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Mass. hospitals show how to fix military medical care
Courtesy Boston Globe / Associated press
Army Surgeon General Lieutenant General Patricia Horoho speaks about military health care at the Pentagon in October. http://www.bostonglobe.com/opinion/editorials/2015/01/05/mass-hospitals-show-how-fix-military-medical-care/2IWh1zeNGC2goyYXho0KeP/story.html
Military hospitals charged with one of the country’s most important missions — serving active duty personnel — are roiled by dysfunction. As reported by The New York Times over the last several months, military hospitals suffer from chronic lapses in patient care and safety. Outgoing Secretary of Defense Chuck Hagel addressed the problem in October, when he ordered the military health system to reassess and revamp its procedures. But it might take nothing less than an act of Congress to change practices and procedures that are ingrained in military culture.
The command and control system that works well on the battlefield puts the military health care system out of touch with most modern medical institutions, where questioning of the system is a crucial component of everyday practice. The latest Times report described a system in which physicians and nurses who point out lapses in care are transferred or passed over for promotion, compromising patient safety and quality of care.
The Times report found that two areas of treatment in the military health system were particularly vulnerable — maternity care and surgery. A Pentagon review of the military’s hospitals found a systemwide problem: a reluctance by medical workers to identify problems, for fear of reprisal.
The reluctance to report errors is understandable. But in a medical setting, decision-making can literally be a matter of life or death — which is why civilian hospitals and medical centers have been working hard over the past 20 years to encourage “blame-free” reporting.
At three of Boston’s biggest hospitals, various high-tech systems for reporting errors are in place. Such a system is sometimes called a culture of safety or, after one model that was developed in the late 1990s, “just culture.” Massachusetts General Hospital, Brigham & Women’s, and Beth Israel Deaconess Medical Center all follow some version of the “just culture” model for reporting errors. Anyone from a janitor to a nurse to a surgeon is encouraged to report errors in a non-punitive environment, and there are active campaigns to encourage reporting. The principals of “just culture” defer blame from an individual to the system as a whole.
To gather these reports, hospitals establish websites available to all employees. The reports are vetted and analyzed, with protocols for followup. In some cases, individuals are held accountable for a decision that’s seen as reckless. But for the most part, “just culture,” says Karen Fiumara, director of patient safety at Brigham & Women’s, describes “a culture of trust and shared accountability.”
Such a reporting system sounds like common sense. But “just culture” is antithetical to the military hospital system for a very basic reason: chain of command. As hospital administrators point out, the “just culture model” won’t work unless leadership insists on it. The assistant secretary of defense for health affairs, Dr. John Woodson, an Obama appointee, has made strong statements about reforming the system, but his power is restricted to making policy recommendations. He cannot give orders to military commanders, and they’re the ones charged with running military hospitals.
One person who does have responsibility for change is the Army Surgeon General, Lieutenant General Patricia Horoho. Horoho has issued a statement demanding transparency regarding patient safety, and she has won praise from at least one member of a civilian agency in charge of inspecting and accrediting hospitals. “I applaud the way she’s handled the situation,” Dr. Ronald M. Wyatt said in an interview, adding that hers are the kind of actions “that resonate throughout the system.”
But the system, as it’s structured now, is working against Horoho, a decorated Army nurse. For one, commanders rotate out of assignments approximately every three years. And there’s no guarantee that Horoho herself, who has been Army surgeon general since 2011, will remain in her job much longer. “Imagine if the CEO at a civilian hospital changed every three or four years,” said Wyatt.
The problems in leadership stability are also compounded by the fact that the military hospital system is divided into three units for each branch of the armed services. What’s more, the system — whose primary mission is to train medical personnel for combat— is under strain after 12 years of war.
Clearly a system overhaul is required, one that at the very least involves the implementation of a stable leadership program in which just culture protocols are implemented. At best, the system would be streamlined, unifying all the branches of the military into one hospital system. Military service men and women put their lives at risk regularly overseas. They and their families shouldn’t be put in harm’s way when they seek medical help at home.