Clinical Quality Management in the Combat Zone: the Good, the Bad, and the Unintended Consequences

MILITARY MEDICINE, 176, 4:375, 2011

Clinical Quality Management in the Combat Zone: The Good, the Bad, and the Unintended Consequences

COL Robert A. De Lorenzo, MC USA * † ; COL James A. Pfaff , MC USA (Ret.) † ‡

ABSTRACT Clinical quality management (CQM) is a fi xture of modern U.S. healthcare to include fi xed military medical treatment facilities. CQM is now being applied to the battlefi eld. In a related fashion, standards of care have been proposed in the context of combat medicine. The overall goal is to improve the medical care of casualties. Despite good intentions, the concepts and execution of CQM and standards of care are neither well-described in the literature nor estab-

lished in offi cial military doctrine and regulation. This has resulted in variable and haphazard applications that range from Downloaded from https://academic.oup.com/milmed/article/176/4/375/4345373 by guest on 04 October 2021 the positive and supportive to the negative and counterproductive. This article outlines the use of CQM in combat operations and asserts that a deliberate analysis of the benefi ts and risks is needed before its continued use. Future directions should focus on the impact of CQM on mission, doctrine, training, staffi ng, and unit organization. Rigorous adherence to evidence of effectiveness is essential before applying CQM in the combat zone.

I have a system, very much like yours. Only difference THE GOOD is I don’t shoot the rope, I shoot the legs off the stool. CQM in the Combat Zone –Tuco, the “Ugly,” from the 1966 Western The Good, the Bad, and the Ugly . Among the fi rst to elucidate the potential benefi ts—and limitations—of implementing CQM in the war zone was Clinical quality management (CQM) can be defi ned as Cohen 2 in 2005. He declares that selected quality processes “a systematic, organized, multidisciplinary approach to the can be applied to any military setting including fi eld units, ongoing assessment, monitoring, evaluation, and modifi ca- so long as the standard measures are modifi ed to fi t the con- tion of the processes of health care and services to enhance straints of the austere environment and limited resources of quality. These activities are associated with incremental and the combat zone.2 He is careful, however, to draw a distinc- focused processes or [performance improvements] to meet tion between quality processes that are an appropriate activity the health care needs and expectations of eligible benefi cia- in the deployed setting (eg, those that minimize variance) and ries.”1 Along with the related concepts of quality assurance, those that are inappropriate. The latter, he noted, includes a performance improvement, and standard of care, CQM has “vague, ill-defi ned sense of a general standard” that refers to become a fi xture of modern U.S. healthcare to include pro- misguided attempts to impose a standard of care when condi- vided by the military in fi xed medical treatment facilities tions preclude this.2 (MTFs). More recently, however, CQM has made a formal De Jong et al 3 state that the goal of perhaps the best-known appearance on the battlefi eld. Combat hospitals, far-forward CQM initiative the Joint Theater Trauma System (JTTS) is medical units, and command-and-control headquarters in to “ensure that battle and nonbattle casualties receive opti- both Iraq and Afghanistan now devote substantial energy mal care.” The impetus for JTTS was a perceived defi ciency towards CQM programs. Many of these programs are well in the battlefi eld placement of surgical assets, disorganized intended. Lacking, however, is a critical appraisal of the wis- movement of casualties, and inadequate clinical data col- dom and effects of CQM on an austere, distant, and rather lection and, as such, was focused on battlefi eld trauma.3 violent environment of care. In an effort to illuminate the The implementation of JTTS is credited with contributing issues, we will explore the positive and negative aspects of to improved survival on the battlefi eld. 4 In particular, the battlefi eld CQM, with special attention to the possible unin- adoption of battlefi eld clinical practice guidelines was felt tended consequences. to improve outcomes in the context of burns, hypothermia prevention, and massive transfusion.4 JTTS also served as a mechanism to improve acute care processes and clini- *Department of Clinical Investigation, Brooke Army Medical Center, cal documentation and utilization of professional provider Fort Sam Houston, TX 78234-6200. resources. Much like its civil trauma system counterparts, it †Department of Military and Emergency Medicine, Uniformed Services also provided education and advocacy and served as a con- University of the Health Sciences, Bethesda, MD 20814. duit for policy change.5,6 With the possible exception of an ‡Department of Emergency Medicine, Brooke Army Medical Center, episode felt by some as a coercive and premature experi- Fort Sam Houston, TX 78234-6200. The opinions or assertions are those of the authors and do not necessar- mental use of a hemostatic agent, JTTS has generally been ily refl ect the position of the Army Medical Department or the Department received as a positive and supportive infl uence in battlefi eld of Defense. care.3–9

MILITARY MEDICINE, Vol. 176, April 2011 375 Clinical Quality Management in the Combat Zone

Competence and Performance Indicators Joint Commission and Standards of Care Assuring appropriate personnel qualifi cations is a fundamental Taking the focused application described by Cohen, Stannard, aspect of CQM, and the high rate of turnover of combat per- and others a giant leap further, Budinger15 argues for the sonnel adds to the signifi cance. It is a prerequisite for health- implementation of Joint Commission–style standards and care professionals to possess a valid and unrestricted license principles at all levels of care in the mature theater of oper- before deploying; in a similar fashion, many enlisted health- ations, such as in post-surge Iraq. In fact, a comprehensive care technicians are required to have appropriate credentials program of inspections and performance assessments of pro- such as emergency medical technician-basic certifi cation for cesses, documentation, and the environment of care is now Army combat medics. The importance of these requirements in place throughout U.S. medical forces in Iraq and, to a in assuring minimal competency cannot be overstated.10 Of lesser extent, Afghanistan. Even the National Patient Safety course, by itself licensure does not guarantee competence in Goals are integrated into the operational plans of deployed combat casualty care, but when combined with appropriate medical forces.13 Budinger 15 sees the introduction of combat- Downloaded from https://academic.oup.com/milmed/article/176/4/375/4345373 by guest on 04 October 2021 specialty board certifi cation, it represents the accepted “gold zone CQM as a natural extension of theater maturation that standard” in general competence.10 It also reassures service will ultimately evolve into the fi xed MTFs in Germany and members, commanders, and the public that the military medi- Korea that provide peacetime-based care. The impact is far- cal force employs credible clinicians on the battlefi eld. reaching, with individual clinicians, evacuation assets, medi- There are other examples of CQM programs in the the- cal companies and platoons, forward-deployed surgical units, ater of operations ( Table I ). Patient-satisfaction surveys have and combat hospitals participating in activities ranging from been used, whereas others involve clinical laboratories and competency assessment and credentials verifi cation to risk human-subjects research.11,12,17 Clark and Brewer13 outline a management and peer-review. The implicit goal, of course, is more comprehensive approach to CQM, including healthcare to ensure that deployed service members have access to care system assessment, patient safety, and standards-based deliv- that refl ects stateside standards.13 ery of care. Stannard et al14 introduce a set of key performance Clark and Brewer13 explicitly declare that a standard of indicators for use by British medical units. Unlike most other care exists for the combat zone: “we can expect and should initiatives that approach quality from a generic perspec- hold ourselves to a U.S. standard of care—one founded on tive, their metrics focused on combat medicine. For exam- proven guidelines, practices, and patient safety.” Their model ple, a prehospital indicator examined “the time from point was applied primarily to nursing, equipment logistics and of wounding to appropriate surgical care <2 hours,” and an operation, and medical records completion, but conceivably operative indicator asked “did penetrating abdominal injury could fi nd relevance in other areas of combat health support. with blood pressure of 90 mm Hg systolic undergo laparo- It would appear a laudable endeavor to strive for such high tomy in under 30 minutes from arrival [to the surgically capa- US-based standards, and in fact, there is anecdotal support for ble unit]?” An advantage of this approach is the relevance and this pursuit. Implicit in all such activities is a desire to improve near-universal applicability that transcends unit composition the quality and reliability of the combat zone health system.15 and circumstance. As Stannard et al14 themselves emphasize, To date, however, there is little published information specifi c any indicator used must withstand the scrutiny of the avail- to the “standard of care” in the combat zone or other deployed able evidence. settings. This lack of information extends to offi cial military doctrine and rules.

TABLE I. Clinical Quality Management Initiatives in Combat THE BAD 1,2,4–7,11,12–15,1,6 Zone Medicine Offi cial Guidance Void Clinical Practice Guidelines The implementation of CQM on the battlefi eld has proceeded Case Management Review Videoconferencing largely without doctrinal or organizational changes in the Quality Healthcare Assessment Visits Modeled on Joint Commission deployable medical force. Current fi eld manuals on com- Methodology bat hospital employment, theater hospitalization, and medi- Competency and Workload Metrics Risk Management and Process Outcomes of Selected Cases cal operations in counterinsurgency make scant mention of National Patient Safety Goals CQM and only then in the context of laboratory quality con- Laboratory Clinical Processes trol. 12,18–20 Military quality assurance regulations, too, either Total Quality Management and Variance Reduction exempt deployed units or are notable for an absence of detail Patient Satisfaction Surveys regarding applicability to combat operations.1,21–23 A recent Peer-review of Medical Records Competency-based Assessment and Credentialing historical review of military medical quality assurance pub- Delineation of Privileges for Physicians and Providers lished by the Offi ce of the Assistant Secretary of Defense Specialty-specifi c Key Performance Indicators for Health Affairs makes no mention of the battlefi eld.24 The Morbidity and Mortality Reports omissions in offi cial guidance may not be unintentional and in Advocacy, Education, Policy and Research Agendas fact could refl ect a tacit desire to avoid imposing potentially

376 MILITARY MEDICINE, Vol. 176, April 2011 Clinical Quality Management in the Combat Zone onerous requirements on the combat medical force; however, survival rates of trauma patients reaching the hospital and the situation is not clear. 99.3% return-to-duty rates for behavioral health encounters.27 The apparent vacuum of offi cial guidance and regulation Not mentioned, however, is that a decline in acuity and patient has led to variations of opinions for battlefi eld CQM. Clark volume may have a greater impact on improved rates.28 The and Brewer13 caution against haphazard application of “that’s implementation of combat care clinical practice guidelines is how we do it back home” practice standards to the deployed touted as improving survival, but only three of 27 guidelines environment where equipment, logistical, and staffi ng con- have been associated with improved outcomes, and even then, straints dictate an alternative approach to healthcare delivery. the evidence shows the improvements were not directly attrib- As the theater matures and casualty rates decline, the clinical utable. 4 The value and effectiveness of CQM in general is workload in the combat hospital shifts to primary and sub- variable, with widely used activities such as clinical practice specialty care as commanders seek to preserve deployed end guidelines and root-cause analyses coming under serious ques- strength. 15 With fewer critical cases to occupy their time, clini- tion. 26,29–31 Even supporters of evidence-based CQM note that Downloaded from https://academic.oup.com/milmed/article/176/4/375/4345373 by guest on 04 October 2021 cal staff fi nd more of their productivity consumed by CQM improved outcomes are often multifactorial and not always activities focused on low-acuity lines of care.13,15 Although it directly related; in the case of combat trauma survivability, may be natural to focus CQM on the low-intensity tasks dur- multiple factors including improved body armor and prehos- ing lulls in the action, there is the potential hazard of overlook- pital care have likely played far greater roles than CQM.4,6 ing high-risk but low-frequency events that represent the core combat mission (such as resuscitation and emergency surgery). Is There a Combat Standard of Care? In this regard, JTTS may counter this tendency because it is Perhaps few concepts engender greater confusion and poten- focused almost exclusively on critical casualties.5 In any case, tial for misuse than the term “standard of care” as applied to resources are still required to accomplish the CQM mission. the combat zone. An accepted generic defi nition is “health care diagnostic or treatment judgments and actions of a provider/ Burdens of CQM professional generally accepted in the health care discipline In some combat hospitals in Iraq, it is now common for the or specialty involved as reasonable, prudent, and appropriate.1 number of reports required by headquarters each month to Implicit is the understanding that the defi nition is specifi c to exceed the number of patients treated in the same period. the conditions of the case at hand.32 A standard of care for the Although not all such reports are attributable to CQM, many theater of operations, then, requires reference to the same or are, and overall this refl ects an environment increasingly bur- similar circumstances, which belies its use in the highly change- dened by bureaucracy. Welling25 bluntly describes such non- able, resource- and personnel-constrained (and often danger- patient care activities as “fl uff,” and notes it is perpetrated ous) environment of combat. Further obscuring the defi nition is largely by personnel not active in clinical practice. In a sharply the uncomfortable reality that different “standards of care” may worded commentary, Tate26 refers to the computer- and clip- exist depending on the nationality or status of the casualty. 33 board-wielding quality improvement “police” as antithetical Accounting for a single, precise, and measurable standard can- to good clinical practice. Regardless of perspective, scal- not succeed when nearly every deployment circumstance pres- ing the CQM activities to match the clinical caseload would ents radically different—and ever-changing—conditions. Thus, appear fundamental.16 the use of the term should be appropriately and carefully quali- Additional staffi ng and support may be required to over- fi ed (or altogether avoided) when discussing combat care. come the loss of productivity from CQM activities because Despite the foregoing, nothing in this discussion should current deployed unit organizational tables do not account for be construed to suggest there are not high expectations for this overhead. However, increasing the size of a medical unit high quality care in the operational setting or that individu- merely to conduct CQM is unlikely to be sustained unless a als and units do not have an obligation to provide the very clear increase in capability can be demonstrated. Air Force best under the circumstances. The crucial operative is recog- regulations, for example, identify for each fi xed MTF a mini- nition of the variable and often unique environment that man- mum of 4 managers (eg, credentials manager and performance dates a nuanced understanding of the applicable standards and improvement coordinator) and 16 committees to support the a sophisticated manner of quality measurement.2 To date, the CQM process. 21 Deployed units attempting to incorporate case for this has not been well-elucidated in the medical litera- Joint Commission–like processes without the benefi t of the ture or in military service doctrine. extra staffi ng risk burdening clinical personnel with the task. In fact, to meet this burden, it is not uncommon for more THE UNINTENDED CONSEQUENCES senior-ranking non-physician caregivers to spend the major- ity of their time engaged in activities away from the bedside.25 Balancing Mission Priorities This inadvertently undermines the quality by depriving the It is very likely that some types of CQM activities yield greater patient of experienced caregivers. benefi ts at lower cost than others; some have proven value, Arguments for CQM in the combat zone have been sup- while others may simply be a waste of time or worse force ported with statistics of improved outcomes, including 98% standardization when innovation is desired (as when the enemy

MILITARY MEDICINE, Vol. 176, April 2011 377 Clinical Quality Management in the Combat Zone changes tactics and wounding patterns evolve, thus forcing fi eld. In fact, it may be the battle space outside the combat rapid shifts of care patterns). Austere and remote health care hospital that is most in need of initiatives designed to improve organizations such as the deployed medical force may inadver- care. Incremental improvements at the point-of-injury or the tently spend substantial resources pursing CQM interventions evacuation chain (eg, role I care by medics and aid stations that have little chance of improving outcomes or diminish- and ground and air transport crews) may yield greater rewards ing harms.34 Wholesale adoption of Joint Commission–style than far larger efforts directed at the hospital-end of the con- CQM only after combat operations wind down (when the clin- tinuum.36 Yet the far-forward environment continues to suffer ical risk has decreased dramatically) telegraphs a message that from a lack of data, benchmarks, and mechanisms to enable quality is unimportant otherwise. Furthermore, such activities effective CQM-driven improvement. risk competing with pressing priorities such as battle drills In discussing JTTS as a positive example of battlefi eld and trauma skills training. As mentioned previously, in some CQM, Lam et al6 emphasize innovation, accountability, and combat hospitals, there is a growing perception that more collegial communication in contradistinction to process-driven Downloaded from https://academic.oup.com/milmed/article/176/4/375/4345373 by guest on 04 October 2021 time is spent on CQM than in activities directly related to bureaucracy. A sophistic application of CQM risks introduc- patient care. ing unintended consequences including negative effects on the patient, physician and other caregivers, and organization.38,39 Competency Contingency Some effects such as lowered morale and decreased profes- sionalism may be worse in large, bureaucratic organizations The distraction away from important priorities can be seen such as the military.40 Gaming behavior (ie, manipulating the in efforts to credential and monitor deployed caregivers. By system) can even be introduced when a well-intended but importing elaborate systems of competency assessment (eg, ill-advised CQM measurement results in either superfi cial 6-part competency folders and detailed delineation of privi- improvement or worse, dysfunctional behavior designed to leges), combat hospitals focus on superfi cial measures of subvert the system. 41 “Checking boxes” and fabricating num- competency while ignoring the core reality of military con- bers to fi t headquarters’ expectations are potential penalties in tingency staffi ng: to overcome genuine personnel shortages, doctrinarian circumstances.42 it is an accepted military policy to substitute selected special- ties with those less qualifi ed.35 This can result in a gynecolo- gist managing major trauma on male patients, a pediatrician Unintended Standards resuscitating adults, and an ambulatory clinic nurse staffi ng a Unintended consequences of CQM can also result from over- surgical critical care unit. In effect, customary levels of com- extension of the “standard of care” concept. In one example, petency are not attained and instead are reduced to the lowest a deployed medical unit prepared a policy that routine U.S. common denominator (eg, any nurse can substitute for any standards of care would apply during a mass casualty event other, regardless of specialty or the clinical scenario). The to include maintaining bedside caregiver-to-patient ratios, problem is exacerbated because predeployment medical train- prohibiting expansion of clinical scope, and enforcement ing meant to bridge the gap is neither required nor reaches the of concurrent medical record charting. National consensus intended audiences.7,10 guidelines, notwithstanding, the rationale was the customary Unable to reconcile the military’s expectation of clinicians “standards” were inviolable.43 Had this been implemented, the practicing far outside their documented areas of competency, consequences could have been disastrous with bedside staff Joint Commission–style assessments instead default to super- unable to fl ex their practices suffi ciently to meet a surge in fi cial minutia such as patient privacy training and electronic casualties or even care for multiple patients simultaneously.44 medical record completion rates. The salient issue of compe- Table II summarizes potential benefi ts, risks, and unintended tency is conveniently sidestepped and the effects on clinical consequences of combat zone CQM. outcomes are left unexamined. Meanwhile, a growing body of evidence suggests that high quality combat casualty care THE MARCH FORWARD (and improved outcomes) rests with correctly matched clini- Improved battlefi eld care is a mission of the military medical cian skill sets. 36,37 The net unintended consequence is either system and the objective of every deployed clinician. CQM a false sense of CQM effectiveness or a loss of confi dence provides a powerful means to help achieve this goal, but like in the process. A more pragmatic approach would at the out- healthcare itself, it must be delivered at the right time and for set fl atly acknowledge the military staffi ng contingencies and the right reasons, must be executed well, and must be cost- then work to leverage real change in terms of predeployment effective.45 Widespread application of CQM systems in the training and staffi ng decisions.7,10,36 combat zone is both new and largely untested. The continued use of CQM requires a deliberate analysis of the benefi ts and Paradoxical Effects risks to the mission and it must be thoroughly vetted against The paradoxical effect of introducing CQM primarily in com- the available scientifi c evidence. Combat CQM must be part bat hospitals reinforces the perception that activities designed of a comprehensive and deliberate combat strategy and not to improve quality are unimportant elsewhere on the battle- merely a result of mission creep.

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TABLE II. Potential Benefi ts, Risks, and Unintended 6. Lam DM , Fecura SE Jr : The trauma continuum-of-care quality forum Consequences of Implementing CQM in Combat Medical integration committee system-wide video teleconference . Mil Med 2007 ; Operations 172 (6) : 611 – 5 . 7. Cordts CR , Brosch LA , Holcomb JB : Now and then: combat casualty care Benefi ts policies for Operation Iraqi Freedom and Operation Enduring Freedom Reinforces the Goal of Quality Care compared with those of Vietnam . J Trauma 2008 ; 64 (2) : S14 – S20 . Care Environment Refl ects U.S. Standards 8. Berenson A : Army’s Aggressive Surgeon Is Too Aggressive for Some . Improved Processes and Outcomes New York Times , November 6, 2007 . Available at http://www.NYTimes. Reduction in Variance com ; accessed July 7, 2010. Risks 9. Little R : Dangerous remedy: military doctors in Iraq say that Factor VII Lack of Doctrinal or Regulatory Guidance saves wounded soldiers, but other doctors and medical research suggest Distracts Away from Core Combat Mission that it can cause fatal clots. Baltimore Sun November 19, 2006 . Available Increases Workload and Manpower Requirements at http://www.baltimoresun.com ; accessed July 7, 2010.

Misapplication of Standard of Care 10. De Lorenzo RA : How shall we train? Mil Med 2005 ; 17 (10) : 824 – 30 . Downloaded from https://academic.oup.com/milmed/article/176/4/375/4345373 by guest on 04 October 2021 Unintended Consequences 11. Zimlichman E , Kreiss Y , Mandel D , et al : Evaluating delivery of pri- False Sense of Effectiveness vs. Undermines Confi dence in Process mary health care to military personnel during low-intensity confl ict using Gaming of System (eg, Reporting Infl ated Results) a patient satisfaction survey . Mil Med 2003 ; 168 (6) : 471 – 4 . Reduces Unit Flexibility and Ability to Adapt 12. Aldous WK , Co EM , Hamilton L : Establishing a quality assurance pro- Paradoxical Degradation of Clinical Quality gram in the clinical laboratory in the combat zone. Mil Med 2010 ; 175: 77 – 80 . 13. Clark S , Brewer R : Clinical quality management in a mature combat By the same token, implementation of combat medical environment . US Army Med Dep J 2008 ; Oct–Dec: 51 – 6 . standards of care must take into account the austere, dynamic, 14. Stannard A , Tai NR , Bowley DM , Midwinter M , Hodgetts TM : Key per- and often extreme circumstances encountered in the combat formance indicators in British military trauma . World J Surg 2008 ; 32: 1870 – 3 . zone. It is counterproductive to routinely default to custom- 15. Budinger DP : Healthcare system planning along the combat theater matu- ary U.S. standards (even if qualifi ed with adjustments for cir- rity continuum: transitioning an expeditionary medical force to an inte- cumstance); many clinical conditions encountered in theater grated healthcare system . US Army Med Dep J 2008 ; Oct–Dec: 11 – 8 . simply have no practical civil counterpart—they are unique 16. Mant J : Process versus outcome indicators in the assessment of quality of unto themselves. A more fruitful approach would entail set- health care . Int J Qual Health Care 2001 ; 13 (6) : 475 – 80 . 17. Brosch LR , Holcomb JB , Thompson JC , Cordts PR : Establishing ting evidence-based and combat-focused clinical performance a human research protection program in a combatant command . J Trauma goals and using these targets to drive system improvement and 2008 ; 64 (2 Suppl) : S9 – S12 . reengineering.15 18. Department of the Army : Field Manual 4-02.10. Theater Hospitalization . To be fully effective, doctrine, training, staffi ng, and unit Washington, DC , Department of the Army , 2005 . organization should all be updated to incorporate the best 19. Department of the Army : Army Training and Evaluation Plan 8-855(MRI). Mission Training Plan for the Combat Support Hospital. practices of combat-focused CQM. The entirety of the com- Washington, DC , Department of the Army , 2000 . bat casualty care continuum from point of injury, evacuation, 20. Department of the Army : Field Manual 8-42. Combat Health Support resuscitation, and hospitalization should be included. Finally, In Stability Operations And Support Operations. Washington, DC, combat zone CQM should be subject to rigorous assessment Department of the Army , 1997 . of effi ciency and effectiveness. Statistical justifi cation of 21. Department of the Air Force : Air Force Instruction 44-119. Medical Quality Operations . Washington, DC , Department of the Air Force , improved care should always include suffi cient detail and con- 2007 . text to support a complete interpretation of the facts. Although 22. Department of Defense : Department of Defense Directive 6025.13, a lack of concrete evidence does not necessarily imply lack of Medical Quality Assurance (MQA) in the Military Health System effectiveness, it should spur an examination of the unintended (MHS) . Washington, DC , Department of Defense , 2004 . consequences, which can be especially diffi cult to control in 23. Department of the Navy : Operational Navy Instruction 6320.7A. Health Care Quality Assurance Policies for Operating Forces. Washington, DC, the Spartan environment of the combat zone. Department of the Navy , 2007 . 24. Granger E , Boyer J , Weiss R , Linton A , Williams TV : Historical evolu- tion of medical quality assurance in the Department of Defense . Mil Med REFERENCES 2010 ; 175 (8) : 581 – 6 . 1. Department of the Army : Army Regulation 40-68. Clinical Quality 25. Welling DR : Ineffi ciencies in military medicine . Mil Med 2008 ; 173 (12) : Management . Washington, DC , Department of the Army , 2009 . xii – xv . 2. Cohen DJ , Lisagor P : Medical errors—is total quality management for 26. Tate JS Jr : Quality improvement and peer review . J Am Coll Surg 2007 ; the battlefi eld desirable? Mil Med 2005 ; 170 (11) : 915 – 8 . 205 (1) : 196 . 3. DeJong MJ , Martin KD , Huddleston M , et al : Performance improvement 27. Sargent PD : Task Force 62 Medical Brigade combat healthcare support on the battlefi eld . J Trauma Nurs 2008 ; 15 (4) : 174 – 80 . system in the mature Iraq theater of operations. US Army Med Dep J 4. Eastridge BJ , Costanzo G , Jenkins D , et al : Impact of joint theater trauma 2008 ; Oct–Dec: 5 – 10 . system initiatives on battlefi eld injury outcomes . Am J Surg 2009 ; 198: 28. Moskop JC , Geiderman JM , Hobgood CD , Larkin GL : Emergency phy- 852 – 7 . sicians and disclosure of medical errors. Ann Emerg Med 2006 ; 48 (5) : 5. Eastridge BJ , Jenkins D , Flaherty S , Schiller H , Holcomb JB : Trauma 523 – 31 . system development in a theater of war: experiences from Operation 29. Ortiz E , Eccles, M , Grimshaw J , Woolf S : Current Validity of Clinical Iraqi Freedom and Operation Enduring Freedom. J Trauma 2006 ; 61 (6) : Practice Guidelines . Technical Review 6. AHRQ Publication No. 1366 – 73 . 02-0035. Rockville, MD: Agency for Healthcare Research and Quality.

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September 2002 . Available at http://www.ahrq.gov/ ; accessed July 7, 38. Werner RM , Asch DA : The unintended consequences of publicly report- 2010. ing quality information . JAMA 2005 ; 293 (10) : 1239 – 44 . 30. Shortell SM , Bennett CL , Byck GR : Assessing the impact of continuous 39. Bardach NS , Cabana MD : The unintended consequences of quality quality improvement on clinical practice: what it will take to accelerate improvement . Curr Opinion Pediatr 2009 ; 21 (6) : 777 – 82 . progress . Milbank Q 1998 ; 76 (4) : 593 – 624 . 40. Casalino LP : The unintended consequences of measuring quality on the 31. Wu AW , Lipshutz AKM , Pronovost PJ : Effectiveness and efﬁ ciency of quality of medical care . New Engl J Med 1999 ; 341 (15) : 1147 – 50 . root cause analysis in medicine . JAMA 2008 ; 299 (6) : 685 – 7 . 41. Lilford R , Mohammed MA , Spiegelhalter D , Thomson R : Use and mis- 32. Empey M , Carpenter C , Jain P : What constitutes the standard of care? use of process and outcome data in managing performance of acute Ann Emerg Med 2004 ; 44 (5) : 527 – 31 . medical care: avoiding institutional stigma . Lancet 2004 ; 363 (9415) : 33. Kondro W : Afghanistan: Outside the comfort zone in a war zone . CMAJ 1147 – 54 . 2007 ; 177 (2) : 131 – 4 . 42. De Lorenzo RA : Checking the box on training tasks . Mil Med 2010 ; 34. Werner RM , Asch DA : Clinical concerns about clinical performance 275 (8) : 544 – 7 . measurement . Ann Fam Med 2007 ; 5: 159 – 63 . 43. Altevogt BM , Stroud C , Hanson SL , Hanﬂ ing D , Gostin LO (editors);

35. Department of the Army : Army Regulation 601-142 . Army Medical Committee on Guidance for Establishing Standards of Care for Use in Downloaded from https://academic.oup.com/milmed/article/176/4/375/4345373 by guest on 04 October 2021 Department Professional Filler System. Washington, DC, Department of Disaster Situations, Institute of Medicine: Guidance for Establishing the Army , 2007 . Crisis Standards of Care for Use in Disaster Situations: A Letter Report . 36. Gerhardt RT , De Lorenzo RA , Oliver J , Holcomb JB , Pfaff JA : Out of Washington, DC , National Academies Press , 2009 . hospital combat casualty care in the current war in Iraq . Ann Emerg Med 44. Veenema TG , Toke J : When standards of care change in mass-casualty 2009 ; 53 (2) : 169 – 74 . events . Am J Nurs 2007 ; 107 (9) : 72A – 72H . 37. Lettieri CJ , Shah AA , Greenburg DL : An intensivist-directed intensive 45. Swensen SJ , Meyer GS , Nelson EC , et al : Cottage industry to postindus- care unit improves clinical outcomes in a combat zone . Crit Care Med trial care—the revolution in health care delivery. N Engl J Med 2010 ; 2009 ; 37 (4) : 1256 – 60 . 362 (5) : e12 .

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