Lawmakers Hold Hearing on Military Health System

A House Armed Services subcommittee hears testimony about patient safety and the quality of care in the military health system. Testifying before the Subcommittee on Military Personnel are Army Lt. Gen. Ronald J. Place, director of the Defense Health Agency, and others. March 30, 2022


The military personnel subcommittee will reconvene and MS Ellis is back. Alright the spices here. Let’s see. We left off with miss Escobar. We will now go to MS Spice from Oklahoma for five minutes. Would you like to pass for a moment madam chair if that would be okay? Sure of course. We’ll go to Mr. doctor Westrup, Give it two seconds. She’s right. All right Miss by she recognized for five minutes. Thank you madam Chairwoman and I want to say first of all uh to the lucky family, my condolences to all of you. Um I can’t imagine um getting that knock at the door so please know that my heart and prayers go out to both of you Um and Mr. Joe Barbara You and I had the chance to speak briefly as the mother of a 21 year old myself. I cannot imagine um that the suffering that you go through and how traumatic that’s been for your parents um and certainly your story is incredibly important for us to all here so that no other service member has to endure the type of pain that you have, I have endured over these last months and years before we sort of. I I ask a couple of questions I think to Miss Silas, I do want to ask, can you talk a little bit about your recovery um from the infections that you had. Yes of course. Um So I was in the icu at Fort Sam Houston uh Brooke Army Medical Center for 100 days. um I did have 43 surgeries. I was discharged from the hospital in May towards around Memorial Day weekend. Um I learned how to walk on a prosthetic, um did a lot of strength training and stuff from my leg. It took me until about March, so almost a year to finally walk and be able to come home to my family and friends. Um Yeah, it’s the the wounds Taken over two years to heal and they still got the scars will never look anything like normal ever again in my life, but they’re still healing honestly. To this day, they’re still so very fragile my leg is and um I still go to pt every week for my right leg as I have nerve damage on my right leg where I can’t really walk correctly because of my ankle. Um And yeah, that’s pretty much it, Thank you for that. Um This question is actually um to Miss Silas. The G. A. O. Report stated some facilities which have cases that resulted in payments. Silas Silas Silas. My apologies. Um The G. A. O. Report has stated that some facilities have had cases that have resulted in payments um that have exceeded the time required for those reviews. Can you elaborate on the process in which should be um you know implemented to improve the delays and was Fort Benning included in the review on this G. A. O. Report? Well, first I can’t identify the military treatment facilities that we included. Our view. It was something that we negotiated with our clients as part of this review because it’s important to have some confidentiality so that folks um the staff that we’re talking to um will be forthcoming in the information. So um I can say that we did include of the four facilities. Two of the facilities were on the west coast and one was on the east coast and one was in the south. Um In terms of the patient patient safety events that resulted in um payment. Um Those reviews are conducted by D. H. A. Once the military treatment facilities have determined that there hasn’t been a uh standard of care matt D. H. A. has kind of what I call two bites of the apple to conduce some additional reviews. Um and they have 270 days to conduct these reviews. And um what we found as I mentioned in my testimony about half of the 12 cases that we included in our review exceeded that 270 today timeframe. Um and the range of days that we found for those cases was from 420 days to up to 746 days. Um And the clocks for those starts um As soon as the payments have been made either to the patient or the families And quick follow ups, you mentioned that you you reviewed four facilities um Are the rest of these facilities across the country being evaluated in some way shape or form? And are they being graded on their performance by these metrics? Not as part of our review. We limited our review to the floor selected military treatment. Only four. Um We made the selection based on um one limiting it to so that we’re able to conduct the review in a reasonable amount of time. Um We had to look through a number of records for to look at um all three types of procedures. Um but we did try to ensure that you know at least with the providers, we looked at a sample of 100 providers. It was a non generalize double sample. We took a sample of 25 providers from each of the four military facilities and then for the focused professional evaluations and the patient safety events. We selected the total number of patient safety events that occurred at those four facilities. Great thank you madam chair. My time has expired. I yield back The gentlewoman yields back. The gentleman from California. Mr. Sonja is recognized for five minutes. Thank you madam Chair and thank you to the ranking member for having this hearing and being so tenacious as you always are. Mr. Del Barra and Barbara and family. Thank you for being here in your courage. Dad, thank you for just telling me your story as well. Mr. Lucky Derek. Thank you and your wife and your family for having my staff be part of your life. We talked about this often. So tell me how long was it before Daniella gets sick and when she saw a doctor uh Danielle had been going back and forth to medical I believe from 10 From 10 32 ah man From 10 3 to 10 from 10 3 – 10 9. She had been going back and forth to medical and she kept being turned away and I believe on the the day she died. Uh I need a few minutes was I as I remember the story she was in for five months. She was on the ship for two weeks. 10 days, two weeks. Yeah she was on she was on the ship for two weeks and she became sick and she kept going back and forth to medical for several days until the day she died. And that’s when they figured out that she had died I guess So Daniel um Tell me tell my colleagues the story about when she was lying on the ground and one of the medical office one of the medical shipmates said Danielle was trying to get to medical but the Corman would not help her. So her sailor Brothers and sisters. Speaker two to medical because he could no longer walk. And she basically laid on the floor. If that wasn’t for her Sailor Brothers and sisters that’s where she would have died right there on the floor. So you’ve you’ve heard from some of her friends were on that ship at your house. I was lucky enough to meet one of her best friends. Tell us their side of the story does not is not consistent with the Navy side of the story of what happened factually. Well I believe Danielle was being evacuated to another destination. But the person who we spoke to said that she they didn’t see her get off the aircraft. So basically she died on the Reagan. That’s that’s that’s all. Um So you mentioned in your opening testimony and one of the things I think we need to change on this is she was not in a medical facility onshore in the United States of America. So your claim was denied because she was on a US Navy ship. Is that correct? That’s correct. And that’s one of the things that needs to be changed in this. That’s correct. The congress intended to bring justice and accountability. The military malpractice. However, D. O. D. Went and narrowly interpreted your intent by denying our victims that were harmed on ships outside of the U. S. This is not fair. How did you feel when you found that out? I mean you sent your daughter out to serve in the military and then on this seems like a technicality. That makes no sense. You couldn’t seek justice. No this could have been prevented. This could have been prevented. If they would have gave her medical treatment. But even after that, your ability to seek justice with your attorney has been difficult. It’s been very very difficult. Do you know of any repercussions to the people who were in the chain of command, Who denied, were they promoted? Do they? I’m pretty sure someone has been uh how should I say this? No uh promoted. That’s correct. I believe a lot of them has been promoted including the captain of the Reagan Captain Donnelly. I believe they have been promoted and the other service members. I believe they may still be in the military to continue their career while my daughter lost her life and her career. Thank you. Mr. Lucky. My time’s up at your back. Thank you madam Chair. Gentleman’s time has expired. The gentleman from Ohio Dr went strip is recognized for five minutes. Thank you. I just want to express my condolences Mr. Del Barba and hello your family and our lucky family. Um I just I just I want to say that I thank you for being here today and know that the effort will be made from this end as best we can to make sure that all of our troops always have the right providers in the right places with the right credentials and the appropriate complement of all the tools that they need treat people at all times. So God bless you all your in my thoughts and prayers. Now you’re back. The gentleman yields back. The gentle lady from California MS Jacobs is recognized for five minutes. Well, thank you so much madam chair and I want to thank all the witnesses for being here and telling what are not easy stories to have to relive. And I’m so sorry that you have to keep doing it to get us to take action. MS Silas, in a recent jail report that was published on September 17th 2018 reported that MHS largely uses separate measures for direct and purchased care on its dashboards and tracks the quality of care delivered by civilian providers and purchase care in the aggregate rather than individually. The MHS lacks the information. It needs to make comparable assessments of the quality of care delivered across the MHS as a whole to your knowledge. Is this report still accurate? And what if anything has the military health system done to overcome this information gap? So to my knowledge, um I believe that some of the recommendations are still open from that review. I can’t speak directly to the particular recommendations. Um But I am familiar with some of the findings from that report but I’m glad to take this for the record and get back to you about the status of the recommendations on that and what progress has been made. Thank you. I appreciate that. And um one other question for you is in reviewing these medical treatment facilities. Clinical quality management efforts. Has G. Io discovered any reasons why facilities are not consistently adhering to D. H. A. Procedures. Okay. Yeah I mean based on our preliminary observations again this work is ongoing. It seems to appear again that there’s a lack of clarity in the procedures. For example we found that it’s um some of the language that’s used in there in the procedures are is not consistent. Um There’s also a lack of definition in some of the facility staff um had different interpretations of what was initiation of a potential compensable event and what was the the end of a potential compensable event review. Um And then there was just a general kind of lack of awareness and a lack of understanding of the procedures. Okay thank you. Well I will look forward to your answer for the record on my first question and Madam chair. I yield back The gentlewoman yields back. I’ll now ask questions for five minutes. Mr. Del Barba. Is it true that at one point you were so depressed that you attempted to take your life? Mhm. No. Yes. Uh November 12, 2019. Which was um same year as the accident happened and when you were um seeking care, your drill sergeant was reluctant to take you. Is that correct? Yes correct. So one of my drill sergeants was notified by my peers in the barracks that I was not feeling good and that I needed to go to the hospital. He proceeded to tell this battle buddy that has he already got a sick call and the battle buddy said yes a couple of times and he said well there’s nothing we can really do and this was a 24 to 40 hours before my body went into septic shock. So if I remember correctly on Friday you went to sick call and complain about a sore throat and pain in your legs. So um Thursday I went to sick call and complain about a sore throat and pain in my legs. I was swab for strep. There’s two types of swabs. They do. One comes back Rapid test about 5-10 minutes. The other one takes 24-40 hours rapid test came back negative the next day that 24 to 48 hour test came back positive. However in the system, whoever wrote that note said, notified Monday in the morning and this was on Friday. They waited, they wanted it was in your record at that. It was in my record. Yes. And then on Sunday you went to the er and the doctor showed showed you enough time, three minutes to say that you were fine and evidently didn’t even look at your record because it would have been in your record, correct? Yes, correct. Um I did I went to the er doctor on Sunday February. Uh I want to say it was February 9th 10th, February 10th. Excuse me. Um And I saw the doctor for each clutch clocked in and clocked out for three minutes. Um That was the time and he told me I was fine and that my legs were sore, do the running and he just prescribed me throat lozenges for my sore throat. That is such gross incompetence and it doesn’t take a Q AI for three years to determine that that’s gross incompetence. Now, if I’m if I’m not mistaken, if I’m not mistaken. Um you also were um mistreated by the drill sergeant who forced you to go up the stairs at the hospital, is that right correct? So um I mean I I experienced a lot of bullying and harassment from the drill sergeants um that Sunday when I went to the doctor at sick call um there was it wasn’t the emergency room but it was up a flight of stairs. My legs did feel like sandbags and they were hurting, they were in so much pain that I wanted to take the elevator up. But you know, we as privates were advised to take the stairs. So I literally had to have my battle buddy carry not carry me on my shoulder, but I had to put a lot of weight on his shoulder just to get those flights of stairs to be seen for three minutes by this doctor and after you were diagnosed with strep, was there an outbreak? Yes, correct. Uh So on Tuesday February 19th martin Army hospital Surgeon general. Lieutenant Colonel Ethan Miles contacted my parents. I was in a coma at this time. Uh 56 positive cases in my company bravo company 405 positive cases in two brigades at Fort Benning. Fort Benning requested requested an order of 10,000 units from Fizer at the estimated cost of $1.7 million. Fighter told ford bending. They only had 60,000 units available for the entire world. Christopher Private Christopher Hus who was also in my company. He died January 22 due to Sepsis. He had a heart attack again. Um Does your remarkable young man and um this is such a gross disservice to you and your family and I hope that our colleagues who are here listening to you recognize that there’s there are changes that have to be made. Mr. Lucky. Um Did the Navy ever take responsibility for their failures? No, not at all. Did the Navy tell you if they made any changes in response to Daniel’s death? We haven’t heard anything from the Navy. Alright, just for the record. Mr. Lucky. Um There’s something called legislative intent and since I was the author of the legislation, the intention was to recognize that when you’re not in a war zone when you’re at a military medical facility, whether it’s in the countess or if it’s in Europe or if you are on a ship, um you should be receiving quality care. If there is malpractice associated with that care and you’re not in a war zone, then you should be eligible for compensation under the state school act that was my intention. That’s what passed the House and the Senate and became law. So if we have to clarify that in the NBA this year we will attempt to do that. MS um Silas, am I pronouncing it right or wrong? Silas? Yes, it’s Silas. Silas, thank you for your outstanding work. I want to ask you a question If it’s been over 270 days and there is a Q. A. I. There might even be too cute guys that that are not in sync But it’s over 270 days. Is there a requirement that it be reported to the national database? You’re muted? I think. Oh can you hear me now? Okay. Yes, that’s correct. They need to be reported to the national practitioner databank and what’s the the penalty of? It’s not I’m not sure. I don’t think there is a penalty for it. Um Yeah. Okay. You also referenced that In your review, you found selected facilities did not adhere to the D. H. A. requirements for these 19 potentially compensable events. Event reviews in two key areas. First, at the initiation of the reviews, the selective facilities did not document their consideration of whether to remove the providers from care and take adverse privilege. Privileging action against any of the providers in your review. So it wasn’t documented and you have no reason to believe that there was action taken. Is that correct? That’s correct. I mean based on our review is the only way because we’re reviewing documents. Um the only way that we know that any consideration was taken is that it needs to be documented and and it should be documented in the file and for all of those reviews, we did not have any documentation of that consideration of taking an adverse privileging, privileging action or pulling that provider offline. And whether it was actually a com compensated Evette or an a potentially compensable event, it should be documented and there should be an effort made to assess whether or not the provider should be removed from providing care. Exactly. Because even the patient safety events that result in payment, they start out as a potential compensable events so that that consideration should always be taken. Alright. I thank you. I have exceeded my time. Um we will now thank all of our witnesses who have done a remarkable job under I think very painful circumstances. I think you’ve heard from every member on this committee that we are deeply troubled by um the events were saddened by the loss of Daniel’s life. It was an unnecessary loss of life. It was not a complicated, complicated set of circumstances and to Mr. dale Barbara, um what you’ve endured is just unforgivable and uh I just hope the rest of your life is everything you wanted to be and I hope by virtue of both of your experiences here today. Um that the military is going to recognize it has an obligation, has an obligation to communicate with the families and the service member who had been injured or there’s about a loss of life. There has to be more transparency. And we’ve got to make sure that we have quality care provided to our service members. Um, it’s just fundamental to everything that we believe in. So again, I thank you. Um we’re now gonna recess for just a few minutes to allow our next panel. Excuse me, Can I read this place? Mr. Lucky, yes, I have this here. This is the the Corpus Men’s Hospital pledge. I solemnly swear myself before God and these witnesses, These corpsman raised their right hand. I solemnly pledge myself before God and these witnesses to practice faithfully. All of my duties as a member of the hospital corpsman. I hold the care of the sick and injured to be a privilege and a secure trust. And I will assist the medical officers with loyalty and honesty. I will not normally permit harm to come to any patient. This is what they did to my daughter. I will not partake nor administer any unauthorized medication. I will hold all personal matters pertaining to the private lives of the patients in strict confidence. I dedicate my heart, my mind and strength to work before me. I’ll show do all within my power to show myself an example of that is honorable and good. Throughout my naval, my naval career. My daughter’s career was taken from her while these people here continue with their lives in their career. Thank you. Thank you. Mr. Lucky. Thank you both. We are now going from our 2nd panel. Lieutenant General Ronald Place, Director of the Defense Health Agency. Lieutenant R. Scott Dingle, Surgeon general of the Army, Rear Admiral, Bruce, Gillingham, Surgeon General of the Navy. Lieutenant General Robert, I. Miller, Surgeon General of the Air Force. Welcome. Mhm. Lieutenant General Place. Do you want to begin? Chairwoman spear ranking member Gallagher, distinguished members of this subcommittee. I’m honored to represent the Defense Health Agency and it’s dedicated military and civilian medical professionals in the military health system. In describing our comprehensive enterprise approach to ensuring high quality of care in the military health system. The NHS However, before doing so, I’ve added some handwritten comments if I could because I think it’s important for me to address Mr. Del Barba And the Lucky family. Your testimony today was compelling and heartbreaking. It’s clear that you’ve suffered tremendous losses and I apologize for those losses. I take it very seriously when they’re bad outcomes from the medical care provided within our system. I’m deeply committed to ensuring we learn from your losses so we can better our health care system so we can have fewer losses. My goal is to make this health system stand as one of the finest, if not the finest in the nation and those who serve their country should expect that. I say this not only is the leader of the defense health agency, but as a husband, a father of two currently serving service members and grandfather has found family also receives their care in our system. You have my word, madame Chairwoman. The DHS now exercises authority, direction and control over all MTs. Worldwide quality starts with the individual medical personnel. We recruit and on board every day. The credentialing and privileging process serves as the foundation for high quality and safe care by ensuring qualified and competent staff deliver care in a manner consistent with their education and training the D. H. A. Overseas accreditation and certification for hospitals and clinics as well as specially specific certifications and quality assurance programs. In fact, the D. O. D. Participates in multiple civilian accreditation programs and has held to the same standards as our private sector healthcare colleagues. I mentioned just a few of those programs here. While my written testimony provides a more comprehensive list. The D. H. A. Manages an enterprise level contract with the Joint Commission for all MTs and all D. O. D. M. T. S. Are fully accredited at the specialty level. The MHS participates in numerous voluntary healthcare collaborative that helped drive improvement, allow us to compare our performance with others. These include the national surgical quality improvement program. This quip a collaborative led by the American college of surgeons. The National perinatal Information Center and pick the consortium of more than 80 health systems with high volume obstetric care. The list goes on and on from laboratories to blood banking pharmacy programs and so much more for patient safety. R. D. H. A. Programs similarly incorporates strategies and practices from the private sector and uses widely accepted measures for performance. Over the last four years, the duty has seen improved patient safety performance. Again, specific performance improvements were noted in the testimony submitted by the department while I’m confident in our processes for ensuring high quality care and proud of our performance as measured against peers in American medicine. The department also has clear policies and procedures in place when patient safety incidents occur. The department has taken steps to methodically implement Section 7 31 of the Fy 2020 N. D. A. Which amended the military claims Act by allowing members of uniformed services or their representatives to file claims for compensation for personal injury or death caused by the medical malpractice of a. D. O. D. Healthcare provider in an empty F. And those claims where a claimant disagrees with the determination. We have an appeals process with appeals board members who have no prior connection with the cases they’re reviewing in cases where a military medical malpractice claim. Active duty, disability or death payment is made. Additional reviews are required by the D. H. A headquarters including an external peer review and specialty consultant review. Following these additional reviews, I am responsible for rendering a final provider determination and reporting decisions. The department is grateful for the support and oversight from this subcommittee on patient safety and quality of care programs in the military health system. We’re confident that recent changes put in place within the NHS properly respond to both the spirit and letter of legislatively directed changes and will continue to closely manage these vital programs on behalf of the service members and families were privileged to serve. I appreciate the opportunity to appear before you today and I look forward to your questions. Alright, Lieutenant General Dingle, chairwoman, spear ranking member Gallagher and distinguished members of the subcommittee. Thank you for the opportunity to speak to you on behalf of our armies health professionals. The committee’s investment combined with the army’s deliberate emphasis on patient safety enhances medical readiness and I thank you. I appreciate the first panel expressing their personal stories and testimonies it resonated because people are our number one priority. My unwavering commitment as the 45th Army surgeon general is to ensure the health and safety of our soldiers and families first and foremost, maintaining the confidence at military treatment facilities or at our operational sites requires a dedicated total Army medicine force. This is about taking care of our people together with the Defense health Agency. We will, we will accomplish these goals By focusing on advancing towards zero preventable harm and the delivery of medical care As a key enabler. Army medicine is committed to our high reliability organizational mission in the operational environment and the core competencies of patient safety in conjunction with the Defense Health Agency. We are advancing toward zero preventable harm through training and oversight across the continuum of healthcare to maximize reduction of medical risks. Army medicine is also synchronized with the Defense Health Agency to meet the needs of the operational force. From the fox hole to the fixed facility. Army Medicine follows one Clinical Quality Management Standard. The military departments, operational units and the medical treatment facilities are inextricably linked. The medical treatment facility is the premier readiness platform for our medical personnel to hone and sustain the mission essential clinical skills needed to perform their duties. Downrange my enduring responsibility is unchanged to exercise my duties as the Army Secretary, senior medical Advisor and medical Integrator. By certifying army healthcare capabilities are trained and ready. Are the medicines focus has pivoted to the operational medicine but we will ensure operational standards are in accordance with the policies, guidelines and procedures. Patient safety is essential for a strong, healthy and resilient army and is the most critical indicator of our readiness to deploy, fight and win our nation’s wars. In closing Army medicine is committed to people First we remain vigilant as we strive towards reduced preventable medical errors. I appreciate the subcommittee’s work and the continued support to our soldiers, families and your long standing support to Army and the army medicine. Army medicine is army strong. I look forward to your questions. Thank you, Chairwoman spear first and most importantly, Mr. Lucky and Mr. Del Barba, thank you for your powerful testimony. I know this wasn’t easy and that we are grateful for the courage you demonstrated. I learned a lot listening to your statements and as the leadership of the military health system we needed to hear from you to Mr. Lucky and the Lucky family, you suffered a profound loss with Daniel’s tragic death. I know you continue to grieve. I want you to know that we Daniels. Navy family mourn her passing as well. The loss of a shipmate and family members heartbreaking and impacts all of us who serve in America’s Navy Madam, Chairwoman, ranking member Gallagher members of the subcommittee, thank you for conducting this hearing on patient safety and quality of care. You rightfully hold us accountable to provide service members and families healthcare that is high quality, safe and accessible please. No, we never waver from our commitment to protect the health of those who go in harm’s way as part of our solemn obligation to the sailors marines and their families. We are continuing our strong commitment to high reliability within navy medicine appropriately in conjunction and collaboration with the Defense health Agency, Army and air Force, high reliability practices are critical for success and high risk Navy environments such as submarines aircraft carriers and diving operations in order to enable teams to avoid the detrimental impacts of mistakes. We have emulated their example within the military health system because we recognize that the three H. R. O. Pillars, leadership, engagement, continuous process improvement and a culture of safety directly translates to better outcomes and the sustained delivery of high quality paper patient care for me. This commitment to HR was deeply rooted in my early professional development. As a pediatric orthopedic surgeon, I was mentored by highly regarded Navy orthopedist Captain john Webster who demonstrated high reliability in all aspects of patient care. In my view, he was ahead of his time into playing key principles of safety and quality in the operating room. But he also recognized that he couldn’t do it alone. He knew that patient care and the relentless pursuit of better outcomes and fewer errors is interconnected and complex and involved teams of people, people working together in a culture of trust cooperation and mutual respect for a common purpose and I should add all empowered to speak up about issues impacting the safety of the care we deliver. I have seen the powerful impact of high reliability throughout my career as a surgeon operating in commands such as Naval Medical Center san Diego in combat where I lead a surgical shock trauma platoon in Tacoma Rock During the 2nd Battle of Fallujah in command of military medical treatment facilities with large medical staffs and as the fleet surgeon guiding the provision of care on the naval operational forces Now in my current role as the Navy surgeon general, These experiences inspire me to broaden and deepen our efforts to eliminate preventable patient harm for Navy medicine. High reliability represents a commitment to safety, quality resiliency and operational success wherever, wherever naval forces operate. To this end, we established the Navy Medicine Quality and Safety Leadership Academy specifically equipped our leaders with a charro tools to communicate, anticipate, identify, resolve and then ultimately rapidly share and apply the lessons through the enterprise. Our providers are expertly trained and we hold them accountable for the care they provide. We do rigorous work including provider credentialing, privileging patient safety reporting and other critical components. Following the requirements specified in the clinical quality management program as well as in compliance with other applicable Navy directives. We recognize that we cannot completely eliminate all errors, either human or systemic, but we must be persistent. Are rigorous self assessment, rapid cycle feedback and high velocity learning to continuously improve as a high reliability organization privileged to care for our nation’s war fighters and their families. We can never be content. Gentlemen, spare, thank you for your leadership in this area and look forward to your questions. Good afternoon, chairwoman, spear ranking member, Gallagher and distinguished members of the subcommittee. It’s an honor and a privilege to appear before you today as a surgeon general of the Air Force and Space Force to discuss Air Force medicine, clinical quality management processes and functions to include patient safety and health care risk management. Before I continue, I also want to thank Mr. Del Barbara and Mr. lucky for their testimony, I want to reiterate my commitment to patient safety for all military health system beneficiaries. We started our journey towards becoming a high reliability organization in 2015 when my predecessor, Lieutenant General Mark Edgar, launched the trusted care program. Even now, high reliability remains the foundation for the care we provide. Additionally, we remain partnered with the Defense Health Agencies. High reliability efforts. Together our processes ensure a culture and practice of safeguarding patient safety in the operational and non operational environments. Today I would like to highlight two aspects of that collaborative partnership towards quality and safe patient care. First, the FMS clinical Quality Management transitioned to the D. H. A. And second, the FMS operational Quality program. Due to the D. H. A. Transition, the Air Force Medical Operations Agency, Legacy Clinical Quality Quality Management Office transitioned from a large organization that supported 76 military treatment facilities all downrange facilities and patient transport missions to a streamline office supporting the operational environment. Currently our clinical quality management division falls within the Air Force medical readiness agency or Acura and has been renamed after Maria Operational Quality. This support now focuses on our deployed facilities and air medical transport capabilities. I’m happy to report the Air Force operational facilities comply with D. H. A. Clinical quality management Procedural manuals. Additionally, the Air Force quality policies have been updated to align with the D. H. A. Procedural manuals. The Akron operational quality division is focused on development, implementation and sustainment of clinical quality management procedures and guidance for safe and quality healthcare and operational environments are patient safety and health care. Risk management teams use proactive assessments to reduce risk and harm across the enterprise as well as afford an analysis of events to identify gaps in health care, delivery and mitigation strategies to prevent future harm, mitigation and reduction of risk in the delivery of operational health care is paramount. Proactive management of safe and quality care includes review of joint patient safety reports from our downrange and patient transport environments to develop and improve processes to reduce the potential for harm in the deployed environment regardless of location. If a patient safety event occurs, the event is entered into the joint patient safety reporting system. These can be events that could have caused harm and did not reach the patient or one that caused harm by reaching the patient. In either case, an event review occurs through an analysis of the healthcare delivery process with the aim of identifying the gaps that contributed to or directly caused the event. Additional healthcare risk management activities involved a review of the care that was delivered. If the standard of care review identifies potential misconduct, a significant deviation from the standard of care or other significant concerns, then an adverse action to hold the involved provider accountable is pursued in summary FMS remains committed to being a high reliability organization and is committed to maintaining the quality and safety of care delivered in the operational environment. Our program focuses on risk mitigation, transparency and delivery of trusted care anywhere. We work hand in hand with the defense health agency, culture of learning and safety is paramount to the success of our operational quality program. R. A. F. M. S. Team is working to ensure our airmen and guardians get the safe, high quality health care they deserve and I remain dedicated to safeguarding that diligence as their surgeon general. I look forward to your questions. Thank you. Thank you all. I’ll um resist asking my questions until the end. Um ranking member Gallagher, you’re recognized for five minutes and I would like to yield my time to the gentleman from Ohio dr Wenstrom dr wen strip your recognized. Thank you madam Chair and thank you ranking member for the opportunity to participate in this today. And I want to thank our witnesses here today for being here. Um I uh personal point of personal privilege if I can. General Dingle, I want to thank you for your opening up the opportunity for the service members uh to be able to converse with you uh with my expansion of your consultant program and I want to, I want to thank you for that. I think it’s been a great opportunity for us and for the for army medicine. Um you know, the Mh, as a vital component of our National Security Strategy, there’s no doubt about it. It needs to be. And the Defense Health Agency is a critical element of the MHS. It was established as part of a larger effort to reorganize military healthcare programs and and services. We’ve learned a lot in the last couple of years as well. I think through covid population medicine is extremely important in the military. We need to preserve that. And there are concerns that the Congress has tasked D. H. A. With increasing responsibility despite it’s being limited by its construct as an integrated Combat support agency. And I’ve been working on this issue for several years now. Um you know, even after leaving this committee, but as a surgeon who serve reserve and active personal experiences as as a surgeon conversations I’ve had with active and retired officials, uh some that sat in your seats um experiences in private practice uh grown some concerns with MHS transition. I think a lot of people have looking at further changes in the MHS. I think we need to ensure that we’re able to provide. Um What we often hear is the medical medically ready force and a ready medical force operationally and all the while preserving population health for service members, their families at home and abroad retirees for that matter. Uh So we want to make sure that we are not sacrificing readiness for population health and make sure that we can do the best of both. Ah So through the experiences and listening to many stakeholders, I think that we could greatly benefit the MHS and all the patients in their care with a functional specified command is what I call it. And if I could, I would like to submit for the record some of what we have worked on involving the military health system and possible reforms to it. Uh certainly this isn’t cut and dried. Um but it offers a specified command, three star command that I think would potentially make us all more functional across everything that we’re trying to achieve. And I certainly would want input on that from each and every one of you as I have sought some of that already. As you know, um you know, I know that some of the concerns that we have came from Congress and I remember it a hearing with uh previous surgeon general, your predecessor, General Dingle where we were discussing as we, one of the members was reading a letter from combatant commanders saying this is going to be difficult for us to really challenge that. We’re worried about this. And General West said, well we’re just doing what Congress asked us to do and that’s why I want to engage from this end because if we’re asking some things to do maybe good intentions that aren’t necessarily the best for us, you know, where do we go from there and how do we make a difference to make your life easier and more productive. In many ways we want flexibility. We want the services to be able to weigh in a compass across all compositions. We have joint situations, we have service specific situations, reserve flexibility or you backfill ru operational, are you both? And uh certainly respecting the value of R. M. T. F. S. And I think that’s an important thing. So we want to enhance also opportunities between military and civilian um operations where we can learn to train each other and we see a lot more of that happening today, which I think has been very, very helpful. Um I guess in the time that I have, I’ll just go with one question with the understanding that each service has unique needs. How would you describe for us? That’s the level of ownership you have over the personnel and medical training readiness within each of your services. Representative wisdom about I’ll start from the army, I own the soldiers, I’m responsible for their readiness, trained and ready for us. And I do that through what we call individual critical task list. So for every specialty I am responsible to make sure that that soldier can perform his or her duty. Uh not just in the fixed facility where we um sharpen the acumen but also downrange in the operational environment. So I do have control over those soldiers to ensure the readiness and in conjunction with the Defense Health Agency. I leverage internal training Cross Lebanon as well as military civilian partnerships. Thank you congressman. Similarly in the Navy my responsibility is command and control of all naval medical forces um within our uh medical force um and demanding training and equipping of them to make sure they’re ready to perform. Downrange. Um We have found that by establishing naval medical readiness training commands within the MTs to oversee those responsibilities uh in conjunction with the D. H. A. As a training range that that model is working well albeit um some growing pains. But we continued to collaborate with the DHS to make that successful. Thank you congressman and similar for the Air Force. Um I would say that as we focus on organized training and equipping our force and especially our medics um R. M. T. S. Are our readiness planning training platforms. It’s the focus sometimes we do need to uh go to civilian facilities as needed uh supplement that training. But the preference is always to work within the military training facilities. Uh That training starts at Mezey for enlisted medics different for for the officers. And and I would also like to comment that it’s more than just the active duty. It’s Total Force, it’s the Guard, its reserves and and you put that whole team together which is critical to make sure that we’re delivering that trusted care across across the globe, they mentioned working with D. H. A. I think that’s an important component of that company. Yes sir, as already indicated by the three surgeons, the services control the forces. We are in dialogue about how they might help within the MTs. But the services control the forces. Yes. Gentleman yields back. Uh the gentleman from Texas dr Jackson is recognized for five minutes. Thank you. Um I just want to briefly say as a relatively new member of Congress and and new to this subcommittee as such. I’m looking for opportunities to make a difference. And I’ll tell you the only physician on this subcommittee and as a career Navy emergency medicine physician, I think that this is an area anything all these issues involving military medicine is gonna be one of the main areas that I’m that I intend to focus on for my foreseeable future here in Congress on on having a big impact. I just think that everybody needs to pick their niche. I think that my uh this this will become my niche in this subcommittee. And so I say that because I uh you know, just looking and Per per last year’s budget, almost 8% of the D. O. D. funding was dedicated to the military health systems. That’s quite a lot. And I’ve been trying to you know, figure out where where can I make an impact in military medicine. And I start by saying that I’m not doing it to to shake anything up or to identify any problems I’m doing it to uh as, as somebody who comes from your community to find ways that I can help you make military medicine better for all of us because just like general place was saying, I too have family members including a daughter, a son and a daughter in law that are on active duty as well. And I want their career to be fulfilling and I want them to get the medical care that they need in the process and be ready to fight and do what they have to do as well. So, uh, I I approach it in that regard and I’ve had the, the uh, the honor to spend a little time with General Miller and I really enjoyed that sir. And I think, I think you’ve got a great attitude and I think we’re going to work together. Well, I’m gonna enjoy working with you. I I personally know Admiral Gillingham pretty well and he’s a, he’s a, he’s an aggressive and well respected leader in Navy medicine. I hope to get to meet to get to know the two of you a little bit better as time goes on. But my question would be, I guess in general, you know, I, uh, and, and I’m trying to figure out exactly where we’re at in the general process because I was, I was on active duty back in 2012, 2013, whenever DHS came about and the the branches were trying to figure out how, where everybody fit in and how it was all going to work and I know it was a mess to start with and you know, right, you know, you would assume that it would be with an organization the size of, of military health care, you know, trying to come together and just completely restructure. I know that there was some growing pains early on. I’m assuming that a lot of that stuff has been overcome. I have been going out and trying to be active and and figure out exactly where I can have an impact and what’s broken and what I can help fix from here. And I’ve been to san Diego, I’ve been to Walter reed. I’ve been out to Brooke medical our Brooke army Medical Center. So I’m making my rounds and I’m gonna continue to do that. I’m gonna continue to visit as many MTs clinics and things as I can to continue to ask people what’s working, what’s not working as a member of congress, what do you know, what would you like to see me work on? What would you like to see me help you fix on and so forth? But I ask you guys that as well and I’m sure that the stuff that, that that comes to your level might be different than the stuff that that’s happening, you know, with the, with the folks that are on the ground, some of the doctors and nurses that are, you know, um directly taking care of patients. Uh, but I will say that, you know, I still think that there’s a little bit when I talk to folks, uh and and I’m hoping that, you know, try to disarm people as much as you possibly can when you go into these situations. Especially, I don’t think of myself as a congressman quite honestly, at this particular point, I just when I get back in the military M. T. F. I feel like, you know, You know, that’s this is where I’ve been for the last 25 years. I don’t feel like, you know, I’m out of place, but I think a lot of people are hesitant to talk to me about certain things. And I get a lot of people that are just like, well, everything’s fine. We don’t need any help, you know, you know, but I get the sense that everything might not be completely fine, there may be issues, but I don’t know what they are. So, my question to you all to start with would be what’s working and what’s not working with the transition and what is a member of Congress on this subcommittee that deals with military health. Can I do to help you guys facilitate your to to make military medicine is absolutely to make it the absolute best that it can possibly be well represented. Jackson. Thanks for the discussion and the question, uh, knowing how all the process works, the legislative proposals have, you know, they’re working their way through and be and you’ll see them. Um Yeah, I think all of us will say that we are working way better today than we did a year ago and I think we’ll say that we’re working way better a year ago than we were three years ago and way better three years ago, five years ago. So I think you’ll see a united organization here between all of us and the organizations that we lead. I think that that that the best discussions are often held informally as a as a as a methodology of organizational ideas exchanging. So I think I I speak for myself when saying I look forward to getting to know you a little bit better as well and how we can have those discussions but I don’t have specific things that I would recommend that you address today along those lines and represent Jackson. I would add that. Um we are not where we were and we are moving the ball down the field. However, there are challenges that we are learning and so we’re in the assessment phase because this is new. Um we as as a team from the director and all the surgeon general’s working together to implement the law as well as diode policy. We are learning Discovery learning as we go through to include the initial question for representing one strip about readiness and as I assess the readiness of soldiers. And so I I had to welcome you know, the discussion um you know um at the same time um imperative that we give the opportunity to uh do a D assessment internal as well as external. And then as general place mentioned we are using the legislative proposal process uh through the Department of Defense for the initial ones. Thank you Admiral. I’m a congressman Jackson for that question. Um I would say us specifically what’s working I think um Covid taught us the power of our unified approach. Um The D. H. A. Did a terrific job interacting in the inter agency. Typically as we got ready for vaccine distribution and then working closely with with them, we were able to translate that into our unique operational environments. Um I think that rapid cycle feedback uh that uh General place has spoken about in terms of the practice management guidelines for the treatment of COVID, which is now in its 8th edition demonstrates demonstrates the power of having a you know, a large central organization that can collate that experience and then allow us to to execute through our respective services. So I to welcome the opportunity. I think we’ll be speaking next week. I look forward to that sir and appreciate your support and advocacy. The gentleman’s time has expired. Alright, um let me start off with Admiral Gillingham, you heard um Mr. Lucky talked about the loss of his daughter. What have we learned from the loss of her life? What has the Navy done differently because she received such incompetent care. Thank you for that question madam. Chairwoman. I can assure you that Navy medicine investigated the facts and circumstances surrounding semen Lucky’s medical care that we examined lapses in systems and protocols that we made standard of care determinations but that we developed improved processes not just aboard Uss Reagan but but we shared those throughout the fleet and across our medical treatment facilities and with the D. H. A. And that we have addressed the accountability to involve care providers. We have grown as an organization due to that unfortunate Travis. Can you be specific about what changes have been made in terms of providing medical care on ships? Certainly. Um We um we developed a fleet wide sepsis screening. Uh so when an individual comes to sickle aboard ship, the Corman can use that screening tool to detect whether there are risk factors for that individual to develop sepsis. In addition then the treatment protocol that follows should sepsis be identified and that that has also been shared with our MTs we implemented a process, we call surge which is supporting urgent responses across the global enterprise. These are reviews that go to a site if there has been an event, even potentially near misses so that we can learn the maximum from those cases and apply that. And we also have deployed the joint patient safety reporting system across the fleet and in our all of our operational environments. Thank you. Lieutenant General Dingle since um Don’t Mr. Del Barbas incident. What changes is the army made and how they care for service members and training units represents spear, you know, again, not to repeat what Rear Admiral Gillingham said. You know, we have conducted all of those investigations in conjunction with the Defense Health Agency, the lessons learned, the clinical practice guidelines. Uh not just at that location but across the military health system we work through and with the Defense Health Agency because it is I understand all of that. I want to know what you’ve done differently. What’s pretty clear to me is that the likelihood for um whether it’s strep or sepsis is much more likely in a setting where you have people living very close together. It appeared that in the case of Fort Benning there wasn’t enough antibiotics to provide to the other service members. So how are you anticipating that? Earth and Spirit? If I can take that for record, um I can give you much more detail than the numbers and what we have done as I synchronize that with the Defense Health Agency. Alright. In in all of your settings. Um spinal meningitis is um much more prevalent and spreads much more quickly in living situations where people are close together. It’s um it happens in college campuses um and it can happen in a setting where you’re on a on a ship or in close quarters in the barracks have all of the service members upon um participating in basic training receiving the the actual shot. I guess it’s a vaccine. I’m not sure. And we are we haven’t started the minister and that I’m sorry you have started doing that man. We have stopped for a period at that location and then re implemented through the lesson learned from this incident. So are are all basic training recruits actually receiving that kind of a vaccine? Yes ma’am. penicillin and how about in the navy? Yes ma’am. To my knowledge, we are doing that. General miller Air Force. Yes, ma’am also. All right. Um General place in your opening comments, you reference the goal of the D. H. A. Is ready, reliable care. And that struck me kind of um oddly reliable is not quality, reliable is not comprehensive, Reliable, arguably could be three minutes in the er So why is that word used versus one that kind of emphasizes quality. The use of the word reliability is, is taken from high reliability concepts to become a high reliability organization and the tenants of high reliability is, is where that word is coming from. Well, I would recommend that you re evaluate that your we’ve all heard about the J. O. Study. It’s preliminary in nature. The one question I didn’t ask Miss Silas is what grade would you give These services based on the fact that 16% of the credentials of the healthcare professionals are never verify, never confirmed. Now that falls under you. Lieutenant general place, that’s your responsibility. You can delegate it. But the fact that 16% haven’t been looked at should send alarms, does it not send alarms to you? Congressman? The alarm uh is always on. I mean the the depth and breadth of the requirements that uh the GTO study is looking at is significant and and quite honestly, I’ll agree with the preliminary results that she described you. I think those are accurate but I’m not sure that the characterization that you’re making is as accurate as it could be. And here’s what I’m saying that one of the examples and I happen to know some of the preliminary results that she was describing When it came to licensing the specific case that she’s talking about. That particular provider had 10 licenses, 10 and eight of them were primary source verified. Now is the requirement to do all of the answer is yes. Should we have done better. The answer is yes. But I wouldn’t infer from that that there’s no checking for the licensor of the providers. Well, I mean the fact of the matter is I wish she was still here. There were 100 cases pulled at four installations And of those 100 Records, 16 of them had not been verified. Now in this one you’re referencing that eight of the 16 licenses had been of this one person. But I think the expectation is that we’re not credentialing, we are not allowing anyone to provide health care to our service members unless we have verified their credentials. So if you need more staff then you should tell us do you need more staff to complete that function? Uh At this point I think it would be premature to say that. And that gets back to the the other comment that she mentioned, the quality requirements that we have now that I signed out as one of my first acts as the director of the Defense Health Agency in October of 2019 was a market expansion of the clinical quality rick requirements massive. And we are still in the process of implementing all of them perfectly. And quite frankly, I think the help of the G. A. O. To help us see ourselves better where we’re not meeting those expectations. My expectation is to be perfect. Okay. So she’s also said very clearly that if A Q. A. I takes more than 270 days, you’re supposed to report it to the national practitioners Databank bank. Have have you done that in all of these cases? No, ma’am. Not in all these cases and why not? Part of the reason the clock starts when the payment is made? Not when we find out that it’s not right. That is actually not right. It starts on day 270 whether you’ve completed the Q. A. I. Or not. I understand that. And there are cases where you do not compensate but they are compensated Ble but have not been reviewed for whether or not that practitioner should no longer be providing services. I think we’re all interested in the same thing. We don’t want practitioners out there providing services to our service members who um either need more training or have forgotten their training or just are not good physicians or healthcare professionals correct? Yes, ma’am agreed. So it seems like we should be checking their credentials, we should be reporting it to this um data bank and we should be evaluating whether or not they should be put on administrative leave pending the results of the cases. I mean when, when a police officer shoots his gun and someone dies or is injured, they are immediately put on administrative leave. While there is an investigation that’s undertaken in many of these cases, these practitioners continued to practice and some were even promoted, correct? I don’t know the details of all the cases were describing, but I can see how that would happen. Yes, ma’am. Alright. Um so my understanding is that whatever the gao report finalizes, you are going to embrace it and you’re going to make the changes necessary to comply with it. Absolutely. Yes, ma’am, the the personnel performing these guys, How are they selected? How do you ensure their independence from command influence or personal loyalties within their unit. Is that a question for me? They’re not a part of units. The headquarters people that I have are are not associated with units. Okay, so the question is how do you guarantee that this kind of review that’s being done is by persons that are independent from different facilities? Don’t know the provider that’s being reviewed. How do you make sure there’s not a conflict of interest? Well, exactly, as you described at first, they’re not part of the same unit. And and the panel that we use within our headquarters is not associated with the health care being delivered. Similarly, we use a uh commercial program, a commercial company as an independent second opinion for these cases as a as another independent way of evaluating them. So when do you send cases for external reviews? So the status, what’s the determination is made if the if the local level says status or standard of care met um than those go to an external peer review. If standards are met? If we say internally in our evaluation of the standard of care is met. Those are the ones that are sent to an external peer review. So it’s not just well we all got together and you know, we’re all together here. So no nothing to see here. If we determine internally that standard of care is met, then we send it to an external peer review. How many QA eyes has the department completed over the past three years, Man? Because of Title 10. I can’t tell you that in this forum. I’m happy to provide that to you. Um, offline as your status as chairman. Okay. Would you do that please? Yes, ma’am. And then also provide to us how many found that the standard of care was not met and how many providers were reported to the national practitioners database for failing to meet the standard of care? Yes, ma’am. I’ll give your staff for the specific questions will provide that. All right. Those are my questions. Anything else anyone wants to add? All right. We thank you very much for your service and for being here today, we’ve got to get this right. Those two results are untenable. I think. You appreciate that. I hope that you will redouble your efforts with that. We stand adjourned.

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