NY Times Attacks on Mil Med

[Jedi Doc]

Anyone have any thoughts on the recent articles that have been coming out of the NYT hammering military medicine? Although military medicine has its unique challenges, I found the articles unjust. Here are the links to the articles:

http://www.nytimes.com/2014/06/29/us/in-military-care-a-pattern-of-errors-but-not-scrutiny.html

http://www.nytimes.com/2014/09/02/us/smaller-military-hospitals-said-to-put-patients-at-risk.html?_r=0

1. Fat on tragic anecdote, sparse on scientific rigor.

2. Who are they comparing us to?! It seems like all the comparisons are to 'leading civilian hospitals'. Is it really fair to compare Winn Army Hospital to Johns Hopkins and expect similar outcomes? Let's compare apples to apples.

3. All of the problems the NY Times accuses the military of are shared by our civilian counterparts. Its the entire healthcare system that is broken!

[deaddebate]

I don't really want to discuss this topic because it's been discussed too many times. It is important, it is relevant, but there is little to add that hasn't already been said. I agree that it is unfairly critical of the military health system, especially as the MHS is at least half-comprised of civilian organizations, contractors, MOU's with local hospitals, etc. As you say, this is America's problem, not just the DOD's. Take a look at the state health systems in Tennessee, W. Virginia, or California and tell me if they are any better.

Hopefully @JCJ can add his two cents. He has plenty of experience to speak from.

[jcj]

I read this in some detail when it first came out. The events noted are tragic and shouldn't happen anywhere. Unfortunately, they happen (I hope in very small numbers) in every health system.

My current take on the military health system (short version, and from my viewpoint only): Largely world-class people doing exceptional professional work in an environment where there may be a serious risk of fundamental cultural clashes between the professional peer respect/peer review health professional system and the hierarchical rank-ordered military leadership system.

Military health records are improving, but not yet where they should be. The gold standard for electronic health records now (civilian or government) is the VA.

It seems that the DOD may be behind the curve in transparency in quality and safety systems. A lot could be gained by combining the DOD branches (and USPHS) into a combined system in that regard. Again, the VA is a world class leader in this regard. There is also a relatively new, but well functioning civilian model operating through the AHRQ.

The model for patient safety reporting systems is the Aviation Safety Reporting System (ASRS) which was conceptualized by the FAA to collect safety threats in a "no harm, no foul" manner from (civilian) pilots to improve flight safety. But pilots were so distrustful of the FAA they wouldn't participate so it ended up that NASA actually runs the program and provides safety recommendations and data to the FAA so there is a barrier between reporters (pilots and air traffic controllers) and the FAA. it's a fascinating story if you ever choose to read into it.

I guess if I were king of this particular world I would have the military/PHS run a confidential QA & patient safety reporting program for the VA, and the VA run a confidential QA & patient safety reporting program for the military/PHS system - so there is the same firewall between reporters and regulators.

I'd agree the article is anecdote, not scientific rigor. It is what it is - a newspaper article. But the DOD health system (not just the Army) has chosen to hold itself to the same standards as civilian peers - as I think it well should**. It does need to be able to measure its performance. You can't improve something if you can't measure it. And I'd agree with you, there's a quality spread in DOD hospitals just as there is in the civilian world as well.

**by DOD health system I mean routine health care, not deployed under combat/austere conditions. If you're meeting the Joint Commission standards taking care of people in the desert standing in a tent within a bunch of sandbags wearing a helmet and body armor, even more good on ya!

Edited September 19, 2014 by jcj

[Jedi Doc]

Thanks for the responses DeadDebate and JCJ.

I concur that mil med could definitely do better in regards to transparency and some aspects of patient safety. Clearly, military medicine has unique challenges that our civilian counterparts don't face (doctors and patients PCS'ing, difficulty maintaining particular skill sets within the military healthcare system, not to mention unique mental/physical pathologies associated with deployments), but as JCJ points out, there are many things that we do exceptionally well. Yes yes, I also return to the fact that this is what it is...a newspaper article, but the damage that a media powerhouse like the NYT does to military medicine is not trivial.

If the accusations were just, I would accept them. We can (and SHOULD) do better in areas that we lag, but I don't believe any of the accusations aimed by the NYT are unique to military medicine. The choice of comparing military medicine to 'leading civilian hospitals' is in itself the wrong position to take. Would the American public really want to pay the budget that DHA would need to be on par with a Mayo Clinic, Johns Hopkins, or Cleveland Clinic? At least military medicine functions as a system- with one budget, common data tracking systems, a standardized EMR (not the best currently, but getting better) and enforced quality programs. How does this compare to the civilian non-system? The Times is trying to piggie back a non-existent scandal on the recent buzz from the VA one. But, all they are really doing is leading their readers astray from the bigger, more pertinent problem of fixing the entire U.S. healthcare machine.

A couple rebuttals to the NYT's articles on my flight medicine blog. I found some interesting statistics about hospital sizes across the U.S. Apparently, a majority of the smallest hospitals across the nation are not federally-managed (VA or DHA):

http://goflightmedicine.com/military-medicine-defense/

and

http://goflightmedicine.com/nyt-mil-med-attack/

Penny for your thoughts...

[deaddebate]

Like many of my posts, this one is long and somewhat boring, but I know many, many people that are highly invested in the quality, safety, and timeliness (access) of military healthcare. I encourage you to read this post to inform yourself on the developments, improvements, and weak points in one of (if not the) largest healthcare systems in the nation.

Hagel Orders Improvements in Military Health Care - http://www.defense.gov/Transcripts/Transcript.aspx?TranscriptID=5511

Highlights:

"SECDEF HAGEL: [...] I'm directing the Department of Defense to take steps to ensure that the entire military health care system is not merely an average system, but a leading system, because that's what America's troops and their families deserve. [...] all health care facilities identified as outliers in the categories of access, quality and safety to provide action plans for improvement to Deputy Secretary Work within 45 days. [...] I'm requiring that all currently available data on our health care system be made publicly available.

Other news articles:http://www.defense.gov/news/newsarticle.aspx?id=123314 |http://www.reuters.com/article/2014/10/01/us-usa-defense-healthcare-idUSKCN0HQ52Z20141001 |http://www.stripes.com/hagel-military-health-care-system-not-good-enough-1.306063 |http://www.nytimes.com/2014/10/02/us/military-hospitals-veterans-affairs-chuck-hagel.html

The full report is available at:http://www.defense.gov/home/features/2014/0614_healthreview%C2'> Here are some excerpts of those documents:

[...] no single set of metrics is used across the enterprise to monitor performance in the areas of access, quality, and safety, nor are there performance reviews of the system as a whole in these areas. Moreover, the purchased care component is not aligned with the direct care component in terms of data collected or metrics used, making it difficult to draw comparisons between the two components.

[...] One important finding was the notable difference between data that reflect compliance with access standards and the reported satisfaction of patients with their ability to receive timely care in MTFs [...] Surgical mortality (death rate) is within the expected range at all 17 DoD MTFs that participate in [National Surgical Quality Improvement Program] [...] Of note, only 10 percent of U.S. hospitals participate in the NSQIP and this may represent a unique subset of health care systems that are leading the way in high-quality surgical care. [...] Only 17 of 56 MTFs participate in NSQIP [...] no patient should be told to call back the next day for an appointment. I direct that within 30 days, all MTF identified during the review as outliers with respect to access standards will have action plans to improve their performance in ensuring timely access to the integrated system of direct and purchased care. [...] within 90 days, the DHA will establish a MHS performance management system (PMS) to support the Services as they manage and monitor MTF performance. The DHA will also use the PMS to manage the performance of the MTFs under their purview. The PMS will monitor MHS-wide core measures and dashboards for the purpose of monitoring system level improvements in all areas identified in the MHS Review. By July 15, 2015, I want a report that clearly demonstrates the PMS capability to drive system wide improvement for the identified common executable goals against common standards and for the dashboards to have measures identified in all areas covered by the MHS Review. [...] Within 30 days, the MHS will have a plan to provide all currently available aggregate statistical access, quality and safety information for all MTF and, to the extent possible, all purchased care providers publically available on health.mil.

If there is a particular area you want to review (sentinel events, telephonic/electronic counseling, site visits, anecdotal stories, etc.), that can probably be found quickly. But there is a TON of data in these reports, far more than I could review in a single post.

[Jedi Doc]

Is this responsible unbiased reporting or an attempt to create a scandal when one does not exist? Let me know if you see any inconsistencies below.

NY Times Headline:

U.S. Military Hospitals Are Ordered to Improve Care, Access and Safety

AF Times Headline:

Report: Military hospitals show broad disparities in patient care

The actual executive summary of the report:

The review found that the MHS delivers safe, timely, and quality care that is largely comparable to care delivered in the civilian sector. The MHS demonstrates wide performance variability with some areas better than civilian counterparts and other areas below national and Department benchmarks.

The review team included the participation of six independent, esteemed, external experts who serve as national leaders in patient quality and safety. These experts reviewed both the methodology of the report and the performance of the MHS. Their individual reviews are included in the report.

On October 1, 2014, Secretary Hagel signed a memorandum directing the MHS to take specific action on access, quality, patient safety, transparency and patient engagement. Read the Secretary's memorandum.

Wouldn't it be more accurate for the headlines to read:

"MHS delivers safe, timely, and quality care that is largely comparable to care delivered in the civilian sector."

I suppose humans' negative bias leads to more views and newspapers purchased with the originals.

'The entire report can be downloaded at: http://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/MHS-Review

Edited October 4, 2014 by Jedi Doc

[jcj]

Is this responsible unbiased reporting or an attempt to create a scandal when one does not exist? Let me know if you see any inconsistencies below.

NY Times Headline:

U.S. Military Hospitals Are Ordered to Improve Care, Access and Safety

AF Times Headline:

Report: Military hospitals show broad disparities in patient care

The actual executive summary of the report:

The review found that the MHS delivers safe, timely, and quality care that is largely comparable to care delivered in the civilian sector. The MHS demonstrates wide performance variability with some areas better than civilian counterparts and other areas below national and Department benchmarks.

The review team included the participation of six independent, esteemed, external experts who serve as national leaders in patient quality and safety. These experts reviewed both the methodology of the report and the performance of the MHS. Their individual reviews are included in the report.

On October 1, 2014, Secretary Hagel signed a memorandum directing the MHS to take specific action on access, quality, patient safety, transparency and patient engagement. Read the Secretary's memorandum.

Wouldn't it be more accurate for the headlines to read:

"MHS delivers safe, timely, and quality care that is largely comparable to care delivered in the civilian sector."

I suppose humans' negative bias leads to more views and newspapers purchased with the originals.

'The entire report can be downloaded at: http://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/MHS-Review

Yes - and although they (I think correctly) issue lots of disclaimers about validity problems with the comparison and problems doing a direct comparison, the civilian institutions they've chosen as comparator groups (Kaiser, Geisinger & Intermountain) are all really recognized as "above the median" in quality in the civilian healthcare world.

Edited October 5, 2014 by jcj

[deaddebate]

I didn't see a thread dedicated to the recent VA scandal so I'm putting this here:

http://www.cbsnews.com/news/robert-mcdonald-cleaning-up-the-veterans-affairs-hospitals

Yesterday, 60 Minutes interviewed the new VA Secretary, Robert McDonald. Some highlights:

Scott Pelley: How many employees do you think should be fired based on what you know?

Secretary McDonald: The report we've passed up to the Senate Committee and House Committee, has about 35 names on it. I've got another report that has over 1,000.

[...]

Secretary McDonald: Right now [veterans] face nine different organization structures across the country so they don't know where to go and if they do find somebody to go to that person may be an expert in benefits but not an expert in heath care. And we want to create a customer service representative that that person can go to. Secondly they face multiple websites that require multiple user names and multiple passwords and that's not acceptable. We've got to get to one website, one entry point, and then fan people out from there.

[...]

Scott Pelley: How many doctors and nurses and medical professionals do you need to hire right now?

Secretary McDonald: If we could do it today we would tell you we probably need about 28,000, is what we said in our committee testimony.

[deaddebate]

http://www.va.gov/opa/pressrel/pressrelease.cfm?id=2657

Press release from new VA Secretary, Robert McDonald:

The changes we plan to make are as follows:

• Establish a new VA-wide customer service organization to ensure we provide top-level customer service to Veterans. [...]

• Establishing a single regional framework that will simplify internal coordination, facilitate partnering and enhance customer service. This will allow Veterans to more easily navigate VA without having to understand our inner structure.

• Working with our partners to establish a national network of Community Veteran Advisory Councils to coordinate better service delivery with local, state and community partners. [...]

• Identifying opportunities for VA to realign its internal business processes into a shared services model in which organizations across VA leverage the same support services, to improve efficiency, reduce costs and increase productivity across VA. Right now, we’re looking at options used in the private sector to enhance our rapid delivery of services, and also at our own business processes that are suited for shared services.

Various news agencies pieces (if you feel you need some extra spin and bullshit in your life):

http://www.stripes.com/news/va-moves-to-overhaul-customer-service-1.313457

http://thehill.com/policy/defense/223547-veterans-affairs-unveils-new-structure

http://www.azcentral.com/story/news/politics/investigations/2014/11/10/va-overhaul-announced-secretary-offers-few-details/18807203

http://www.cnn.com/2014/11/10/politics/va-reforms-and-restructuring

http://www.cbsnews.com/news/robert-mcdonald-announces-plans-to-reorganize-the-va

[matmacwc]

You read the NYT? Why even try to debate?

Edited November 11, 2014 by matmacwc

[Jedi Doc]

Valid point GB!