A Culture of Safety and Quality

As a system of health, and as individuals in that system, we rightfully take great pride in our combat medicine performance over the last twelve years of war.

There are a number of characteristics evident in that performance that are hallmarks of a learning system focused on continuous improvement: a demand for data – paired with an openness to reporting, continuous feedback to front-line units informed by the latest evidence and research, an improvement model focused on identifying and correcting systemic risks…not individual failures, and a sense of teamwork that spanned the entire system – more than a single organization, more than a specific geographic area, more than a single Service. All of us…together…achieved these outcomes.

As our patients returned to the United States, these same characteristics were evident.

image001The results speak for themselves.  As the wars progressed, we continued to increase survivability rates – even though the severity of injuries also increased. Today, we deliver the highest survivability rates in the history of warfare and that survivability is also coupled with greater post-injury quality of life.

There is an urgency and bias for action in battlefield medicine that is considered hard to sustain in a peacetime environment: but if there is an organization that can, and must, sustain that urgency, it is ours – the Military Health System.

We, like every other leading health system in this country are committed to continuous improvement. When mistakes occur, we do everything to identify and improve the process.  Over the last several years, we have witnessed increased reporting of potential – and actual – adverse events in our health system. We applaud and encourage that transparency ranging from just better ideas, to “near-misses”, to actual events. Speak up! as though a life depended on it…it just may!

While we endeavor to reduce errors to zero, we also must ensure we have a culture in which acknowledgement of errors is understood to be a good thing: an opportunity to learn, an opportunity to share, and an opportunity to improve.

We want every member of our Military Health System to understand that your leadership is committed to a culture that is transparent in our patient safety performance, encourages the identification of potential – or actual – risks, and acts upon them in ways that increases the confidence of our patients and our staff.

We know that we can do this – because we have done it already in some of the most inhospitable environments in the world while under some of the most austere working conditions for medical professionals anywhere.

Front line staff – if you see a problem, report it. Act immediately to do something to prevent it from happening again while we find a way to fix the underlying problem.

Supervisors – help create a culture where we reward people for identifying and correcting problems. Leaders need to help all of their teams understand that we can have a goal of perfection while knowing that we may never reach it. By identifying problems and fixing them every day we will get closer and closer to our goal. But that will not be possible without the willingness to bring problems to light so we can fix them.

Leaders – set audacious goals and hold everyone accountable in meeting them. The goal should be zero preventable harm events and 100% adherence with evidence based guidelines.

And for everyone – our workplace should be equally safe for those who work within our medical facilities.

Our MHS Patient Safety Analysis Center provides excellent resources and information that every organization should take advantage of, and use. You can find that information here:

http://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/Quality-And-Safety-of-Healthcare/Patient-Safety

Thank you for what you do on behalf of the more than 9 million Americans who rely on us every day.

Sincerely,

Dr. Jonathan Woodson, Assistant Secretary of Defense for Health Affairs

Lieutenant General Patricia Horoho, Surgeon General, United States Army 

Vice Admiral (Dr) Matthew Nathan, Surgeon General, United States Navy 

Lieutenant General (Dr) Thomas Travis, Surgeon General, United States Air Force