The message the Army, Navy and Air Force surgeons general have taken from the military health system review released earlier this month is that their hospitals and clinics are performing on par with the nation's top private systems.
But they say some adjustments — as well as long-term maintenance — is needed for the military system to become exceptional.
The Military Health System Review, released Oct. 1 by the Defense Department, compared military medical facilities to each other as well as to three private health systems of similar scope and size: Geisinger Health System in Pennsylvania; Intermountain Healthcare in Utah and Idaho; and Kaiser Permanente, a national nonprofit with 38 hospitals, 618 medical offices and an operating budget of $53.1 billion.
The review found most of DoD's 56 hospitals and 361 clinics stood toe-to-toe on performance metrics and quality to these systems, but also fell short in some areas.
Dr. Peter Pronovost, senior vice president for patient safety and quality at Johns Hopkins and a review participant, said the investigation "found no evidence of substantive deficiencies in the safety, quality and access to care at MHS that would warrant broad and urgent changes."
That assessment was welcome news to Army Surgeon General Lt. Gen. Patricia Horoho, Navy Surgeon General Vice Adm. Matthew Nathan and Air Force Surgeon General Lt. Gen. Thomas Travis, who told Military Times in separate interviews that they've spent several years redesigning their systems to improve patient careand believe their facilities provide care comparable to the private sector.
"The review pointed out what we already were aware of in Navy Medicine — the good, the bad and the ugly. And we follow those and train our efforts on those. What it did do was crystallize in the minds of many MTF commanders specifically where they are," Nathan said.
Reassuring feedback
"What I found with the review is that it was timely, really good feedback for us," Horoho said. "It verified that we deliver safe, timely and quality care, and it's comparable to quality civilian systems. It showed us where we are leading in the nation, where we are comparable to these high-performing organizations and where we had areas that were outliers."
The unprecedented review, ordered by Defense Secretary Chuck Hagel in May amid the scandal at Veterans Affairs facilities over wait times for patient appointments and leadership failures, was designed to determine how DoD's medical facilities stack up.
Although the 665-page report concluded that the system is operating favorably when compared with others, nearly every hospital failed to meet at least one benchmark for patient safety, quality or access to care.
"We cannot accept average ... we can do better," Hagel said during a press conference marking the report's release.
The surgeons general noted that the review didn't compare their facilities to "average" facilities; it measured them against some of the nation's best medical providers — and they say that means their system is, in fact, among the best.
"While many Air Force facilities had both positive and negative outlier measures in this review, the overwhelming trend was that all ... were within the expected range of performance for over 90 percent of the measures reviewed in this study," Travis said.
Still, the review, accompanied by orders from Hagel that each facility fix its shortfalls in quality or patient appointment problems, provides direction for each medical command to improve, they added.
Among the areas of focus are improved patient satisfaction with appointment times, common performance and measurement standards, and wider availability of quality of care and patient safety data for all facilities and services.
"If you are a beneficiary — be it active duty, family member or retiree — you may get your medical care in a Navy hospital one day and the next week in an Air Force facility. We have to be congruent," Nathan said.
"While some measures may lend themselves to quick fixes, we're more interested in addressing the underlying processes to assure an enduring focus on performance," Travis said. "Our focus will be less on short-term remedies and more on long-term improvements."
Disconnect on wait times
Among the report's most notable findings was the broad disconnect between facility assessments of their appointment wait times and patients who say they can't get timely appointments with their primary care providers.
That is the top health care complaint among active-duty members in a poll conducted annually by Military Times.
An active-duty Army officer who requested anonymity said he often visits a private urgent care center for appointments even though he has a documented heart condition because he can't get an appointment with his primary care doctor.
"I called today, 8 October 2014, and got the next available appointment for 3 November 2014 ... nearly a month away," the officer wrote.
The medical chiefs said they plan to do a "deep dive" to figure out the source of that disconnect, which could lead to "educating patients better" on MHS access standards — 24 hours for acute care, seven days for routine care and up to four weeks for specialty care — and reexamining the expectations of patients.
"One, do we have the right standard? Secondly, are we communicating the right standard, and third, are we measuring it correctly? I do believe no patient should be told to call back. It should be one phone call, either get them in that day or book them," Horoho said.
Horoho, Nathan and Travis said their commands are looking toward organizations with stellar safety standards, including Navy nuclear programs and the Air Force, Army and Navy aviation communities, for guidance in instilling accident-free standards in their health care systems.
"We are looking at how we can drive out mistakes and drive out individual problems," Nathan said.
By Hagel's order, facilities not meeting access standards must provide a plan for improving appointment times by Nov. 1.
Those failing to meet quality and safety standards must develop their plans for remedies in 45 days.
Nathan said patients at some facilities may see immediate tangible changes, but it will take time to develop other improvements.
"We recognize that health care is an emotional commodity. It should be. People will tolerate a lot of fluctuations in their interactions with a retail or auto repair place but they would not and should not tolerate fluctuations in health care," Nathan said.
Patricia Kime is a senior writer covering military and veterans health care, medicine and personnel issues.
