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, Budinger 15 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 al 14 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 Zone Medicine 1,2,4–7,11,12–15,1,6 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.

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