Report | Feb. 8, 2018

The DoD’s Response to the Quality of Care Elements in the 2014 Military Health System Review DODIG 2018-067














We evaluated the DoD’s response to the August 2014 “Final Report to the Secretary of Defense, Military Health System [MHS] Review.” Our evaluation examined issues specific to quality of care to determine whether:

  • the DoD responded to all of the MHS Review’s quality of care recommendations;
  • the DoD improved performance at the military treatment facilities (MTFs) that the MHS Review identified as outliers for National Perinatal Information Center (NPIC) measures
  • the DoD improved performance at the MTFs identified in the MHS Review as outliers needing improvement for the National Surgical Quality Improvement Program’s (NSQIP) morbidity measure
  • the DoD improved performance at the MTFs identified in the MHS Review as negative outliers for the Primary Care Manager (PCM) Continuity measure
  • the MHS developed policy that gave the Military Services common quality of care goals, in accordance with the MHS Review’s recommendation; and
  • the MHS used a performance management system to improve quality of care as the Secretary of Defense directed



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.


We found that:

The MHS action plans contained courses of action to resolve all 44 recommendations in the quality of care section of the MHS Review. As of November 2017, the MHS has completed 22 of 26 action plans to address the 44 quality of care recommendations.

We found that all MTFs identified in the MHS Review as outliers for the NPIC quality of care measures regarding postpartum hemorrhage, Patient Safety Indicator #17 Birth Trauma, and shoulder dystocia developed action plans to improve performance as the Secretary of Defense directed. Our analysis of the Defense Health Agency data showed that these MTFs were no longer considered outliers, relative to the MHS Review, for the NPIC benchmarks by the end of the first quarter of CY 2017.

We found that all eight MTFs identified in the MHS Review as outliers “needing improvement” in the NSQIP’s measure of morbidity had met standards.

Our data analysis also found that three of the four MTFs that were “negative outliers” for the PCM Continuity measure at the time of the MHS Review were no longer negative outliers. The DoD deactivated the remaining MTF in FY 2015 and it is no longer in operation, so it is no longer being tracked.

In addition, we observed that the DHA-developed action plans, in response to the MHS Review, included implementing quality of care and process improvement governance. We also found that the DoD was developing a quality of care governance structure with common policy, procedure, and direction in accordance with the National Defense Authorization Act for FY 17.

Finally, we found that the MHS developed the Partnership for Improvement (P4I) performance management system. The MHS uses the P4I to monitor quality of care for areas requiring improvement.


We recommend that the Director of the Defense Health Agency notify the DoD Office of Inspector General when the MHS has implemented all actions in the MHS Review Action Plans regarding quality of care.


This report is a result of Project No. D2016-D00SPO-0222.000.