Military Graduate Medical Education: Training the Military Health System into a High-Reliability Organization

The recent Military Health System (MHS) Review commissioned by Secretary Hagel identified both strengths and weaknesses in Department of Defense (DoD) health care delivery.1 Unfortunately, a system that should be dedicated to providing the best to American's finest citizens was perceived by some to have become overall satisfied with mediocrity. Among other things, the executive summary noted performance improvement would be aided by "alignment of training and education programs." I propose in this commentary, the MHS recognize and optimize the potential of its current training platforms, particularly those with Graduate Medical Education (GME), to help launch this journey from mediocrity to excellence. The Accreditation Council for Graduate Medical Education's new Clinical Learning Environment Review (CLER) program was a catalyst for a paradigm shiftwith enhanced focus on patient safety and quality in clinical learning environments within our military treatment facilities (MTFs) that host GME.2 Dr Peter Pronovost, external consultant to the MHS Review, and other national leaders in the quality and safety movement believe physician leadership is crucial in this journey, particularly in academic medical centers.3,4 Ironically, the MHS has two unique circumstances that if properly exploited, could move us forward on this journey to our MTFs becoming high-reliability organizations (HROs), relatively high physician turnover, and the only health care organization in the United States that hires 100% of their GME graduates. We owe it to taxpayers and our beneficiaries to provide high-quality medical care that is safe, patient centered, effective, efficient, equitable, and timely.5

We have a moral imperative to perform GME in MHS HROs. Asch et al6 effectively demonstrated training locations impact graduates' practice outcomes for years. The difference in obstetrical maternal complication rates between obstetricians who completed GME in hospitals with the lowest rates had 30% lower complication rates than graduates from hospitals with the highest maternal complication rates. Intuition and a well-designed study support a long-held belief that one practices health care how one was taught. Given that we hire all of our GME graduates, we should have the greatest level of investment in ensuring we train them in high-quality, safety-focused MTFs. This is where the CLER program aids the goal at our GME training sites. The CLER uses short-notice (2-3 weeks) visits to our teaching MTFs to assess the clinical learning environment in six focus areas: patient safety, quality improvement, transitions in care, supervision, duty hours/fatigue mitigation, and professionalism. 7 The visit includes meetings with hospital leadership, GME leadership, and quality/patient safety officers to understand the hospital's quality improvement and patient safety (QIPS) priorities, GME integration into these processes, and identification of initiatives involving residents to reach the MTF's goals. Residents, faculty, and program directors provide candid feedback on the six focus areas through anonymous responses during group sessions. Interspersed between these meetings are "walk-abouts" to clinical care delivery areas to observe transitions in care and visits with hospital staffto better understand the penetration of goals and priorities to the bedside. Further, the CLER Pathways to Excellence document outlines a roadmap in the six focus areas and the metrics by which our MTFs and GME sponsoring institutions will be evaluated in the future.8 The first visit was primarily formative for the MTF and GME leadership. Although still focusing on helping organizational progression along the pathways, expansive national normative data will allow subsequent visits to link significant failure to progress with potential accreditation actions. Therefore, the CLER program provides both a carrot and a stick to help MTFs that host GME along the journey to becoming HROs.

Our MHS training platforms are not immune from some challenges facing civilian colleagues: economic pressures, culture change, and physician leader development. The MHS is probably more uniquely positioned than other large health care systems to make quality and patient safety the core of its business model as recommended by Dr Brent James from Intermountain Health.1 One of the greatest barriers is associated with the necessary culture change. Hierarchical organizations, such as the military, have significantly greater challenges shaping a culture of safety, but production- oriented organizations are even more tested.9 Furthermore, strong executive and physician leadership is crucial to culture change. Yet, physicians are too often perceived to be obstacles in many health care systems.3,4 In addition, the lack of continuity of MTF leaders at every level can undermine culture change. How do we ensure military executive leaders and managers grown in a hierarchy-rich culture are effective in leading and developing cultures that value collaboration and teamwork intrinsic to quality cultures? The CLER Pathways emphasize interprofessional training and collaboration rather than traditional stove-piped models of training and practice. Another key to culture change in academic medical centers is esteeming QIPS science as much as biomedical research and medical education.10 In general, our MTFs do not have as broad a base of faculty steeped in biomedical research nor provide a significant proportion of support and rewards to faculty who garner grants and publish. Therefore, we can more rapidly achieve a culture that perceives QIPS as a scientific endeavor worthy of significant value. Furthermore, our relatively frequent turnover of faculty provides an ideal opportunity to quickly develop the next generation of teaching physicians better educated in the science of QIPS and who will role model this from the C-Suite to the bedside. When QIPS is embraced by GME training programs and a QIPS physician expert career pathway is recognized and valued, we can transition to hospitals with a critical mass of QIPS experts and leaders faster than our civilian counterparts.

Finally, I would like to briefly describe some of our early experience in this journey at the San Antonio Uniformed Services Health Education Consortium (SAUSHEC). Following a mock-CLER visit in October 2013, we identified several opportunities to improve our learning environment and launched the "Alliance for Safety." "Alliance" is the appropriate word because GME is a partner in the integration of the QIPS priorities of our two major teaching sites, the San Antonio Military Medical Center and the Wilford Hall Ambulatory Surgical Center. Using Institute of Health Care Innovation (IHI) questions, over 500 of our faculty and residents told us that we had a relatively healthy framework in which to launch the Alliance. We began by building a foundation of understanding of QIPS by requiring all incoming residents to complete IHI Open School Patient Safety Modules. Shortly after, the GME Committee adopted the Common Core Curriculum for Quality and Safety that outlined a pick list of various QIPS endeavors (e.g., QI Project, Root Cause Analysis, IHI Modules) with associated point values residents could participate to meet a minimum requirement to graduate. Accountability being important, we subsequently audited compliance of all programs in building this QIPS foundation. We also restructured ourselves to align with the new Accreditation Council for Graduate Medical Education CLER direction. We established subcommittees in the focus areas, included residents and nursing on subcommittees, and appointed the head of the MTF quality division as a Graduate Medical Education Committee voting member. In addition, we ensured greater resident and GME leader integration into the MTF quality structure; one example was the Risk Management Committee. We established the first Chief Resident of QIPS in DoD, in part modeled after the Veterans Administration initiative, to serve as a critical liaison between residents, SAUSHEC, and the MTF in QIPS matters. The Chief Resident has already improved resident use of the Patient Safety Reporting system, identified as a deficiency in our mock CLER, and played a significant role in launching an interdisciplinary, MTF-wide Morbidity and Mortality conference. Our recently selected Assistant Dean of QIPS will play a crucial oversight role ensuring alignment and integration of SAUSHEC QIPS endeavors and faculty development. This new position also provides a senior, academic leadership position for career progression. A QIPS poster competition and initiation of QIPS awards alongside of the traditional research awards at this year's graduation ceremony are other tangible steps to enhance recognition of quality science as a legitimate academic endeavor. The Alliance for Safety, although a good start, is too much in its infancy to boast of significant, tangible, and sustained results. This must be followed by other initiatives such as GME and MTF leadership communicating best practices and lessons learned across the MHS.

In conclusion, we are early in this journey toward becoming HROs. Although we have some unique challenges in the MHS, we also have a remarkable opportunity to undergo the culture shiftby optimally leveraging our significantly imbedded training platforms. Our GME MTFs will provide the very gardens to grow a new quality-focused generation of military, physician leaders to overcome some of these traditional barriers. As the MHS develops QIPS education, our hope is they will become more aware of what is already happening to enhance rather than duplicate or replace GME and MTF QIPS initiatives. We have an opportunity to move from a culture of mediocrity in the realm of QIPS to being national leaders by growing future physician leaders who will be enculturated in the importance and science of QIPS to the benefit of our DoD beneficiaries.

REFERENCES

1. Military Health System Review. Final Report to the Secretary of Defense. August 2014. Available at http://www.health.mil/mhsreview; accessed March 23, 2015.

2. Weiss KB, Bagian JP, Nasca TJ: The clinical learning environment: the foundation of graduate medical education. JAMA 2013; 309(16): 1687-8.

3. Pronovost PJ, Miller MR, Wachter RM, Meyer GS: Perspective: physician leadership in quality. Acad Med 2009; 84(12): 1651-6.

4. Hines S, Luna K, Lofthus J, et al: Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. (Prepared by the Lewin Group under Contract No. 290-04-0011.) AHRQ Publication No. 08-0022. Rockville, MD: Agency for Healthcare Research and Quality, April 2008. Available at http://archive.ahrq.gov/professionals/qualitypatient- safety/quality-resources/tools/hroadvice/hroadvice.pdf; accessed March 23, 2015.

5. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Committee on Quality of Health Care in America, Institute of Medicine, March 2001. Available at https://www .iom.edu/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-Systemfor- the-21st-Century.aspx; accessed March 23, 2015.

6. Asch DA, Nicholson S, Srinivas S, Herrin J, Epstein AJ: Evaluating obstetrical residency programs using patient outcomes. JAMA 2009; 302: 1277-83.

7. Weis KB, Wagner R, Nasca TJ: Development, testing, and implementation of the ACGME clinical learning environment review (CLER) program. JGME 2012; 9: 396-8.

8. Accreditation Council for Graduate Medical Education. CLER pathways to excellence: expectations for an optimal clinical learning environment to achieve safe and high quality patient care. Available at http:// www.acgme.org/acgmeweb/Portals/0/PDFs/CLER/CLER_Brochure.pdf; accessed March 23, 2015.

9. Singer SJ, Falwell A, Gaba D, et al: Identifying organizational cultures that promote patient safety. Health Care Manage Rev 2009; 34: 300-11.

10. Wong BM, Kuper K, Hollenberg E, Etchells EE, Levinson W, Shojania KG: Sustaining quality improvement and patient safety training in graduate medical education: lessons from social theory. Acad Med 2013; 88: 1149-56.

Col Woodson S. Jones, USAF MC (Ret.)

Office of the Dean, Graduate Medical Education, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Drive, Fort Sam Houston, TX 78234-4504.

The opinions or assertions contained herein are the private views of the author and are not to be construed as official or reflecting the views of the Department of the Air Force, Department of the Army, Department of Defense, or the U.S. Government. This work was prepared as part of their official duties and, as such, there is no copyright to be transferred.

doi: 10.7205/MILMED-D-15-00167