Navy Medicine West (NMW)is a regional medical command that reports directly to the Navy Burerau of Medicine and Surgery (BUMED).

With more than 17,500 Sailors and civilians, NMW oversees 10 Military Treatment Facilities (MTFs),two Dental Treatment Facilities (DTFs) and eight Navy Medical Research and Development Laboratories positioned throughout the globe.

Charged with improving patient safety, quality and experience of care, NMW is realizing a region-wide paradigm shift as these facilities commit to the application of high reliability concepts in all areas of their daily operations. In October 2014, the Secretary of the Defense directed the Military Health System (MHS) to adopt the principles of High Reliability Organizations (HROs) as the foundation for fostering an ever-attentive and responsive culture of patient safety.

At the core of high reliability organizations are five key principles that create an environment of "collective mindfulness," which in turn is a prerequisite for safety. The Agency for Healthcare Research and Quality describes these key HRO concepts as follows:

* Preoccupation with Failure - When near-misses occur, these are viewed as evidence of systems that should be improved to reduce potential harm to patients. Rather than viewing near-misses as proof that the system has effective safeguards, they are viewed as symptomatic of areas in need of more attention.

* Reluctance to Simplify - Oversimplifying explanations for how things work risks developing unworkable solutions and failing to understand all the ways in which a system may fail, placing patients at risk.

* Sensitivity to Operations - Preserving constant awareness by leaders and staff of the state of the systems and processes that affect patient care. This awareness is key to noting risks and preventing them.

* Deference to Expertise - If leaders and supervisors are not willing to listen and respond to the insights of staff who know how processes really work and the risks patients really face, you will not have a culture in which high reliability is possible.

* Commitment to Resilience - Leaders and staff need to be trained and prepared to know how to respond when system failures do occur. Errors will happen but need not be disabling.
NMW is achieving this revitalization in its patient safety culture with steadfast commitment from every member, and by leveraging the "cutting edge" tools, concepts and methodologies of Continuous Process Improvement (CPI).

High Reliability Culture of Patient Care

The concept of "high reliability" developed in industries, such as aviation and nuclear power, where even rare or seemingly insignificant errors could have disastrous results. Uniquely, "high reliability" is not predicated on a certain organizational structure, measures, or even protocols. Rather, it is the single-minded focus of the entire workforce to identify potential problems or high-risk situations before they lead to adverse events. Leaders of high reliability healthcare organizations commit to achieve 'zero' preventable patient harm, and every staff member sees his or her role in a larger, holistic context to quality and patient safety.

From the clerk who checks patients in, to the Corpsman or nurse who takes their vitals or assists in their care, this commitment empowers everyone to identify conditions or circumstances that may lead to patient harm, and more importantly, take action before that harm occurs.

Whether calling a time-out to ensure everyone is on the same page before starting a procedure or formally chartering a CPI project to improve a process, every member of the organization knows he or she can make a difference. The result is an organization that celebrates transparency and the contributions of every individual, regardless of their role or position, with the overall objectives of achieving zero preventable patient harm and improving patient outcomes.

Elements of NMW's HRO culture trace their earliest beginnings to Naval Medical Center San Diego's (NMCSD) adoption of the "Med Teams" program in 2005, which promoted the "Two-Challenge Rule," encouraging staff members to question any order that did not seem right. The "Med Teams" concept was a precursor to current patient safety-focused, team-based communication programs, such as the Agency for Healthcare Research and Quality (AHRQ) TeamSTEPPS® program, whose key principles of communication, leadership, situation- monitoring and mutual support, are on the front lines of patient care. TeamSTEPPS® stands for Team Strategies & Tools to Enhance Performance & Patient Safety. All MTFs and DTFs throughout the Navy Medicine enterprise train the TeamSTEPPS® program to their staff.

"The 2014 Navy Medicine 'Culture of Patient Safety' Initiative and the MHS Review directed by the Secretary of Defense that same year, were watershed moments for Navy Medicine and Navy Medicine West," said Capt. Christopher Cornelissen, regional chief medical officer (RCMO) and deputy chief of staff (DCOS) for the Directorate for High Reliability at NMW headquarters, San Diego, California. "Both of these events empowered an internal look into our patient safety and quality processes, bolstering staff at all levels to speak up and prevent the next potential patient harm, driving us further to new heights in patient safety through the application of CPI tools in clinical settings."

Continuous Process Improvement (CPI)

We have all heard the adage, "to err is human." In an interview published in the December 2009 issue of The Joint Commission Journal on Quality and Patient Safety, Gary S. Kaplan, M.D., a practicing physician, Chairman and Chief Executive Officer of Virginia Mason Medical Center, Seattle, stated, "...humans make on average six errors a day." If you consider the number of staff in an average sized facility, that is a significant amount, perhaps in the thousands, of errors made every day. Kaplan's point, however, was not about human foibles, but underlying systems and the need to change them to make errors impossible. This is where Continuous Process Improvement (CPI) comes in.

According to the U.S. Navy Handbook for Basic Process Improvement, a process is, "...no more than a series of steps and decisions involved in the way work is accomplished." Whether buying groceries, changing a light bulb, or preparing a cup of coffee, every task we perform throughout our daily lives involves a process. Moreover, for every task, there may be multiple processes available to accomplish it.

"Not all processes produce the same results with the same efficiency, meaning that the processes an organization chooses to employ will influence its prospects for success or failure," said U.S. Navy Captain Cheryl Ringer, NMW director of CPI. The ability to design optimal processes and continually improve upon them is critical to the effectiveness of an organization - a reality Ringer confronts every day.

"Change is inevitable, and those who continually strive to improve the processes around them situate themselves in the best position to manage that change," said Ringer.

The NMW CPI office, situated within the Directorate for High Reliability, was officially created in February 2015, in response to Navy Medicine's enterprise-wide focus on becoming an HRO. Since then, NMW patient safety, quality and CPI systems have flourished and Ringer and her team have led the entire region on a journey to utilize CPI methodologies and resources to improve and reduce variability of processes related to healthcare, dental care, research and development.

The initial, albeit paradoxical, step on the HRO journey was to establish a process for improving processes. Having commands perform CPI tasks in the same way ensures consistency across the region, resulting in a program Ringer is certain will continue leading the Navy Medicine enterprise from the front.

In developing the NMW CPI program, Ringer and her team used a project management approach to outline and map all constructive program areas. Then, to ensure the program was comprehensive, they brought together both Quality and Process Improvement representatives from every regional command to review and comment on the proposed program. In addition, they worked with each MTF and DTF, both virtually and onsite, to guarantee the program was teachable, actionable, measurable, and exportable. The resultant program ensures CPI projects and initiatives conform to command objectives and strategy, culminating into a total package supporting the entire Navy Medicine enterprise.

Ringer and her team conducted site visits to numerous facilities and laboratories to train and assist them in addressing their pain points using Lean Six Sigma (LSS) process improvement tools and methodology. This methodology relies on a collaborative team approach to improve performance by systematically removing process "waste," which includes the following categories:

* Over-production - doing more than what is necessary, or sooner than is needed.

* Wait times - waiting for the next event or activity to occur.

* Transportation - needlessly moving patients, specimens, or materials.

* Over-processing - work that is not aligned to the patient's needs.

* Inventory - costs, storage, spoilage and waste related to excess inventory.

* Motion - excessive movement of staff to accomplish a task.

* Defects - excessive time doing something correctly, inspecting, or fixing errors.

In health care, any of these categories can contribute to inconvenience or harm to patients. With the LSS framework and training in place, regional facilities can now strategically identify operational problems using data, and then using internal staff and resources, systematically improve these processes. To date, the CPI office has trained a record number of 171 Green Belt candidates throughout the region since the start of fiscal year 2017. In addition, the CPI office developed innovative training methods to include Green Belt training for healthcare providers who were otherwise unable to take the necessary time off from their clinic duties.

Regional Quality Collaborative (RQC)

In July 2015, then Commander, NMW, Rear Adm. Bruce Gillingham, established the NMW Regional Quality Collaborative (RQC). The RQC leadership consists of the RCMO, all MTF Command Medical Officers (CMOs), DTF Command Dental Officers (CDOs), and command-designated heads of Quality Management (QM) with the purpose of optimizing patient outcomes by eliminating patient harm and creating patient-centered value.

In the current Navy Medicine High Reliability healthcare model, the CMOs and CDOs form an important collaborative cross-linked network between their respective commands to foster the promotion and adoption of healthcare quality, patient safety and CPI initiatives developed at enterprise and regional levels for execution by MTFs and DTFs. The CMO and CDO model ultimately serves to enhance cross-regional communication, collaboration and sharing of patient safety, quality and CPI best practices. In this way, all NMW commands are able to leverage ideas for enhancing healthcare quality wherever they may originate, whether within military medicine or from the private sector.

Initial Results of the RQC

The first project assigned to the RQC was, "to assess the current performance of NMW MTFs that provide obstetric services in order to anticipate, prevent where possible, and respond when necessary, to postpartum hemorrhage (PPH)." PPH is an obstetrical emergency in which the mother experiences a significant blood loss within the first 24-hours following childbirth, vaginally or by cesarean section.

While the rates are higher in developing countries, in the United States the pregnancy-related mortality rate is approximately seven to 10 women per 100,000 live births, with approximately 8 percent of these deaths caused by PPH, according to the Obstetrics & Gynecology monograph on Postpartum Hemorrhage, which Medscape.com published online, March 2016.

In 2014, the Association of Women's Health, Obstetric and Neonatal Nurses, estimated that of all PPH-related deaths, 54 percent to 93 percent were preventable with improved clinical response. Even if PPH does not lead to death, the resulting blood loss, possible anemia, and escalating interventions can be stressful and debilitating for the patient. Though the risk of PPH-related maternal death is extremely low, with approximately 14,000 to 15,000 live births performed annually across Navy Medicine, it is vitally important that PPH is recognized early, resourced appropriately, and managed quickly.

Led by an obstetric physician advisor to the RQC, a cross-functional team at Naval Medical Center San Diego (NMCSD) undertook a process improvement initiative in October 2015, to determine the best multidisciplinary, evidence-based clinical approach to reduce the occurrence of PPH. The team conducted a comprehensive literature review, developed an evidence-driven protocol, and delivered education to all relevant departments. Within 10 months after rollout, the average monthly rates of delayed PPH decreased by over half to 2.1 percent, which is well below the national average of 3.6 percent measured by the National Perinatal Information Center (NPIC). With the teams' notable accomplishment, the NMW RQC incorporated their recommended obstetric clinical model and guidelines known as a "Postpartum Hemorrhage Safety Bundle," into a region-wide policy Instruction, issued July 11, 2016.

On September 27, 2016, Navy Medicine's Quality Collaboration Synchronization Board (QCSB) reviewed the NMW PPH Safety Bundle and implemented it across the enterprise. The final step included translating the PPH Safety Bundle into a BUMED policy instruction to facilitate annual reviews, follow-up and sustainment, and site visits to monitor for utilization, challenges, and new ideas.

The successful implementation of the NMW PPH Safety Bundle helped lay the foundation for a robust, regionally based process improvement program that would bolster all future NMW RQC initiatives. Today, the NMW RQC has several ongoing initiatives, to include reducing or eliminating surgical tissue tracking errors, pediatric medication errors, immunization errors, and post-sterile processing deficiencies of surgical equipment.

Cornelissen says the true highlight of these projects is they are led at the lowest levels by an MTF or DTF project lead with representation from each treatment facility. Under the direction of a regional project Champion and LSS Master Black Belt, these projects demonstrate commitment and collaboration across the continuum of regional leadership. The involvement and engagement of those treating our patients at the point of care are critical to the success of these regional projects.

Not Resting on Our Laurels

Overall, the NMW CPI program has proven itself an overwhelming success, producing tangible results leading to better healthcare for thousands of patients. Despite these achievements, a deep-seated penchant for perfection compels the NMW CPI team to make the program even more effective. Whether working with their counterparts in Navy Medicine East (NME) and with BUMED to expand and mature the Enterprise-wide Process Improvement Model, or challenging commands to incubate fresh ideas and approaches to shared problems, NMW continues to foster a collaborative, all-inclusive CPI culture throughout the region. Everyone, from cook to cardiologist, has an equal voice in improving health care.

Looking ahead, the NMW CPI office is investigating how to best quantify and evaluate patient outcomes for every patient, which includes determining how human factors can affect patient care. "For decades, military medicine's focus has been on positive Return on Investment (ROI) measured in monies saved or costs avoided, but positive patient outcomes are where the focus should be. Regardless of how much money is saved, if patient outcomes are negative then we are not successful," said Ringer, who believes, as Navy Medicine becomes a fully realized HRO, the resultant process improvement breakthroughs will revolutionize the way healthcare is delivered throughout the entire enterprise. "It's been a great journey but it's never over. Our regional High Reliability team is hands down the best in the MHS enterprise, and it gives me great pride knowing I have the honor and privilege of serving in what I believe to be Navy Medicine's vanguard for finding better ways to care for our patients."

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