By: Lt Gen Eric B Schoomaker
Surgeon General of the Army and commander of US Army Medical Command

Army medicine is committed to serving the military family. We achieve this through strategic performance improvement to optimize health and well-being and to maximize the value of health services provided soldiers, retirees, their family members, and commanders in support of the nation. As the Army Surgeon General and commander of US Army Medical Command (MEDCOM), I lead a worldwide professional military, civilian, and contractor team in pursuit of excellence using a framework around the following seven tenets:

Leadership: Our leaders are engaged, selfless, accountable, and inspiring.

Strategic Planning: The Balanced Scorecard Strategic Management System guides, measures, and focuses our actions to improve operational and fiscal effectiveness.

Customer Focus: Everything we do furthers the end of meeting and exceeding the needs of our patients, customers, and stakeholders.

Measurement, Analysis, and Knowledge Management: Disciplined data-driven decision-making and leveraged knowledge optimizes and accelerates our value creation.

Workforce Focus: Our #1 asset is the talented team of Army medicine professionals whose daily individual contributions ensure collective mission success.

Process Management: We embrace a culture of change through championing the Army’s Lean Six Sigma deployment, other industry best practice continuous performance improvements, and change management tools and methods.

Results: It’s all about execution! We will never lose sight that all said to this point, together, must yield measured results propelling our mission accomplishment toward a compelling vision of the future driving value for those we serve.

This article will address five critical focused initiatives Army medicine will resource and execute over the next 18 to 24 months to improve quality of care and create value.

Comprehensive Behavioral Health System of Care

In the years since the United States became engaged in the Global War on Terror and Overseas Contingency Operations, behavioral health (BH) care providers across the Army have developed innovative ideas and programs to address the BH concerns of soldiers and their families.

In February 2010, MEDCOM established the Comprehensive Behavioral Health System of Care (CBHSOC) working group to standardize, synchronize, and coordinate BH care across the Army and throughout the Army Force Generation cycle (ARFORGEN). The objective is a system of care that will optimize care and maximize limited BH resources to ensure the highest quality care to soldiers. Development and implementation of the plan is a multi-year endeavor to completely institutionalize a broad array of BH improvements.

A broad range of subject matter experts developed a plan that synchronizes BH screening and intervention points immediately and establishes many near and long term initiatives to further synchronize and optimize BH care.

Near term goals of the CBHSOC are the standardization of BH screening information requirements and screening instruments; greater and more synchronized coordination with the Veterans Administration, local and state agencies, the Defense Centers of Excellence and the National Intrepid Center of Excellence; greater coordination with other Army programs like Comprehensive Soldier Fitness, Army Substance Abuse Program, and military family life counselors; and development of strategic communication.

Long term CBHSOC goals are development of a common BH information technology system; development and implementation of local fusion cells to coordinate BH efforts; full integration of tele-BH activities; and complete integration of the reserve components. These efforts will also be integrated with the efforts to screen and treat for traumatic brain injury and pain management.

Fundamental to the CBHSOC’s success is a continuous assessment and program evaluation by the US Army Public Health Command (USAPHC) and a strong strategic communication plan. To help ensure this success, MEDCOM established a General Officer Steering Committee (GOSC) to provide executive oversight and strategic guidance to the CBHSOC as it is implemented and refined in the coming months and years.

Comprehensive Pain Management Campaign Plan

Pain continues to be the number one reason people seek medical care in the US. The transient nature of the military for patients and providers makes continuity of care a challenge for the Army and the Military Health System. Our nation expects the Army and Department of Defense to provide the highest level of care to those carrying wars’ heaviest burden -- our soldiers and other service members and their families.

I chartered the Pain Management Task Force in August 2009 to provide recommendations for an Army Medical Command comprehensive pain management strategy that is holistic, inter-disciplinary, and multimodal in its approach; uses state of the art/science modalities and technologies; and provides optimal quality of life for soldiers and other patients with acute and chronic pain. This task force reported in May 2010 with 109 recommendations on improving and standardizing pain care in the Army. The report outlines the innovative steps the Army will take to better care for soldiers and family members who suffer from acute and chronic pain. Some of the key recommendations are: focus on the warrior and family—sustain the force; synchronize a culture of pain awareness, education, and proactive intervention for medical staff, patients and leaders; provide tools and infrastructure that support and encourage research advancements in pain management; and build a full spectrum of best practices for the continuum of acute and chronic pain care.

The pain management strategy must be integrated with the Comprehensive Soldier Fitness Program, the Army Suicide Task Force recommendations, and other Army and Department of Defense initiatives with the objective to improve the health and well-being of our soldiers and families.

MEDCOM is executing a long-term Comprehensive Pain Management Campaign Plan (CPMCP) focused on prompt, appropriate treatment of acute pain to minimize chronic pain issues for soldiers and families. Initial efforts will focus on the complex and high-risk soldiers within Warrior Transition Units, but will ultimately be expanded to all soldiers and family members.

Medical Management Center Pilot Program

We have a significant number of soldiers who have medical issues that prevent them from fully performing their duties in preparation for deployment. We want to systematically manage their care to ensure that they are moving to full health and medical readiness as soon as possible.

MEDCOM is evaluating pilot programs at Fort Stewart, GA, and Fort Knox, KY, that created medical management centers (MMC) to more closely monitor soldiers with limiting medical profiles in order to assist them in returning to their optimum state of health and back to their full military duties. If appropriate, these initiatives may be proliferated to other installations.

The MMCs have care coordinators who work with nurse case managers to track these soldiers, assist in care coordination when needed, and advise and educate unit commanders of any issues related to the medical care of their soldiers.

MEDCOM recognizes that commanders with soldiers on temporary profile may need more focused support in assisting those soldiers through the healing process. This is a partnership with unit commanders. With our focus on medical readiness in support of high operational tempo, we want to ensure we are fully supporting rear detachment commanders who have injured, ill, or wounded soldiers in their units.

Unit commanders may request assistance for soldiers who meet the established referral criteria to the medical management centers. The centers are not designed to replace unit oversight and management of soldiers who are pregnant, on convalescent leave, or nondeployable due to dental conditions or lack of immunizations.

Commanders and healthcare personnel work in collaboration to assist a soldier through the healing process. MMCs are designed to support, not rush, the healing process and it is recognized that some soldiers need more time than others to heal.

We are also collaborating with the established Medical Evaluation Board and Physical Evaluation Board processes to ensure that the efforts are as streamlined as possible.

Patient Centered Medical Home

For the past three years we have been focused on fulfilling Army medicine’s contribution to the Army Family Covenant: improving access to high quality healthcare services. We have made remarkable improvements in access to care, and in continuity of care with a patient’s primary care manager (PCM) and primary care team. These have resulted in dramatic improvements across the Medical Command in patient satisfaction—now exceeding 90% satisfaction with our care. These efforts have laid the foundation for a revolutionary effort to improve health and the outcomes of healthcare delivery: the patient centered medical home.

The Patient Centered Medical Home (PCMH) concept is being adopted throughout the Military Health System. The Army’s first major effort will be in the 17 community-based primary care clinics being established off-post at 11 sites. In 2011, Army medicine will start transforming all current primary care clinics located at military treatment facilities around the world.

The Army medical home will offer beneficiaries their own personal healthcare team centered on meeting patients’ needs in new ways. The medical home will partner with patients and encourage active participation in their own health management. Patients will have improved continuity with their physician and their team. Army medical homes will use the latest medical information technology to assist the care teams in better meeting patients’ needs with emphasis on prevention of disease and improved management of chronic diseases. Access to primary health care will be convenient and available 24 hours a day.

Key aspects of the PCMH:

• Offers a personal healthcare team, centered on the patient.
• Encourages active participation in medical decisions. The patient is an active member of the team, not a passive recipient of care.
• Improves the continuity of care; patients see their primary care manager (PCM) and PCM team.
• Uses a devoted care coordinator who follows up on test results, emergency room visits, referrals, and any specialty care that was not received in the clinic.
• Uses the electronic medical record within these clinics, the same as that used on every Army installation. Patient’s records move with them, electronically—no more lost medical records.
• Stabilizes primary care manager, nurses, and support staff. Patients will always see a familiar face.
• Improves communication between patients and their team, among the staff, and with external services.
• Offers multiple ways for patients to get the care they need or desire.

In order to be called a patient centered medical home, every primary care clinic is being reorganized from the ground up to meet the rigid standards set forth by the National Committee for Quality Assurance, as well as those created by the Joint Commission. Through patient feedback, they have also been tailored to meet the needs of a unique group, the military family.

Culture of Trust

Making all these initiatives more effective will be a culture of trust throughout Army medicine. Each of these programs reinforces our commitment to the needs of our patients and will be implemented based on the foundation of trust.

What is a culture of trust? It is a shared set of attitudes, values, and practices that distinguish Army medicine’s commitment to our beneficiaries to provide the highest quality and access to health services. It is based on confidence – confidence that we are competent, capable, and committed; that we will tell the truth and keep our promises.

In a culture of trust, transparent communication forms a foundation for building relationships. A sense of safety and a comfort level with interpersonal interaction pervades a workplace that has developed a culture of trust.

Systems and processes often fail because the underlying organizational trust level is low. Employees can be coached to adopt specific behaviors, beliefs, and mindsets that increase trust. High trust organizations achieve more with less. High trust employees are able to better focus on achieving the mission.

Patient satisfaction scores, error reporting scores, and patient safety scores will improve; productivity will increase and costs decrease; employee morale will increase while turnover rates, EO/EEO complaints and union complaints will decrease.

The culture of trust supports our vision of bringing value and inspiring trust. Trust is the foundation of Army medicine, and I have charged Maj Gen Patricia Horoho, deputy surgeon general, to champion a Center of Excellence to execute a unified strategy, standardizing processes and improving customer service processes, focusing on outcome measures, and strengthening our culture of trust.

Trust along with transparency creates the conditions in which our internal talent thrives, our patients receive the best care, and our stakeholders trust that we, Army medicine, deliver what we say we will deliver.

Using the seven tenets mentioned at the beginning of this article to pursue these initiatives, we will achieve Army medicine’s vision – to be America’s premier medical team saving lives, fostering healthy and resilient people, and inspiring trust.

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