Quality and Patient Safety Review Processes in Military Treatment Facilities and Operational Clinical Services

The U.S. military relies on the medical readiness of individual service members for its overall readiness and lethality. The Military Health System (MHS) provides health care to service members, family members, and other beneficiaries at military treatment facilities (MTFs) and through TRICARE-contracted private-sector facilities and providers. The MHS also provides health care to service members within operational settings. Care delivered in these operational settings, referred to as operational clinical services (OCSs), and at MTFs is considered direct care. Whereas MTFs are fixed or permanent medical facilities, established for the purpose of delivering medical and dental care to eligible individuals (Department of Defense Instruction 6025.13, 2023), OCSs are “clinical and clinical support services on ships and planes, in deployed settings, and in all other circumstances outside an MTF” (Department of Defense Instruction 6025.13, 2023). OCSs can be provided in temporary, mobile, or permanent locations, varying widely in their infrastructure and capabilities depending on the operational needs, resources, and setting. Across direct care settings, the MHS relies on clinical quality management (CQM) processes to ensure that safe, high-quality care is delivered to service members. To date, however, it has been difficult to understand how these quality and patient safety processes vary across MTFs and OCS settings.

The Fiscal Year (FY) 2023 National Defense Authorization Act (NDAA) required in Section 706 that a federally funded research and development center conduct “an analysis of the quality and patient safety process for health care provided under the direct care component of the TRICARE program and develop recommendations for the Secretary based on such analysis” (U.S. House of Representatives, 2022). Prompted by this requirement, the Office of the Under Secretary of Defense¹ for Personnel and Readiness asked RAND to conduct this assessment. Specifically, we sought to conduct an objective assessment of the quality and patient safety review processes for care delivered in MTFs and OCS settings and identify potential opportunities for improvement. This study presents the findings of RAND's analysis, as well as several recommendations.

Approach

We conducted an assessment of the seven quality and patient safety review processes outlined in the FY 2023 NDAA: credentialing and privileging; quality assurance (QA), standard of care (SOC), and incident review; health care provider accountability; clinical quality metrics transparency; eliminating variation in clinical quality metrics; applying CQM to operational settings; and CQM organizational roles and responsibilities. We used two key methods: (1) developing and deploying an internal assessment (mandated by the FY 2023 NDAA) in which representatives from five U.S. Department of Defense (DoD) organizations (the Assistant Secretary of Defense for Health Affairs; the Director of the Defense Health Agency [DHA]; and the Surgeons General of the Army, Navy, and Air Force) reported the ways in which they ensure that service members receive high-quality, safe care and (2) conducting qualitative interviews with 216 personnel across 19 MTFs and OCS settings who had a role in either overseeing CQM processes or providing care.

Key Findings

Integrating information learned from the internal assessment and qualitative interviews, we identified five key findings.

Complete Lists of Active OCS Settings Are Not Readily Available, Which Makes Routine Monitoring of Quality and Patient Safety Challenging

As of June 2024, complete lists of active OCS settings were unavailable for any service branch. Information received about active OCS settings was incomplete and inconsistent, in contrast with DHA's comprehensive lists of MTFs. Reasons for the lack of maintained lists of OCS settings include overlapping responsibilities, the sensitive nature of some locations, and the dynamic demands of military missions. This information gap hinders effective monitoring of care in operational environments and prevents accurate metrics on health care quality and patient safety for OCSs.

Given OCS Settings' Diverse Operational Contexts and Capacities, Applying One Standard Across Settings May Not Be Appropriate

OCS settings exhibit significant variability in infrastructure, ranging from permanent facilities to mobile setups, such as planes and tents, with durations varying from permanent to temporary. In garrison or training environments, OCS providers primarily focus on primary care and physical therapy, while in deployed settings, they may deliver acute care under challenging conditions with limited resources. Respondents indicated that applying a uniform standard for QA and patient safety across OCS settings is inappropriate because of their diverse operational contexts and resource constraints, making accreditation by organizations such as the Joint Commission often unfeasible. Consequently, a flexible oversight approach tailored to the specific demands of each OCS setting is necessary, with internal inspection activities being site specific and not uniformly focused on quality and safety.

MTFs Have Robust Quality and Patient Safety Processes Across Multiple Domains, with Some Opportunities for Improvement

We synthesized findings into an overall assessment by domain, highlighting strengths and opportunities for improvement in line with a learning health system approach (Table 1). Domains were marked as strengths when MTFs consistently reported having established processes, while opportunities for improvement were noted based on frequent mentions across service branches or where processes were inconsistent with the internal assessment.

Process	MTF Assessment	Justification
Credentialing and privileging	Strength	There is a consistent and systematic process, including use of Centralized Credentials Quality Assurance System (CCQAS) and shared files for documentation.
QA, SOC, and incident review	Strength	There is consistent integration of providers into QA processes, including monitoring and maintaining SOC through peer review, patient safety reporting and incident review, dissemination and implementation of guidance from clinical departments, MTF leadership, service branch medical leadership, and DHA.
Health care provider accountability	Strength	There are consistent processes and timelines for health care provider accountability when individual providers were determined to have caused patient harm or not met SOC. Some respondents described challenges sharing some aspects of peer review and adverse actions determinations across MTFs.
Clinical quality metric transparency	Strength	There are consistent measuring, reporting, and monitoring metrics related to both clinical quality and patient safety. Metrics are widely shared with other providers, staff and leadership, and the public via health.mil and other publicly available resources. There is some variation in the level and degree of sharing metrics directly with patients.
Eliminating variation in clinical quality metrics	Opportunity for improvement	There are robust processes for eliminating variation in clinical quality metrics, including the Ready Reliable Care initiative. There are concerns about variations in the translation of DHA policy to MTF level; frontline staff are not always aware of resources to support standardization. There are frustrations with technical issues affecting standardization in systems such as the electronic health record.
CQM organizational roles and responsibilities	Opportunity for improvement	There are clear roles and responsibilities across all aspects of CQM. There are concerns about short staffing and high turnover among military personnel, which disrupts CQM efforts. Additionally, organizational culture and institutional memory are difficult to sustain without civilian staff, but civilian staff hiring processes are notably onerous.

NOTE: We did not include “applying CQM to operational settings” in this table because it does not apply to MTF settings.

OCS Settings Varied Widely in Their Quality and Patient Safety Processes, with Several Opportunities for Improvement

We also conducted a parallel assessment of OCS settings (Table 2) using the same approach as described for MTFs. We identified additional opportunities for improvement in OCS settings compared with MTFs, largely because OCS settings had less-developed infrastructure and defined processes to execute quality and patient safety review processes in operational settings.

Process	OCS Assessment	Justification
Credentialing and privileging	Strength	Clearly established processes are followed across service branches. Some Navy OCS settings, which handle credentialing and privileging for OCS providers, are drastically less resourced compared with MTF counterparts.
QA, SOC, and incident review	Opportunity for improvement	Consistent processes are in place in OCS settings co-located on an installation with an MTF. Processes are much less consistent in forward locations, particularly deployed locations. Major issues can be reported up the chain of command, but there is uncertainty about how those reports are integrated into larger QA efforts. The internal assessment indicated that processes are in place, yet interviews noted challenges with implementing or executing processes.
Health care provider accountability	Opportunity for improvement	There are similar approaches for accountability as MTFs, providing opportunities for remediation and reporting up the chain of command when needed. In forward or deployed locations, there are substantial challenges to documentation, communication, and personnel availability that can hamper effective and timely accountability processes, which is inconsistent with the internal assessment.
Clinical quality metric transparency	Opportunity for improvement	There is consistent description of metrics to assess readiness to complete the operational mission rather than clinical quality metrics. Measurement, reporting, and monitoring of clinical quality and patient safety metrics did not systematically occur in most OCS settings, which is counter to the internal assessment, although the assessment noted that some of these processes are being developed.
Eliminating variation in clinical quality metrics	Opportunity for improvement	Providers use clinical practice guidelines and strive to meet SOC but also emphasize the challenges of doing so in some operational settings. Accreditations for OCS settings on installations are in progress at some locations but generally incomplete. There are concerns that broad application of standardization efforts are impractical, potentially counterproductive, and overly restrictive, particularly in forward settings, which is counter to the internal assessment, although the assessment noted that some of these processes are being developed.
CQM organizational roles and responsibilities	Opportunity for improvement	There were consistent descriptions of who was responsible for various components of the quality and patient safety process, even if those processes could not always be carried out according to plan because of the limitations of the setting. There are concerns resulting from a dual command structure, with oversight from both medical and operational command and ultimate authority lying with operational command with varying degrees of expertise in medical care.

Improvements to Systems and Staffing Are Needed to Strengthen Quality and Patient Safety Processes

We identified significant infrastructure issues present in OCS settings, particularly regarding credentialing, QA, accountability, and clinical quality metric transparency. Accessibility problems with such systems as CCQAS, Health Assessment Lite Operations, and Theater Medical Data Store hinder documentation and oversight, limiting OCS settings' visibility into provider credentialing and complicating consistent patient encounter documentation because of issues with MHS GENESIS (the electronic health record used across MTFs) and operational electronic health records. Staffing challenges for both CQM personnel and providers in MTFs and OCS settings appear substantial and likely to persist, exacerbated by shortages, high turnover, and deployments, which can lead to inefficiencies and increased workloads that raise the risk of errors. Although civilian staff in CQM roles are seen as crucial for maintaining quality and patient safety, hiring complexities further complicate the situation.

Recommendations

Each service branch should maintain a list of active OCS settings and routinely provide this information to the Office of the Assistant Secretary of Defense for Health Affairs (OASD[HA]). To support improvements in patient safety and quality in the MHS, the services should compile and maintain a list of active OCS settings and routinely report (e.g., quarterly) this information to OASD(HA). DoD could leverage the MTF data collection infrastructure to produce a standardized, active list of OCS settings.

DoD should clarify requirements for quality and patient safety for different types of OCS settings given their unique types of locations. OASD(HA) should task a new or existing working group that includes representation from OASD(HA), DHA, and each of the services with the responsibility of developing and implementing a framework for producing clearer CQM requirements for OCS settings. We provide a preliminary illustration of such a framework in this study, characterizing a sample set of different types of OCS settings along with an indication of the level of CQM activities that could be required.

DoD should address CQM institutional knowledge loss by improving systems and staffing. Two complementary approaches can help mitigate knowledge loss across the MHS: (1) Implement comprehensive knowledge management systems and processes, which can provide a competitive advantage compared to adversaries (Singh and Gupta, 2021); and (2) investigate strategies to increase civilian staffing in CQM roles both at MTFs and in OCS settings.