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DoD’s Response to the Patient Safety Elements in the 2014 Military Health System Review DODIG-2018-036

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Background:

In May 2014, the Secretary of Defense directed a 90-day comprehensive review of the MHS to evaluate DoD beneficiaries’ access to care, patient safety, and quality of care. The MHS is a global, comprehensive, and integrated system of health care for the DoD, which includes combat medical services, peacetime care delivery, public health activities, medical education and training, and medical research and development.

 

Findings:

We found that:

• The MHS Action Plans contained courses of actions to resolve all 28 relevant findings in the patient safety section of the MHS Review.

• The two MTFs identified in the review as underperforming in PSI #90 did not have a current benchmark to compare their performance to other healthcare facilities. However, the two underperforming MTFs each took actions to address individual Patient Safety Indicators that caused their underperformance in PSI # 90. We found that both MTFs improved in individual Patient Safety Indicators.

 • All eight MTFs identified in the MHS Review as underperforming in healthcare associated infection measures were no longer underperforming.

• The MHS improved in six of the seven areas of the “Hospital Survey on Patient Safety Culture” identified in the MHS Review as lower than the national average; however, the area of staffing worsened and was significantly below the national average.5

• The DoD was developing governance for common policy, procedure, and direction but had not yet issued specific patient safety guidance.

• The MHS developed a performance management system, referred to as the Partnership for Improvement. The MHS used the Partnership for Improvement to monitor patient safety for areas requiring improvements.

 

Recommendations:

We recommend that the Under Secretary of Defense for Personnel and Readiness establish and implement specific DoD policy on fatigue risk management for MHS staff.

We recommend that the Commander, United States Army Medical Command evaluate the Madigan Army Medical Center’s Patient Safety Indicator #90 performance after the new Patient Safety Indicator #90 measures and benchmarks are available, to determine if the facility is outperforming, performing the same as, or underperforming compared to other healthcare facilities, and take appropriate action to correct all identified deficiencies. 5 Qualitative survey comments indicated concerns that overall MTF staffing, MTF staffing with specific types of staff, and MTF staff fatigue compromised patient safety.

We recommend that the Commander, Air Force Medical Operations Agency evaluate the 88th Medical Group’s Patient Safety Indicator #90 performance after the new Patient Safety Indicator #90 measures and benchmarks become available to determine if the facility is outperforming, performing the same as, or underperforming compared to other healthcare facilities, and take appropriate action to address any identified deficiencies.

Finally, we recommend that the Director, Defense Health Agency:

• notify the DoD Office of Inspector General when all the MHS Review Action Plans regarding Patient Safety are implemented; and

• determine the actionable root causes in the area of Staffing in the “Hospital Survey on Patient Safety Culture,” and take appropriate actions to improve those factors that pose a risk to patient safety.

 

Management Comments and Our Response:

The Official Performing the Duties of the Under Secretary for Personnel and Readiness (USD [P&R]) agreed with our recommendation to establish and implement specific DoD policy on fatigue risk management for MHS staff. He said that the Defense Health Agency’s (DHA) Patient Safety Program will assess enterprise-wide and MHS-specific factors that influence workforce fatigue risk and resiliency. In addition, DHA’s Patient Safety Program will inform policy planning regarding strategies required to mitigate healthcare workforce fatigue and improve healthcare workforce resiliency. This recommendation is resolved but remains open. We request that the DHA Director send us a copy of the final policy upon issuance.

The Commander, U.S. Army Medical Command and Office of the Surgeon General, and the Air Force Surgeon General, responding for the Commander,  Air Force Medical Operations Agency, agreed with   our recommendations to evaluate the Madigan Army Medical Center and the 88th Medical Group’s Patient Safety Indicator #90 performance after the new Patient Safety Indicator #90 measures and benchmarks become available.  They said that both the Army and Air Force plan to determine if their facilities are outperforming, performing the same as, or underperforming compared to other non-DoD healthcare facilities, and take appropriate action to address any identified deficiencies.

These two recommendations are resolved but remain open.  We request that both the Army and Air Force provide us a copy of the final evaluation which determines that their facilities no longer underperform in Patient Safety Indicator #90.

The Official Performing the Duties of the USD (P&R) agreed with our recommendation to have the DHA Director notify the DoD Office of Inspector General after the MHS has implemented all MHS Review Action Plans regarding Patient Safety.  The Official Performing the Duties of the USD (P&R) explained that DHA’s Patient Safety Program continues to make progress toward implementing and fully closing the MHS Review Action Plans.  This recommendation is resolved but remains open.  We request that the DHA Director send us written notification after the MHS has implemented all MHS Review Action Plans regarding Patient Safety.

The Official Performing the Duties of the USD (P&R) also agreed with our recommendation to determine actionable root causes of low Staffing dimension scores in the “Hospital Survey on Patient Safety Culture” and to take action.  He said that DHA’s Patient Safety Program will identify MHS-wide actionable causal factors underlying low Staffing dimension scores and design, implement, and evaluate improvement strategies.  This recommendation is resolved but remains open.  We request that the DHA Director send us a copy of the final plan upon completion.

This report is a result of Project No. D2017-D00SPO-0009.000.