READINESS THROUGH RELIABILITY AND RESILIENCE

Transcription

1 MILITARY HEALTH READINESS THROUGH RELIABILITY AND RESILIENCE Scott Barr Senior Vice President Paul Hutter Executive Advisor George Weightman Executive Advisor

2 READINESS THROUGH RELIABILITY AND RESILIENCE UNDERSTANDING MEDICAL TREATMENT FACILITIES Medical Treatment Facilities (sometimes known as Military Treatment Facilities or MTFs) are the Army, Navy, Air Force, and Defense Health Agency (DHA) medical centers, hospitals, and clinics that serve as the foundation of modern military medical care by being the location for active duty military to receive treatment while simultaneously serving as the training and education platforms for military medical providers worldwide. These stalwarts of military health care are evolving and changing at a rapid rate. According to testimony provided by Representative Joseph Heck (R-NV), Chairman of the House Armed Services Subcommittee on Military Personnel, in February 2016: The certainty that a military installation will have a full service medical facility is a thing of the past. For example, in 1989 there were more than 500 military medical facilities worldwide, 168 military hospitals and hundreds of clinics. Today, there are 55 hospitals and 360 clinics for a total of 415 MTFs. Large medical centers, such as Fitzsimmons Army Medical Center, once considered an enduring capability, have closed. 1 There are many reasons for the shifts in both scale and scope of the military organizations vested with an interest in delivering health services. Many of the explanations mirror changes in the civilian healthcare system, including using outpatient services such as ambulatory surgery and implementing care models such as patient centered medical homes. In addition, MTFs are adjusting to a new governance structure that resulted from the establishment of the DHA and the enhanced multi-service markets (emsms), designing and launching various enterprise-wide common business processes, and creating mandated shared services in an integrated delivery system. These complex changes are happening while budgets shrink, mission areas expand, new regulatory requirements roll out, privacy issues become more complex, and base realignment and closure and overall deployment patterns of troop units speed up. These issues clearly have had an impact on the delivery of medical support but the leadership within the military health community has maintained a continuing and unwavering commitment to quality health delivery and readiness. For their part, MTFs around the globe remain dedicated to reducing preventable harm to patients the ultimate goal of high-reliability health care. Many MTFs have embraced the Joint Commission s framework for becoming a high-reliability organization (HRO), with its three domains of change (leadership commitment, a culture of safety, and continuous performance improvement) and are aggressively pursuing this transformational challenge. However, since each MTF is unique from both an operational and cultural perspective each is determining its own best course for achievement. When considered in this light, it becomes clear that while the choices made with regard to implementing high reliability goals may improve integrated care at individual MTFs, they may not be enough to make the MTF network, (e.g., the aggregation of all of the MTFs across the three Services and the DHA), a resilient enterprise. 2 Managing Risk Across the MTF Network MTFs serve as important medical readiness platforms, where teams train using the skills necessary to support the full range of military operations around the world. In fact, at a Senate appropriations panel held in March 2016, the Surgeons General from the Army, Navy and Air Force, told lawmakers that maintaining medical readiness for the nation s fighting force aligns with the military s top readiness priority. Understanding and effectively managing the risks to which the network of MTFs is exposed should begin with a holistic view supported by systems-specific risk definitions and an 1

3 organizational risk hierarchy, which applies to all parts of the network. More specifically, maintaining medical readiness by managing risk across the MTF network requires active thought about contingency planning and the associated assignment of responsibility, definition of tasks, decision making characteristics and criteria, and the recommended prioritized execution in response to an unforeseen event or series of events. To be effective, risk management/contingency planning programs should take a network/systems view of the challenge and solution, apply a life cycle approach (pre-event, during event, and post-event), use a common and coordinated risk management framework and link to strategic planning of the Military Health System (MHS). Risk management/contingency planning programs that are best positioned to respond quickly and seamlessly to key challenges share a common set of attributes, including: Flexibility to respond to the unknown all events which occur within the lifecycle can never be totally and exactly anticipated and to plan for all contingencies is too costly (if not impossible). Awareness of the networked relationships and connectivity within the MTF network including operating units, specialized capabilities, health care delivery value chains, the communities in which it operates, its support staff, patients, business partners, and other key stakeholders. Connection to the strategic planning process to allow the MTF network to transcend day-to-day distractions, organization structure, and leadership changes to keep its eye on the main mission objective (i.e., military readiness). Our hospitals are our health readiness platforms... this crucial link to readiness sets us apart from the civilian health system. Army Lt. General Patricia Horoho 43rd U.S. Army Surgeon General Supportive of the culture of the MTF network cognizant of the mission priorities and risks, and the principles for which the institution wants to be known. These efforts should be incorporated into an integrated risk management framework which is in turn reflective of the institution s strategic business objectives. Sensitivity to existing roles, responsibilities and business processes identifying specific contingency planning responsibilities where necessary, but also providing clarity on the roles and responsibilities of any employee who may be involved, impacted, or need to respond to a crisis event. MEDICAL TREATMENT FACILITIES AND RESILIENCE While optimizing operations at the MTF-level through HRO efforts and risk/contingency management is essential to improvement at any given facility, we need to look beyond the individual MTF to fully understand the degree of true readiness within the MTF network. To do this, the MTFs should embrace a complimentary 2

4 philosophy of resilience the capacity of a system to withstand a disruption and to continue operating without impact on output or function. A resilient system is able to incorporate functional changes and operate interdependently without altering the quality of the service it delivers. Readiness is usually seen through the lens of risk management, which looks at the ability of an organization to accomplish its mission. Resilience looks at the consequences. It begins with the acceptance that some disruptions will be successful and that some functioning will be lost. It begins with the network, the 55 hospitals and 360 clinics that comprise the nodes that make up the MTF network. 4 In a traditional health delivery sense we can see these nodes operating independently and relatively autonomously but when it comes time to deploy, the interconnectedness of these 415 entities comes shining through! MTF resilience recognizes the weaknesses of the network structure and, at the same time, makes use of its strengths. In a network, there are many paths to vulnerability and many ways to fail. But there are also many ways for a network to quickly heal itself. Resilience uses the interconnectedness to its advantage. Redundancy and Response MTF enterprise resilience begins by analyzing all of the ways a system could lose functionality (note the focus on systems here, not the individual nodes). Countermeasures are devised to deal with each possibility in a series of if/then scenarios. These options will generally fall into two categories: planned redundancy and rapid response. Ideally, the MTF system would be designed with enough redundancy to protect all vulnerabilities. But in a system as complicated as the MTF enterprise, there are always going to be gaps and shortfalls that represent risk. Moreover, redundancy can be very expensive and in tight budget times, creating backup capacity is not always an easy sell. So a complementary approach is often a high level of sense-and-respond. Technology and other enablers are put in place that allow military leaders to know when the system is below acceptable operating levels, and helps implement the resilient strategies that have already been planned. MTF enterprise resilience can be achieved through a combination of automation and human decision. Though technology-enabled, resilience activities go beyond technology. These activities can range from standard operating procedures to modifications of physical facilities. Some MTFs demonstrate resilience now. For example, robust graduate medical education programs ensure effective responses to external challenges and ensure that MTFs in remote training or operational environments have the necessary resources not to fail because acceptable civilian backups do not exist. Because resilience considers a wide range of means by which MTF readiness could be diminished or lost, it has to be carefully thought out and planned for. We see resilience planning in many systems around us. For example, city officials may develop an emergency management and contingency plan that considers what might happen if an essential bridge into the city collapses. What preparations would need to be made in advance, before anything happens, to make sure people could get to and from work, so the city s economy could keep running? MTF enterprise resilience has the potential to give us the kind of assurance in our military health networks that we now have in necessities such as electricity and telephone service. We are all highly confident that if we flick the switch the light will come on, and that if we pick up the phone the dial tone will be there. And if by some chance there is an outage, we know that it is only temporary. There is no doubt that developing MTF enterprise resilience requires time and resources. But the up-front expenditure makes sense when we see it is far outweighed by what it can save in terms of military readiness. It s a form of buying down the risk. When systems and their 3

5 related infrastructures can quickly recover from attacks, the overall cost of operations goes down. It s like choosing a well-built car over a cheaper model. It lasts longer, requires fewer repairs, is more reliable and ultimately less expensive. Achieving resilience requires more than time and resources it takes a different kind of thinking. PRINCIPLES UNDERLYING A SYSTEMS- BASED RESILIENCE FRAMEWORK Several key principles will drive the design of a systemsbased resilience framework for the MTF enterprise: Principle 1: The military organizations affected with an interest in ensuring health readiness have an inherently governmental role to manage strategic risks for the MTFs which is distinct from their counterparts in the civilian world. The challenge is to understand and manage the risk profile from a systems perspective to assure the ability to deploy under all conditions, while providing superior care to members of the military and their dependents. Principle 2: The military health community will focus on issues which will drive analysis and decision making throughout the risk management process to help allocate limited resources. Conceptually, one of the biggest challenges is deciding how to prioritize proposed risk management programs. In addition, military health officials must work with a very broad array of stakeholders whose priorities may differ from one another. Amid these pressures, they must concentrate their efforts on an achievable set of risk objectives. As these objectives are met, then this list of risk objectives can be amended and expanded. Principle 3: Managing risks across the MTF enterprise requires looking at system-level risk in addition to asset-level risk. An asset-level risk is the combination of threat, vulnerability, and consequence for an individual asset such as an MTF. An example of an asset level risk could be infrastructure problems with older MTFs, potentially limiting operations. Older facilities often have issues maintaining the correct atmospheric conditions in the operating rooms (such as humidity), that might shut down the ability to perform surgeries. System-level risks are those risks associated with combinations of assets, their relationships, their functions, and their emergent properties. System-level risks can include events that would cause a set of assets to be lost or if key relationships between assets brake down. An example of a system-level risk is if service-members and their families could use network care without approval. This would potentially rob the MTFs of needed patient care opportunities that would impact readiness and training of healthcare professionals and teams. Because of the relationships between assets and system components, the consequences of a system- level failure can far exceed the consequences associated with a single asset. System-level and asset-level risk assessments are complementary and each addresses a different type of risk. In this context, a critical system is one which, if lost or seriously degraded, could cause related or dependent systems to suffer serious consequences. Similarly, a critical asset is any element of a system, which if lost, would cause its parent system to be unable to function effectively. Principle 4: Military health is a complex system where the effects of a disruption are often non-linear a small disruption in a critical part of the system can have a huge impact. Linear thinking, that is, an if-then or deterministic approach, does not capture the complexity of the large, interconnected, and adaptive networks that constitute the MTF enterprise. Improving one 4

6 part of the system without due consideration for the others cannot work nor can slicing and dicing the network into various sub-elements and working on each in isolation, since reactions to changes in one area may negatively affect other parts of the system. Introducing resilience into a complex system like the MTF enterprise requires a deliberate and dynamic approach. Principle 5: To capture the complete universe of risk drivers, risk must be analyzed and managed for the physical, process, and institutional layers of the system. The people, processes, and policies that govern and operate the MTFs enterprise are as much a part of the system as the physical infrastructure. The possibility that an organizational failure can be a source of risk to the broader military health system is as important as the possibility of risk posed by physical damage inflicted upon the system. Looking at risk from multiple system and asset perspectives creates a wide array of options to mitigate risks. These principles support a simple concept for a large, complex network like the MTF enterprise the most effective way to assure readiness is to manage risk and build resilience. MTFs will manage risk on two levels first, through HRO efforts they will manage the wide range of risks associated with delivery of health services. Secondarily, they will manage the asset-level risks (i.e., threat, vulnerability, and consequence) associated with being a part of the MTF network. While conducting efforts to effectively manage risk, we must also seize the opportunity to build resilience into the enterprise improving redundancy and response in a cost effective manner. MOVING FORWARD Organizational leaders need to develop a better knowledge of the system-wide issues and the confidence to act. It is always easier to have an operational rather than planning mindset. Risk management focusing on the immediate issue has the feel of action. But there is no advantage to focusing on risk management at the expense of resilience. Nothing is gained neither resources nor protection. And, because resilience requires that a large number of possible scenarios be considered, a more thoughtful and measured approach must be developed. At the same time, leaders know that it is rarely easy to justify costs when they are tied to contingencies that may or may not come to pass. A greater understanding of the MTF enterprise as a system is needed. We no longer have the luxury of dismissing those contingencies as just theoretical possibilities. Disruptions will occur. Military health can become a highly resilient enterprise comprised of highly reliable organizations. The concept is not as complex as we might think we benefit from resilience every day. MTF enterprise resilience will take investment, innovative thinking, and an ability to look at the larger picture. Resilience is just one part of a holistic approach to reaching and maintaining our medically ready force as well as our ready medical force. Ultimately, a focus on resiliency may be the most critical element. NOTES 1. Heck, Joseph, House Armed Services Subcommittee on Military Personnel hearing, Military Treatment Facilities - Opening Remarks, February 3, We recognize that no formal aggregation or network of MTFs exists today. However, we believe that the collection of MTFs forms a de facto network that should be leveraged to enhance readiness and resilience. 3. Kime, Patricia, Top Military Doctors: Our Health System Works Military Times, March 25, benefits/health-care/2015/03/25/military-surgeons-general-tricare-choice/ / 4. While we acknowledge TRICARE and the purchased care system, this discussion is focused on the DOD-operated MTF network. 5

7 ABOUT THE AUTHORS Scott Barr, Senior Vice President Scott Barr (CMAP, PMP) leads Booz Allen s military healthcare market. Mr. Barr has more than 17 years of experience in management and strategy consulting for the Department of Defense, civil government agencies, and commercial and healthcare organizations. His functional background is in organization design and transformation, large-scale process improvement, and organizational change management. Mr. Barr is an Adjunct Professor of Change Management at Georgetown and leads Booz Allen s solutions consulting capability developing intellectual capital, training, and thought leadership in general management consulting capabilities. He and his teams are leading key efforts to help transform the Military Health System into a high-reliability organization to improve patient outcomes for our active service members. Beyond his professional engagements, Mr. Barr also serves on the Board and Executive Committee for the USO Metro providing support and assistance to military personnel and their families. Paul Hutter, Executive Advisor Paul Hutter (J.D., LL.M., M.A., M.B.A.) is an Executive Advisor for Military Health at Booz Allen Hamilton. Paul has extensive experience in the Army, having retired as a Colonel in the Judge Advocate General s Corps; in the Department of Veterans Affairs, where he served as the General Counsel, Chief of Staff and various other positions; and in Military Health where he served as the General Counsel and Acting Deputy Director of the Defense Health Agency. Paul also worked to initiate the Military Commission process after 9/11, and in 2004, helped guide the planning to establish an Embassy in Iraq. Paul and his wife, Mary, have three sons a chef and two Naval Aviators serving at PACOM and Norfolk, respectively. George Weightman, Executive Advisor Major General George W. Weightman (USA, ret.) is a Family Medicine physician and an Executive Advisor in the Military Health market at Booz Allen Hamilton. His vast operational experience includes serving with forward-deployed soldiers during Operations Just Cause/Desert Shield/ Storm/Iraqi Freedom, as well as command appointments at the Walter Reed Army Medical Center in Washington, D.C., U.S. Army Medical Department Center and School at Fort Sam Houston, San Antonio, Texas and the U.S. Army Medical Research and Materiel Command. From , General Weightman served as Chief Operating Officer for the Wake Forest Institute for Regenerative Medicine. He received his Bachelor of Science Degree from the United States Military Academy at West Point, New York in 1973 and was awarded a Doctorate of Medicine degree from the University of Vermont College of Medicine in He completed his Family Practice residency training at Eisenhower Army Medical Center, Fort Gordon, Georgia. 7

8 About Booz Allen Booz Allen Hamilton has been at the forefront of strategy and technology for more than 100 years. Today, the firm provides management and technology consulting and engineering services to leading Fortune 500 corporations, governments, and not-for-profits across the globe. Booz Allen partners with public and private sector clients to solve their most difficult challenges through a combination of consulting, analytics, mission operations, technology, systems delivery, cybersecurity, engineering, and innovation expertise. With international headquarters in McLean, Virginia, the firm employs more than 22,600 people globally and had revenue of $5.41 billion for the 12 months ended March 31, To learn more, visit BoozAllen.com. (NYSE: BAH) 2017 Booz Allen Hamilton Inc. analytics thought piece BOOZALLEN.COM