists. We train as teams; we deploy as teams; we return as teams—and share what we learned with each other and with our civilian colleagues. Our lessons learned from Iraq and Afghanistan have saved lives in theater, and in Arizona and Massachusetts and innumerable trauma centers around the country.

The end of major combat operations in Afghanistan in December 2014—while welcome—is not the end of warfare, nor is it a respite from disaster, humanitarian crises or the threat of infectious disease that also demands our preparedness. But it is a major transition point for the nation, the Department of Defense and the Military Health System (MHS).

Our overriding responsibility is “readi-ness”—ensuring our military forces are med-ically ready to respond to anything, anytime, anywhere, and ensuring our medical forces are ready to join them with the clinical skills necessary to ensure the health and well-being of that force. We want to take the his-toric rates of survivability from wounds and make it even better. We need to continue to build on the historically low rates of disease and non-battle injuries, which are also part of the MHS success during 13 years of war. Our commitment to force health protection in the deployed environment will keep

SpAnning the globe: the MilitAry heAlth SySteM At hoMe AnD DeployeD in 2015By Dr. Jonathan WooDson

assistant secretary of Defense for health affairs

special section: Leadership OutLOOk 2015

www.MMT-CBRN.com MMT 19.1 | 5

more servicemembers in the fight. In order to be successful in the future, we must maintain and improve a full-spectrum integrated health system, medical educa-tion, research and development, and public health programs.

The obligations of our medical forces extend to non-combat scenarios as well. The Military Health System is a unique and irreplaceable instrument of national secu-rity for the department and the nation. Just this fall, as forces drew down from Afghani-stan, we responded with agile, logistical and technical capabilities to West Africa to confront the global risks from the spread of Ebola.

Similarly, our obligations continue to those who served in these recent wars, espe-cially their long-term health and recovery. Many continue to obtain their health care from the department and our civilian net-work of providers. Our expertise in prosthet-ics, rehabilitation, post-traumatic stress and traumatic brain injury is profound—and needs to be sustained.

This capability and expertise cannot be summoned on a moment’s notice, but requires a strong, functioning, ready health system.

After 13 years of war, however, our medi-cal personnel are returning to an American health system that is different from 2001: fewer hospitals, much more care delivered in an outpatient setting, and greater sub-spe-cialization in civilian centers of excellence. And so, our challenge is to ensure that the expertly trained physicians, nurses, medics and corpsmen, and many other medical spe-cialists, sustain their hard-earned expertise for whatever future contingencies may arise.

New approaches for how we sustain these skills are required.

First, we are going to build upon the early success of the Defense Health Agency. Wherever analysis shows that greater inte-gration of Army, Navy and Air Force exper-tise can provide benefits to the system as a whole, we will pursue joint initiatives. The early results from the DHA serving as a critical integrator for shared services are promising. Success is not simply mea-sured in dollars saved or other simple measures of efficiency. Rather, success is measured in more rapid dissemination of best practices, the identification of common processes that support the readiness of all services and an improved ability to serve in joint environments.

Second, we will provide the platforms to sustain our expertise by putting our per-sonnel in the locations where they are best positioned to sustain their clinical skills. In many cases, that will be military hos-pitals. But it will also include expanding our relationships with civilian institutions. We do know this: Maintaining inpatient medical facilities that can no longer sustain active and complex clinical practices is not simply inefficient; it also undermines our readiness mission.

Outreach to our colleagues in other government agencies, the civilian sector and nonprofits is essential. We will deepen our strategic partnerships, foster even greater collaboration and accelerate the dissemina-tion of best practices.

The recent review of the MHS found that, overall, the MHS provides quality care to our beneficiaries comparable to that found throughout American medicine. But, we also found high variation from MTF [military treatment facility] to MTF. Strengthening our partnerships, enhancing

transparency and forging a path in which our health system is seen as one of the safest, most reliable in the country will serve to reinforce the confidence service-members and beneficiaries have in their medical system.

An important element of our strategy also requires us to better integrate our TRICARE network with our military MTFs. The next generation of TRICARE contracts will provide incentives that both ensure timely access to health care for our patients and ensure that the entire continuum of care is captured for the patient and for the provider. We look forward to reforming TRICARE so that it serves beneficiaries more effectively and supports the MHS and its readiness mission.

As we work more closely with civilian providers, it is also likely that more of these providers will be serving in the reserve component. The coming years will also be characterized by recalibrating the active and reserve component mix and finding the right balance of personnel to ensure we can mobilize and scale our medical operations when called upon.

Finally, we will continue to engage with our global partners in preventing or responding to the threats faced from infec-tious diseases. The Ebola crisis was not the first—nor will it be the last—example of how medical crises can destabilize nations and economic structures. Yet it was also a warning shot that the global community cannot be complacent about even the small-est threats in faraway places. We have been part of the solution that helped to stabilize a region and protect citizens here at home and around the world from an epidemic.

The Military Health System has been a central actor in this global health mis-sion as long as a military health system has existed. We have been making investments in research, in medical surveillance, in over-seas laboratories and “boots-on-the-ground” expertise. In our laboratories, we continue to perform groundbreaking research into diag-nostics, vaccines and therapeutics for HIV, Ebola, malaria, Japanese encephalitis—and a list that goes on and on.

We are a system that is indispensable and exceptional, but never complacent. There is much work required to sustain this value to our leaders and the nation. And our future will be defined by greater collaboration with our other government and civilian partners around the globe.


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When the Defense Health Agency was established October

1, 2013, it represented both an important milestone and a simple promise—a shared commitment and mutual obligation from everyone in the Military Health System to work together in pursuit of our common goals: ensuring the medical readiness of the total force and the readiness of our medical force.

Now, with our first year in the books, we can proudly say that the DHA has been a textbook example of what it means to work as a team. DHA supports the services and combatant commands and provides value to the warfighter and to all of our beneficiaries around the globe. By working with and in support of the services, the DHA has acceler-ated the implementation of a number of key

initiatives, driving greater jointness across the MHS and achieving cost savings much earlier than expected.

In fiscal year 2014, the DHA was expected to increase costs as we stood up our organi-zation by making strategic investments that would pay off down the road. Yet, due to the fact that we worked together, the DHA was able to control our infrastructure invest-ments by paying off all initial costs through generated net savings of $236 million in our first year. This represents both a commit-ment to being careful stewards of taxpayer dollars and proof that working together allows us to pursue our mission more effec-tively and efficiently.

A prime example is our medical logistics team who worked with the Defense Logistics Agency and MHS clinicians, standardizing medical supplies and equipment, expanding

the use of eCommerce systems, and lever-aging DoD’s buying power to obtain lower product costs on more than 1,400 prod-ucts—saving more than $10 million. Our pharmacy shared service worked with the services to move select maintenance medi-cation refills out of retail pharmacy and into either TRICARE mail order or our military treatment facilities, generating nearly $75 million in savings. Our health IT staff iden-tified nearly $40 million in savings through consolidating redundant programs and port-folios, providing efficiency both in terms of cost and reductions in overlap and confu-sion. The list of successes goes on and on. I am extremely proud of the work our DHA team has done and the outcomes we’ve real-ized, but this is only the beginning.

As we work to transition our DHA to full operating capability in 2015, we are

Full operAting CApAbility AnD beyonD: the DeFenSe heAlth AgenCy in 2015By lieutenant General DouGlas roBB Director of the Defense health aGency


Thank you for this opportunity to talk about several

initiatives in Army Medicine that are of vital importance to our ongoing journey to provide the best care possible to all of our beneficiaries

Our focus continues to be on quality, safe care to our soldiers, families and retir-ees. We are inculcating this throughout the organization by educating our staff and providers in the principles and imperatives critical to building a culture focused on “zero preventable harm.”

The operating company model (OCM) is the methodology that we are using to become a high reliability organiza-tion (HRO). The OCM, along with unity of effort, has been the driving force in supporting the Army Medicine campaign plan to move from a health care sys-tem to a ‘system for health’ by providing the ability to improve consistency, clarity and accountability across Army Medicine.

This has been demonstrated in multiple areas to include the implementation of ser-vice lines across the enterprise, and it has become the catalyst for Army Medicine’s journey to becoming a HRO.

The Medical Command is conducting HRO regional summits with respective command teams in its move to becom-ing an HRO. During these summits I have emphasized the need for a whole-sale commitment to, and active partici-pation in, instilling a culture of safety. This message has also been shared among our non-patient care commands. In par-allel, we have collaborative efforts with the Combat Readiness Center to leverage their own work in safety culture, with an emphasis on achieving our goal of zero preventable harm.

This journey to become an HRO will be a continual effort to improve the culture of safety within Army Medicine.

The second initiative I would like to highlight is our three-year expansion of

telehealth (TH) to create a connected, consistent patient experience (CCPE). This expansion will augment current Army TH programs to provide world-class capabilities to our partners in health and partner nations, creating a 360-degree care continuum around patients using advanced TH modalities in multiple clinical specialties.

For example, Army Medicine is work-ing to build a seamless, global tele-con-sultations platform that optimizes and integrates its current systems. From bat-tlefield to bedside, providers will be able to access specialty expertise from their col-leagues throughout the world.

As another example, Army Medicine is incorporating TH into our global health engagements strategy plan. Using TH, Army Medicine will work with partner nations to improve foreign armed forces’ and foreign civilian authorities’ health system capacity in support of national security objectives.

A SySteM For heAlth: three initiAtiveS For ArMy MeDiCine in 2015 By lieutenant General Patricia D. horoho

surGeon General, uniteD states army

looking to the future to continue building the foundation that enables more effective and efficient support to our warfighters, our beneficiaries and our MHS staff.

And, on the horizon for 2015, the DHA is leading the way in preparing and executing two major projects for the MHS: enabling DoD’s electronic health record moderniza-tion and instituting the next generation of TRICARE contracts.

As DoD acquires its future electronic health records, DHA will work with the services and the department to ensure the infrastructure, training and support services are prepared to facilitate an effective and suc-cessful rollout. Almost simultaneously, DHA will deploy the next generation of TRICARE contracts—focused on more integrated and coordinated care to our beneficiaries regard-less of where it is received. Additionally, DHA’s contracting and procurement staff will institute an integrated acquisition struc-ture that will help the Army, Navy, Air Force and DHA leverage our strategic capabilities and realize savings through more synchro-nized acquisition and support contracts.

DHA is also looking to take the lessons we have learned in standing up our first 10

shared services and apply them toward other opportunities for collaboration and integra-tion across our MHS. The Future Shared Services Group, led by the services and chaired by a rotating deputy surgeon gen-eral, works to identify opportunities, pro-grams and services that would benefit from greater coordination and collaboration.

Our work at the DHA focuses on inte-gration to support our quadruple aim—improved readiness, better health and better care, which result in greater value and lower costs.

Last summer, the secretary of defense ordered a comprehensive review of the MHS to ensure we were meeting the expectations of our beneficiaries and of the American people—that the quality and safety of our health services were second to none.

The findings from this review—con-ducted by our own people and validated by esteemed independent national experts in safety and quality—showed we compare well to other American health systems. But for the MHS, “good” is not good enough.

An important recommendation emerg-ing from that review was the need for the MHS to have a central, standardized system

to review and evaluate performance across the enterprise. As a result, DHA, in coordi-nation with the services, helped to develop and establish the performance manage-ment system—a first-of-its-kind standard-ized system of metric and performance review that is common across the enter-prise and built to drive MHS system-wide continuous improvement.

As DHA comes to full maturation, I am more encouraged than ever at the commit-ment, collaboration and drive I see every day amongst our staff and the services. In 2015 and beyond, our DHA will continue to fulfill its promise that is prominent in every element of its outreach: “Medically Ready Force...Ready Medical Force.” I am proud of how far the DHA has come organizationally as a support agency to enable a stronger, better and more relevant MHS. We will continue to pursue excellence in all aspects of our operational responsibilities—battle-field medicine, access, patient safety, quality, medical research, education and training, public health and personal wellness—and we will support our warfighters, patients, beneficiaries and service counterparts every step of the way.



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Additionally, Army Medicine commences a pilot in fiscal year 2015 that connects patients who have diabetes with primary care providers through remote health monitoring. Patients will be given remote, Bluetooth-enabled glucometers, blood pres-sure cuffs and other devices to track their vital signs. Vitals are uploaded securely and seamlessly to an Army-developed applica-tion which can be seen by a patient’s care team, who can then communicate with the patient about any resulting changes in their clinical care. This pilot will create a focus on patient-centered care and early medical intervention, preventing poor outcomes and unnecessary ER visits or hospitalizations. The CCPE leverages Army-developed inno-vations to create an integrated global TH system of clinical care.

Army TH expansion complements our global tele-behavioral health (TBH) system of care in both garrison and operational settings. A typical Army TBH encounter involves a clinician (e.g., psychiatrist, psy-chologist or social worker) in one location

providing direct care to a patient in another location using clinical video tele-conferenc-ing systems. Army Medicine has invested in three TBH provider hubs to conduct these kinds of encounters. The hubs are strate-gically located across the world to ensure routine and emergency surge support cov-erage on the ‘awake clock’ (where someone is always awake and ready to support the mission). The Fort Hood shooting is an example of emergency surge support. After the April 2014 Fort Hood shootings, clinical support from Washington D.C., Honolulu, Hawaii, and San Antonio, Texas, were surged quickly via TBH to support our soldiers at Fort Hood.

Overall, expanding TH improves access to care and supports Army Medicine’s jour-ney towards a high reliability organiza-tion. Quality, access and patient safety are enhanced as tele-health offers a clinical capability that enables providers across time zones and locations to consult and collaborate with other clinicians to obtain specialty expertise and second opinions

and extends access to care for patients in remote locations.

Finally, I want to close with a few com-ments about our performance triad initia-tive. The performance triad is an initiative designed to influence soldiers, Department of the Army civilians, families and retirees to set goals to improve their daily activity, nutrition and sleep behaviors—three key components that directly impact cognitive and physical performance and influence their overall health, resilience and well-being.

It is a comprehensive public health edu-cation program that empowers Army leaders to improve physical, emotional and cognitive dominance through strategies that optimize sleep, activity and nutrition. While each component of the performance triad is inde-pendently important, optimal performance and health is achieved when all three are addressed simultaneously. The performance triad will serve to improve readiness and increase resilience, and it serves as the foun-dation for Army Medicine’s transformation to a system for health.


Since becoming the surgeon gen-eral of the Navy in

November 2011, my priority has been to

strategically align Navy Medicine with the priorities of the secretary of the Navy, chief of naval operations and commandant of the Marine Corps. Navy Medicine plays a vital

role in supporting the warfighter and is fully engaged in executing the operational mis-sions and core capabilities of the Navy and Marine Corps. We do this by maintaining

nAvy MeDiCine: Stepping up to the ChAllengeBy Vice aDmiral mattheW l. nathan

surGeon General anD chief, u.s. naVy Bureau of meDicine anD surGery

The United States Air Force’s core mis-sions are air and

space superiority, ISR (intelligence, sur-veillance and reconnaissance), rapid global mobility, global strike, and command and control. These are almost identical (but in different terms) to the missions the USAF had in 1947. But we now do these missions in three domains: air, space and cyberspace. In the Air Force I grew up in, the “opera-tors” were primarily pilots and navigators. There are many more types of “operators” these days, as air power is projected through the various domains in new ways. Air Force Medicine is adapting and innovating to bet-ter support the airmen who safeguard this country 24/7, 365 days a year. In that regard, Air Force Medicine is now focusing on human performance. This is not a huge shift for us. Since the Air Force Medical Service (AFMS) began in 1949, Air Force medics have focused on occupational and population health and prevention. We are simply taking it to the next level. Our AFMS strategy embraces this, and to focus on this as a priority, we recently changed the AFMS vision to:

“Our Supported Population is the Healthiest and Highest Performing Seg-ment of the U.S. by 2025.”

Every airman has performance demands placed on them by virtue of their operational and mission tasks—and these demands have changed, rather than decreased, due to the technologies employed in current mission environments. In view of the evolving Air Force, the AFMS is evolving to ensure that as many of our supported servicemembers are available to their commander as possible and able to perform the exquisite set of skills that are now required of them. Health in the context of mission equates to performance,

and every medic or health care team must know how the mission might affect the health of the individual or unit, and how medical support affects the mission. I think this is just as relevant for other beneficiaries, including family members and retirees, who also have performance goals in their day-to-day activities.

At the clinic level, our intent is to pro-vide customized prevention, access and care for patients, recognizing specific stresses associated with career specialties. Our goal is to prevent physical or mental injuries where possible, and if unable to prevent them, provide rapid access to the right team for care and recovery to full performance. As a result, mission effectiveness and quality of life should improve, and long-term injuries or illnesses are mitigated to provide for a healthier, more active life, long after separa-tion or retirement. Concordantly, long-term health care costs and disability compensa-tion should also decrease.

Patient safety and quality care are foun-dational to supporting our beneficiaries in their quest for better health and improved performance. In order to improve both safety and quality, we are committed, as part of the Military Health System (MHS), to become a high-reliability health care system. This is a journey being undertaken by health care systems across the country. To achieve this goal, we need a focused commitment by our leadership and staff, instilling a culture of safety and quality, constant measurement of the care we provide combined with robust process improvement at all levels. These key tenets will enable the AFMS to achieve the principles of high reliability seen in aviation and nuclear communities, and are aimed at eliminating medical errors. To that end, we are committed to strengthening our perfor-mance improvement programs and training

all medics as “process improvers.” A culture of safety requires that all AFMS members are empowered and understand their responsi-bility to report any unsafe condition or error.

After more than 13 years of war, in which the MHS attained the lowest died-of-wounds rate and the lowest disease/non-battle injury rate in history, the AFMS is envisioning future conflicts and adjusting our concepts of operations to prepare to provide medi-cal support in situations that could be very different than what we have faced in the current long war. Among many efforts, we are focusing on en-route care (aeromedical and critical care evacuation), expeditionary medical operations, and support to per-sonnel during combat operations. Future contingencies may require longer transport times of more acute casualties without the benefit of stabilization in fixed facilities, as we have had in Iraq and Afghanistan. We have to consider worst-case scenarios, which will prepare us well for less challeng-ing circumstances. By enhancing clinical skills through our partnerships with busy, high-acuity civilian medical centers, regular sustainment training for all team personnel, and developing new medical capabilities, we are committed to being just as ready or more ready at the beginning of the next war as we were at the end of the current war. Our nation expects no less—and our warriors deserve no less.

With our vision of health and perfor-mance in mind, the Air Force Medical Ser-vice is committed to providing the best prevention and care possible to a rapidly changing Air Force, both at home base and deployed. I am confident that we are on course to ensure medically fit forces, provide the best expeditionary medics on the planet and improve the health of all we serve to meet our nation’s needs.

Air ForCe MeDiCine: A viSion For the Future By lieutenant General (Dr.) thomas W. traVis

surGeon General, uniteD states air force



warfighter health readiness, deploying for-ward and delivering a continuum of care from the battlefield to the bedside, while also protecting the health of all those entrusted to our care.

The reach of Navy Medicine spans around the globe. Our organization is unique in that our practitioners are called upon to operate in many environments. That’s one of the things I find most professionally rewarding about Navy Medicine. We serve in every environment—not only on land, but also in the air, above and below the sea. From rendering medical aid to friend or foe in austere locations, to delivering babies at our military hospitals, to developing vaccines to protect our forces against disease, to provid-ing humanitarian assistance around the world, Navy Medicine is there.

Every day, no matter what environment, Navy Medicine is there to care for those in need, providing world-class care anytime, anywhere. Recently, our infectious disease experts joined the Centers for Disease Con-trol in fighting the Ebola virus outbreak in West Africa. By setting up two labs in Libe-ria, we helped identify possible Ebola cases and contain the spread of the disease. And although our mission leading the NATO hos-pital in Afghanistan is coming to an end as troops continue to withdraw, we stand ready to support our sailors and marines wherever they are serving.

Focused on Priorities: Readiness, Value, Jointness

It’s an exciting time to be a part of Navy Medicine and military health care. As part of an evolving Military Health System (MHS), we must adjust the way we conduct our business while not losing sight of our Navy Medicine priorities. This year, readiness, value and jointness will continue to guide our mission. As we go forward in 2015 and beyond, Navy Medicine will continue to maintain the highest state of medical readi-ness for our Navy and Marine Corps team, while increasing the value and jointness of our operations.

Readiness is the hallmark of our daily battle rhythm. The bottom line is maintain-ing the readiness of our sailors and marines is our top priority. We are a ready medical force working to ensure our sailors and marines are physically and mentally prepared to meet the emerging needs of the operational commanders. We must ensure our Navy and Marine Corps forces maintain the highest

state of medical readiness, while similarly, as a medical force, we are leaning forward and are ready to deploy in support of any call to duty. Quite simply, it’s what we do and why we exist.

The value of Navy Medicine is measured through the great work our professionals do every day to deliver safe and effective care. We are fortunate to have highly skilled, experienced and dedicated people working in Navy Medicine. Combining that talent and expertise allows us to have a profes-sional team committed to maximizing our available resources and streamlining the way we do business.

We are not only facing changes in the way we do business, but also potential long-term fiscal uncertainty. While the president’s budget for fiscal year 2016 continues to adequately fund Navy Medicine to meet our medical mission for the Navy and Marine Corps, in this fiscal environment, we must remain committed to deriving best value from the resources provided to us.

To ensure our investments and objec-tives are targeted to support our strategic goals, Navy Medicine leaders are achieving measureable progress optimizing our sys-tem, implementing efficiencies and reduc-ing purchased care expenditures for our enrolled patients. I continue to make recap-turing private sector health care a priority for our MTF commanding officers.

Over the next year, we will also be closely monitoring changes proposed to the TRICARE program in both the budget and as part of the Military Compensation and Retirement Modernization Commis-sion. Whatever changes are considered, it is critical that we communicate the impor-tance in retaining the gains made in combat casualty care over the last 13 years of war. Furthermore, we must emphasize that our first priority is ensuring our naval forces, whenever they’re called upon, are ready to deploy and conduct their missions.

Navy Medicine is an organization that continues to step up to the challenge and look for ways to improve. On May 28, 2014, the secretary of defense ordered a compre-hensive 90-day review of the military health system. It examined the current access to care and the safety and quality of care pro-vided to all Department of Defense benefi-ciaries, both in military treatment facilities across Navy Medicine, as well as the health care that the department purchases from civilian health care providers. Overall, the

review found we provide timely, quality and safe medical care across our enterprise that is comparable to our civilian counterparts.

The review also demonstrated Navy hos-pitals and clinics are performing well, in some cases better than or on par with the nation’s best, and discussed where we might be lagging. As a result, we’ve decided to further pursue a critical self-assessment that will help us define opportunities for continuous improvement as we transition to a high-reliability organization.

The implementation and expansion of our patient-centered model of care, Medi-cal Home Port and Neighborhoods, con-tinues to prove a game changer in the way we provide care to our beneficiaries. The increased access to our providers has a posi-tive impact on satisfaction and health care outcomes. In addition, Medical Home Port allows our providers to better collaborate across specialties, which positively impacts the quality and safety of the care provided. It’s our responsibility to aggressively evalu-ate everything we do and seek greater value and transparency in what we provide, and we are doing just that.

Jointness is critical to how we operate and directly impacts readiness and value. With the establishment of the Defense Health Agency just over a year ago and enhanced multiservice markets, we are operating in a more joint environment every day. Navy Medicine is committed to leading the way in engaging with our sister services to develop joint health care solutions. Our unique Navy capabilities enhance the joint military health care environment, and by working jointly with our sister services, other health care institutions, non-govern-mental organizations, the private sector and academic partners, we are building a stronger team. Working together jointly leverages the synergy of creating efficien-cies, removing redundancies and allowing greater transparency, which in turn elevates the care we provide.

I am incredibly proud of the Navy Medi-cine military and civilian team that contin-ues to step up when called upon and step forward when needed. We are fortunate to have our country’s finest health care profes-sionals, marked by an ethos of readiness, agility and commitment, serving in Navy Medicine. It is our responsibility to ensure the care we give each and every benefi-ciary—sailors, marines and their families—is the best we can possibly provide.


In an instant, a bullet or IED blast can create a life-

threatening injury. Thanks to a relentless focus on improving combat casualty care, today’s casualties are more likely to sur-vive catastrophic combat injuries than in any conflict in recorded history. As then-Secretary of Defense Chuck Hagel said in a memo to the services last October, “The Military Health System has demonstrated excellence in … battlefield trauma care, medical evacuation and post-combat reha-bilitative care. In providing medical support for operational forces it is without peer in the world.”

Hagel also noted the results of a detailed review of in-garrison military medical care revealed the performance of U.S. military medical facilities was comparable to those of civilian health care organizations, and then he challenged the Military Health System to become preeminent at home as well as in combat.

This dedication to improving combat care, which has saved so many lives, is a characteristic of HROs—organizations whose leaders are committed to eliminat-ing harm and errors by creating a culture of safety and continuously improving every aspect of their operations. Outside of medi-cine, the nuclear and aviation industries have achieved a remarkable level of safety. In the 1990s, the U.S. airline industry, for example, was considered very safe—averag-ing 129 deaths per year from accidents, or 13.9 deaths per 1 million flights. The indus-try was not content with this death rate, however, and in the decade that followed, it fell by 88 percent to a remarkable 16.6 deaths per year, or 1.6 deaths per 1 million flights. And the aviation industry, like other highly reliable organizations, is committed to continuing to improve safety.

Since the Institute of Medicine’s 1999 report on patient safety in the U.S. health system, many organizations have commit-ted to improving the care they provide. But subsequent reviews have found limited systemic change.

Fortunately, a few health care organiza-tions have significantly improved how they deliver care. Thedacare, a Wisconsin-based

system with five hospitals and multiple clin-ics, is now one of the highest-performing U.S. health care organizations. Kaiser Per-manente, an even larger system that cares for roughly the same number of people as the MHS, is another industry leader in many areas of quality and safety.

The MHS leadership has been learning from the experts about how these—and other organizations—have made so much progress. Each of them has stressed it has taken years of focused effort. The first and most important step is to embrace an unwavering commitment to eliminate harm and errors. Instead of accepting some level of complications, or patient harm, as expected, HROs use each harm event as a learning opportunity to improve their processes with the goal of reducing the chance that another patient will be harmed. Even where hospitals have elimi-nated central line infections, for example, the leadership and staff continue to look for ways to improve. There is no ‘good enough’ level of safety.

These organizations often take five, 10 or more years to implement the changes needed to achieve such a high level of safety. In addition to this constancy of purpose and leadership commitment, another key attribute each of these organizations share is a culture in which every member of the organization is constantly looking for and reporting problems or unsafe conditions before they pose a risk to the patient or to staff. They focus on failures or near misses in order to learn from them and to continue improving. Leadership rounds provide an opportunity for frontline staff to interact with leaders on a regular basis to discuss improvements in their workplace and for leaders to recognize staff who have contrib-uted to improved safety.

The good news for our MHS is our approach to operational medicine is an exceptional foundation on which to build. Our medics downrange have demonstrated repeatedly over the past 14 years of combat and contingency operations that there is no ‘good enough’ when it comes to caring for our ill and injured, and we plan to bring this same mindset to every MHS facility. There is no silver bullet that will work in

every clinic or hospital to eliminate harm and errors overnight, because each cares for different patients and faces different local constraints.

DoD already has excellent training pro-grams, like TeamSTEPPS, which help to develop better team dynamics. Our simula-tion labs are excellent settings for teams from clinics, wards, ORs and other care set-tings to test new processes to improve care. Using a combination of Lean, Six Sigma and change management tools can help medics analyze their performance data in order to identify processes needing improvement.

This multi-year and multifaceted approach to improving relies not only on our staff and leaders changing, but also needs regular input from our patients. To facilitate their awareness of the care we provide, we have consolidated our existing, public-facing performance data online at www.health.mil, showing key access, qual-ity, safety and satisfaction measures for both our direct and purchased care systems. We are in the process of redesigning how we present this data to make it even more engaging and easier to understand. And, we are working with the Centers for Medicare and Medicaid Services to ensure our per-formance is also presented on Medicare’s Hospital Compare site.

This transparency and accountability to our patients is part of our dedication to truly being patient-centered, and we are working with volunteers to improve the presentation of this information to make it easier to use.

MHS leaders have embraced the prin-ciples of highly reliable organizations as the means to achieve the Quadruple Aim: better care, better health, better value and improved readiness. The great news is that across the MHS, there is a shared desire to work together as an integrated sys-tem to eliminate harm and errors. Our patients—whether seeking care at home or downrange in the combat theater—deserve nothing less. O

For more information, contact MMT editor chris Mccoy at [email protected] or search our online archives

for related stories at www.mmt-cbrn.com.

trAnSForMing the MilitAry heAlth SySteM into A high reliAbility orgAnizAtionBy colonel Paul frieDrichs

chairman, mhs hiGh reliaBility orGanization task force



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