Story by Regena Kowitz on 03/14/2019What does a hospital have in common with an airline? For starters, they both operate in complex environments that have the potential for mistakes to result in serious harm or catastrophe. More importantly, both the health care and aviation industries have embraced the principles of high reliability organizations (HRO), an operating model that prioritizes safety by using systems to prevent serious accidents or mishaps.
As Navy Medicine began the journey towards high reliability in 2014, senior leaders identified a need for champions to drive the organization's military treatment facilities (MTF) toward a culture of health care quality and patient safety excellence. As a result, the role of Chief Medical Officer (CMO)/Chief Dental Officer (CDO) was embraced.
In 2015, MTFs across Navy Medicine started identifying CMOs and in 2016, the position of CMO became a milestone billet, meaning individuals were screened and selected for the role based on their having the experience and leadership abilities to be successful in advancing safety and quality.
Navy Medicine also launched the CMO/CDO Competency Model to identify and implement training and resources critical to the professional development of CMOs and CDOs as champions for creating a culture of high reliability.
"Navy Medicine has always focused on safety and quality but the CMO makes it a more integrated and formalized process, which is part of HRO," said Capt. Chris Cornelissen, anesthesiologist and regional chief medical officer for Navy Medicine West (NMW). "We are redoubling our efforts, with leadership commitment, to create a culture of safety. At our hospitals, the CMO is the champion for health care quality and patient safety."
Within Navy Medicine, the CMO and CDO are advocates for HRO and its three pillars:
Culture of Safety
Robust Process Improvement
Each of the three pillars is essentialfor any initiative to succeed within an organization, including HRO, leadership must be committed to its success. To achieve the long-term goal of eliminating preventable harm, patient safety has to be more than a sloganit must be embedded into the organization's culture and built on a foundation of trust and accountability. A robust system of process improvement is also essential so that organizations are continuously striving to root out risk and improve the patient experience, while providing safe, quality health care.
According to Cornelissen, Navy Medicine has taken on numerous patient safety initiatives and the CMO serves as a maestro of sorts. Acting as a facilitator, the CMO ensures that communication and awareness about patient safety and quality care policies, issues, and opportunities don't get stove-piped and are shared across the enterprise at all levels.
CMOs and CDOs are also drivers of collaboration, problem-solvers, and catalysts for change. Stemming from a preoccupation with failure, a hallmark of HROs, they work closely with quality management, risk management, patient safety, and customer service personnel to identify potential risks and lead robust process improvement initiatives.
"When patient safety issues come to light, the CMO plays a role in leadership awareness and coordinating solutions across multiple directorates," said Cornelissen. "Those solutions are then shared across the Navy Medicine enterprise and with other services."
Among the CMO's many roles, they:
Manage clinical quality programs
Chair the MTF quality council (or regional quality collaborative),
overseeing the healthcare effectiveness teams
Recommend priorities for performance improvement activities
Evaluate clinical practice protocols and guidelines
Serve as a voting member of their respective executive steering committee (ESC)
Report quality council initiatives to the ESC
Serve as a clinical advisor to MTF commanding officer
Align policies with those of the region and Navy Medicine headquarters
Collaborate with CMOs at every levelMTFs, regional, and Navy Medicine headquarters
"We've been able to provide a network and forum for CMOs and CDOs to interact, sharing ideas and passing information," he said. "We've established regional quality collaboratives, a governing body and forum for discussing quality and patient safety goals, generating region-wide projects, and sharing lessons learned and leading practices."
Since the inception of the CMO/CDO model, these champions have had several wins, said Cornelissen. One innovative development has been the adoption of the clinical community model endorsed by Navy Medicine as well as the Military Health System (MHS). Under this model, communities of practice led by deckplate clinical staff identify, develop, and implement initiatives to improve patient safety and quality.
In 2015, obstetrical subject matter experts from across NMW came together to support a regional process improvement initiative of the NMW Regional Quality Collaborative and determine the best multidisciplinary, evidence-based clinical approach to reduce the occurrence of postpartum hemorrhage (PPH). In July 2016, the team rolled out a PPH bundle, standardizing the clinical approach to caring for postpartum patients and ensuring PPH is recognized early, resourced appropriately, and managed quickly. Within 10 months of rollout, the average rates of delayed PPH across the NMW region decreased by over half and the bundle was adopted across Navy Medicine in spring of 2018.
Highlighting the scope of influence and alignment across all the services, the MHS has adopted the tenets of the Navy PPH Bundle by developing an MHS-centered bundle and standardizing clinical approaches to care across all three military branches to ensure leading practices are shared at all levels.
CMOs across NMW have been successful champions of patient safety and quality care by spearheading new initiatives, improving processes, fostering better communication, and encouraging collaboration. But they aren't the only champions in the regiontheir dental counterparts, CDOs, are also hard at work creating an enterprise-wide culture that emphasizes quality and prioritizes safety.
When it comes to the CDOs, their role is very similar to the CMO but their focus is on clinical quality, patient safety programs, and quality improvement initiatives at dental treatment facilities (DTFs).
There are, however, some import differences between CMOs and CDOs. First, CDOs are assigned to DTFs that are "greenside," meaning they align under the U.S. Marine Corps' Marine Logistics Groups (MLG) and are staffed by service members assigned to dental battalions. These DTFs operate on Marine Corps bases, serve active duty populations, and are deployable with Marine Expeditionary Units.
Unlike the MTFs, they don't fall under The Joint Commission, the accrediting body that evaluates health care organizations for standards in patient safety and quality care. Instead, DTFs align with guidelines set by the Occupational Safety and Health Administration (OSHA) and Navy Medicine.
"Maintaining safety is a top priority," said CDR Joyce Turner, a Navy periodontist, clinic director at Marine Corps Air Station Miramar, and CDO for 1st Dental Battalion/Naval Dental Center Camp Pendleton. "In creating a culture of patient safety, we are changing the way we think and do things. We are continually looking to improve."
Turner said that part of that improvement mindset has included adopting standards from The Joint Commission, which has more of a focus on the patient experience than OSHA, which focuses on workplace safety. While both are important, its patient safety that's the focus of HRO and the CDOs.
And, when it comes to creating a culture of safety, Turner said sharing knowledge and best practices, networking with other CDOs and patient safety staff, is important.
Turner and her team also share information during patient safety huddles. If something goes wrong, the goal is to share it so they can learn from it. Talking, she says, creates more awareness.
At her command, Turner said they've instituted a tooth marking initiative to prevent wrong-site dental procedures.
"We mark the tooth to be worked on, something unheard of in dental school," she said. "HRO is preoccupied with failure. We don't want to fail, so we mark the tooth. This creates awareness, which is the beginningyou change the practice which leads to changing the culture."
And changing the culture, along with an emphasis on leadership and vigorous process improvement, is what HRO is all about.
Navy Medicine West leads (NMW) Navy Medicine's Western Pacific health care system and global research and development enterprise. Throughout the region, NMW provides medical care to nearly 700,000 beneficiaries across 10 naval hospitals, two dental battalions, and 51 branch clinics located throughout the West Coast of the U.S., Asia, and the Pacific. Globally, NMW also has oversight of eight research laboratories across the U.S. and overseas that deliver high-value, high-impact research products to support and protect the health and readiness of service members.