JOINT BASE LANGLEY-EUSTIS, Va. --
If medical error could be classified as a disease, it would rank as the third deadliest disease in America. A medical error is a mistake by a medical provider which results in harm to a patient. For example, misdiagnosis of a condition or administering the improper dosage of a medicine.
The Military Health System found that it was no more immune to making preventable errors than civilian treatment facilities. Following an independent review in 2014, which rated the MHS better than average, the Air Force Medical Service recognized areas for improvement and set about to emphasize a renewed focus on a culture of safety within its facilities. The goal: Zero Harm.
“The only way to stop (preventable errors) is to admit them and go in the direction we are going, an open environment to identify where errors are before they cause patient harm,” said Brig. Gen. Sean Murphy, Command Surgeon for Air Combat Command.
Trusted Care, the Air Force’s platform to reach its Zero Harm goal, was a main topic of discussion at the 2nd Annual Military Treatment Facility Leadership Conference at Joint Base Langley-Eustis, Virginia, April 5-6. The MTF leaders also discussed manning, training and access to care initiatives.
To reach their goal, the medical community looked to the aviation and nuclear fields to improve their internal processes. Aviation underwent a culture change from embracing the idea of acceptable losses to standardizing practices and empowering their Airmen, regardless of rank, to police their organizations for safety violations. The end result was a huge drop-off in fatal aircraft accidents and loss of aircraft. The High Reliability Organization model, which is based on organizations which perform high risk activities with little-to-no catastrophic failure, is an aid to MTFs across the Air Force as they continue to improve standard safety practices.
“In the last 18 months, we have already decreased the rates of (preventable harm). . . Better than average isn’t good enough; we have got to be excellent. We’re the military health system taking care of the best population you could ever take care of -- the men and women of that go and fight and defend our way of life. They deserve excellence,” said Murphy.
Lt. Col. Christian Lyons, the Air Force Surgeon General Trusted Care lead, briefed the conference attendees on Trusted Care and tools to use when incorporating it into their MTFs with their staff. He stressed that each leader provide the “why” behind Trusted Care.
Lyons shared a personal story from his experience as a junior physical therapist at Eglin Air Force Base, Florida. While serving there he had the opportunity to work with a Navy explosive ordnance disposal technician who had suffered a stroke. The man, who was in his mid-30s, had paralysis and was unable to stand on his own when he reported to Lyons’ clinic for treatment. Over the course of the treatment Lyons was able to help the patient stand, walk and even run again.
“I cannot tell you the joy in that man’s face when he could do all those things again,” said Lyons, his voice breaking with emotion. “And let me tell you what, I don’t know how he did it, but he applied for his naval commission, and he got it. One day I am sitting in the clinic and this ensign comes up to our clinic in his dress whites, and he has a whole gaggle of people with him. Walks through the front door of the clinic, and he asks me to come outside. Stands sharply at attention and renders the sharpest salute. And he tells me, in front of everybody there, ‘I want everybody to meet the man who taught me how to walk again.’”
Lyons said that was his why, the reason he was working in his current Trusted Care role. He felt that all service members and their families were entitled to that level of care and patient centeredness. He would want that for his own children as they were given care at a facility.
While stressing that he did not expect the impossible, Murphy emphasized to his MTF leadership that Zero Harm had to be their mantra. He charged them to be involved in their facilities and to walk their respective “flight lines.” The leaders were asked to present how they would make an impact at their own MTF once they returned from the conference.
Col. Paul Willingham, 49th Medical Group commander, out of Holloman Air Force Base, New Mexico, said living up to their unit motto was his paramount goal. The motto: A great place for care, a great place to give care.
“For me,” he said, “it’ll be about setting the example for my staff such that we continue to move toward full transparency in the interests of creating a just healthcare atmosphere for our patients and our staff. They deserve nothing less.”
To learn more about the AFMS Trusted Care program visit http://www.airforcemedicine.af.mil/