The Military Health System relies on high-reliability practices to improve patient care and ensure its mission of sustaining a medically ready force and a ready medical force. This means improving patient outcomes through more reliable processes to provide safe, high-quality care for all patients and their families.

The Ready Reliable Care framework is the Military Health System’s (MHS) effort to become a high-reliability organization (HRO). With a goal to achieve zero harm while remaining committed to continuous learning and improvement, it abides by four domains of change: The leadership’s commitment to prioritize the effort at all levels of leadership; a culture committed to safety and preventing harm; continuously improving to advance innovative solutions and spread leading practices; and a patient-centered focus on safety and quality of care.

This entails innovation, a key characteristic of HROs. Through its transformation process to assume responsibility over the administration of all military medical treatment facilities (MTFs), the Defense Health Agency “takes a deliberate approach to innovation by optimizing through standardization and identifying innovative approaches that could benefit the DHA strategy,” said Regina Julian, chief of DHA’s Healthcare Optimization Division.

As a result, new and standard processes based on these innovations are continuously assessed for implementation to improve the overall system’s performance.

Once the MHS transformation is completed, the overall system Julian described will include 19 direct-reporting markets within the United States, 18 small markets, and many stand-alone MTFs across the country (which will report to a small market and stand-alone organization), and two overseas Defense Health Region, making standardization that much more significant.

“The MHS is constantly balancing research, innovation, and risk to deliver the highest-quality, safe, and reliable care to beneficiaries,” said Army Col. (Dr.) Sean Hipp, director of the DHA’s Virtual Medical Center.

Everyone Has a Role

MHS leaders, staff, and patients all have a role in contributing to high reliability by implementing seven principles in their daily work:

• Preoccupation with Failure: Drive zero harm by anticipating and addressing risks.
• Sensitivity to Operations: Be mindful of how people, processes, and systems impact outcomes.
• Deference to Expertise: Seek guidance from those with the most relevant knowledge and experience.
• Respect for People: Foster mutual trust and respect.
• Commitment to Resilience: Leverage past mistakes to learn, grown, and improve processes.
• Constancy of Purpose: Persist through adversity towards the common goal of zero harm.
• Reluctance to Simplify: Strive to understand complexities and address root causes.

“DHA is making progress to embody all principles,” said Julian. Since beginning its journey to become an HRO in 2014, “DHA has made great progress towards the goal of implementing these principles and continues its journey in support of continuous process and system improvement.”

As an example of the commitment to preoccupation with failure, Julian explained the DHA established a centralized Clinical Quality Management program in the Medical Affairs division under its authority to “standardize processes and ensure a systems approach to performance improvement to improve quality and safety.”

Likewise, DHA leaders “developed and implemented centralized industry-standard performance measures to drive zero harm,” she said. They then assess those with MTF and market directors to establish accountability, she added.

“Overall, DHA takes a systems approach to the enterprise by establishing standard processes for all programs and codifying those standard processes and workflows in clear, comprehensive, and easy-to-understand guidance by studying what works and then identifying in guidance who is going to do what by when,” she said. “All standard processes are assessed by how well they support, directly or indirectly, system performance and outcomes, which include clinical, operational, and business outcomes.”

Hipp explained they do this by following the metrics on the progression of virtual health throughout the MHS, surveying patients and staff to assess the program and improve the experience.

Julian also discussed examples of programs that establish DHA’s commitment of deferring to experts.

“DHA’s standard processes are informed by leading practices from both high-performing MTFs and industry,” she said. “Each area of responsibility at DHA includes a community of practice with MTFs and markets to establish bi-directional communication with leaders in the field.”

Hipp added that these programs are developed by subject matter experts so that clinical leaders can shape the solution and lead the change. “This supports getting buy in for the program,” he said.

With respect to fostering respect for people through mutual trust, Julian said DHA is developing robust programs to support MHS staff members to grow in personal development, such as Individual Development Plans for each employee, workforce development activities, and formal education programs.

“DHA also demonstrates respect for people by supporting the department’s anti-discrimination and anti-harassment programs as well as to eliminate extremism in the force, which is antithetical to unit cohesion,” she said. “Finally, DHA is communicating at multiple levels with counterparts in the field, including through visits by senior DHA leaders and weekly email updates.”

Hipp added the DHA also does this by “working across the military departments and the DHA to create programs that people believe in and are compatible with daily workflows, bringing all leaders into the conversation and not just imposing a product or plan without understanding.”

As part of the commitment to resilience, Julian explained the DHA is committed to establishing standard processes.

“Through transparent, bi-directional communication, it is willing to revise DHA guidance to correct any processes resulting in negative, unintended consequences and, even more so, to improve current processes based on validated feedback from the MTFs.”

For example, Hipp said, “the DHA also does this by communicating with leaders in the Department of Veterans Affairs and the civilian world to learn from their experience.”

One example is the MHS Video Connect telehealth platform: “It is built on VA experience and is being integrated into the MHS electronic health record based on the experience of successful civilian telemedicine programs,” he said.

“DHA’s authority and commitment to issuing standard guidance for all MTFs is critical to inculcating a constancy of purpose throughout the direct care system,” said Julian. “Standard processes are focused on improving readiness and enhancing outcomes, which include a goal of zero harm.”

With respect to being reluctant to simplify, Julian said: “DHA’s commitment to issue easy-to-understand and clear guidance on standard processes, which identify intent, goals, and who does what to whom by when simplifies processes, focuses staff on priorities, and leads to strong, consistent performance across the system.”