It is at once instructive and disquieting that a noted high-reliability organization like the US Navy1-3 has not written more on quality in healthcare. There really is no excuse. The Navy as a government organization opts not to broadcast its policies for many reasons-not the least of which is a phobia of possible negative public commentary. The paradox, however, is that public scrutiny is exactly what has garnered laurels of high reliability for such Navy institutions as aircraft carriers,1 aviation,2 and nuclear power.3 Despite its lack of self-promotion, Navy quality shines through. Consider that one of the most-read management texts remains It's Your Ship: Management Techniques From the Best Damn Ship in the Navy.4 I am a recovering Navy person, striking out into the civilian world after 28 years in polyester khaki. So some reminiscence-in this case about quality in healthcare-is understandable.
Aboard ships, in aircraft squadrons, and undersea, the optimal system is one that is sailorproof. It must be easily understood. It must minimize moving parts. It must work equally well in any environment; in high sea swells, high humidity, high pressure, and high temperature. A shipboard fire hose nozzle is a good example of a sailorproof object. It fits onto a fire hose only one way. It has 2 settings: on and off. It is solid brass and thus nearly impossible to break. It is paradigm for sailorpoof.
Obviously this is tongue-in-cheek. The median age of the several thousand people on an aircraft carrier-a prime example of quality1-is in the early 20s, and the degree of complexity of that system is awesome (see Fig 1). Nevertheless, for the Navy, simpler is better. The following describes specifics of the mindset and governance that contributes to Navy healthcare quality.
The fact is inescapable that Navy healthcare, like American healthcare in general, bears some responsibility for the 98,000 annual deaths quoted in the Institute of Medicine's landmark 2000 study5; it's just that the Navy goes to extraordinary lengths to minimize that contribution, using several unique aspects of military practice. Irrespective that each Navy facility has a different mission, patient base, medical staff mix and Executive Council, some organizational norms prevail; these are reviewed here.
The first aspect is common to all military organizations, and has nothing directly to do with healthcare in particular: an Overarching Shared Vision. Policy and procedures for the US Department of Defense are directed by the President and implemented by the Secretary of Defense and the Joint Chiefs of Staff. Since Navy Medicine supports both the Navy and the United States Marine Corps, they must be attuned to the strategic goals of each.6,7 Given this rigid hierarchy, the Navy Bureau of Medicine and Surgery has aligned goals as well8-and these are then interpreted individually at each Navy Medicine treatment facility (eg, reference 9). This vision, inculcated during the military socialization process, provides a clear and concrete expectation of "right" and "wrong." While strong top-down governance is anathema to many outside the military, 2 points are clear: (1) effective management is nearly impossible on any large scale without it and (2) it must never ever restrict imagination and innovation at the tip of the spear.
This shared vision is internalized widely within the system. At the core for the healthcare community is the common understanding of responsibility for the care of active duty service members, their dependents, and retirees. The administrative mechanisms for that care vary with different hospitals, and with their differing complexities and assets-but the core value remains that Navy Medicine cares for its own.
A crucial adjunct to successful acceptance of this core vision is subjugation of ego. Overarching vision can work without ego subjugation if it is held deeply enough, but this is not generally the case. Navy medical people live in an eternal "split personality" that, with little or no warning, they may be deployed to support troops engaged in active combat. No one is exempt from this requirement. Further, the rank system maintains that juniors still defer to seniors on issues of military custom; thus a junior critical care physician still salutes a senior hospital administrator. A hospital commander may be a physician, dentist, nurse, ancillary provider, or administrator. Clinical issues are still a responsibility of the Executive Committee of the Medical Staff, but the Medical Director is infrequently the senior physician in terms of rank or tenure.
This rank structure too is anathema to some. They would do well to recognize that rank structures exist throughout American healthcare. Just as my khakis were replaced by coat and tie, the insignia on the collar devices was replaced just as surely by my new academic rank. Within the military construct, the more rigid rank structure allows for more uniform policies in such crucial aspects of hospital governance as Performance Improvement and Credentials.
Not surprisingly, the Navy has an enormous belief in Risk Aversion. This practice involves not only public affairs aspects, but basic business practice as well, and is born from the high complexity inherent in maintaining and using sophisticated engineering and weapons systems. In the Fleet and Marine Corps, one of the most basic levels of risk aversion involves frequent second checks. When the Officer of the Deck (OOD) aboard a Navy combatant gives a rudder order, the helmsman repeats the order verbatim. This allows the OOD to hear what the helmsman understood the order to be, and allows for confusion to be worked out before the wrong action is undertaken. In the Navy's maintenance program, second checks are frequently performed to ensure that the people doing the job have the knowledge, skill, and equipment necessary to perform the function.
It is understood that this is an inefficient aspect of the system, but the risks of not doing so are impossibly high in many cases. We all certainly have mental images of risky Navy or Marine tasks. However, risks exist whether launching a TOMCAT at sea or starting an adriamycin drip. Each of those acts is dramatic to the folks involved; one simply is better theatre.
To this end, the Navy actively automates high-risk processes. This is expensive, and there is always human oversight of such systems, but this applies whether we're talking about missile launching systems or electronic order entry. This has previously been discussed in the context of the Six Sigma metric.10 An example "pulled from the Front Pages" will clarify:
In a December 2002 meeting of the Institute for Healthcare Improvement in Orlando, representatives from Cedars-Sinai Medical Center described their move to an electronic order entry system system-wide. Part of the turnover was a mandate that certification and use of the system was a prerequisite for continued physician certification in the hospital. This struck many of the nonmilitary attendees as fascist in the extreme: that a healthcare system-no matter how noble the cause-would inflict extra keystrokes on staff physicians to automate order entry. The military facilities had been working with such a system for the better part of a decade, and it contributed to an outpatient prescription error rate of only 2.1 per hundred thousand in the outpatient pharmacy at the Medical Center in San Diego.10 That may be compared with the fact that the Navy branch pharmacy dealing almost exclusively with prescriptions handwritten by civilian providers had 2 people employed full time on the phone calling doctors' offices decoding what had been prescribed. The sad end of the Cedars story was related on page B1 of the Los Angeles Times on January 22, 2003: after a mutiny by physicians, use of the electronic system was suspended. We can presume that error rates went up again as well.
Finally, this aversion to risk translates into a corporate will to financially prioritize safety and quality. This is crucial, especially considering the costs of such systems, and emphasizes the paramount value of communication. Electronic medical records (EMRs) and order entry systems are expensive. However, the cost-benefit ratio must be measured not only in terms of better quality care (as such, difficult to quantify), but also in terms of reduced legal risk. With a computerized EMR, compatibility with HIPAA is easier to ensure and monitor. With an electronic system, ordering physicians can get verifiable notification of abnormal radiologic findings or critical lab readings. These safeguards are crucial in an era when radiologists at the viewbox may be unable to otherwise reach ordering providers about unexpected findings.
Another immutable military fact is the transient nature of personnel. The vast majority has "orders" to any job for 2 to 4 years, and then must move to a different post elsewhere. Frequent personnel turnover in the context of high-complexity taskings mandates an Ongoing Education Process. This is especially true in hospital nursing services, where new nurses arrive each summer (generally to the wards), and senior nurses leave each summer (generally from critical care). With about one third of the staff turning over each year, there is a major impact on competency training and skill acquisition. It is well documented that it takes a new graduate nurse 2 years of clinical experience to establish a level of skills that allow him/her to deliver competent care.11 During this novice phase, new graduates are also expected to oversee the skill development of new junior Hospital Corpsmen. With the high turnover rate of all providers, a major challenge lies in ensuring an adequate mix of experienced staff to not only deliver healthcare, but also train new staff. The flip side of this coin is that staff movement reduces the frequency of entrenched personalities doing things "the same way they've always been done."
The crucial task of this for quality processes is fostering attitudes conducive to error reporting. When I first appeared in front of the Admiral with a blood bank error form, he looked me squarely in the eye and said, "People read these. They show mistakes were made on my watch. How many of these will I need to sign for you?" I replied truthfully, "Sir, if you make a big enough deal of it, I can guarantee you that no one will ever bring these to you again. But that won't mean the errors will stop; it just means we won't know they happened." To his credit, he created an environment where not only errors, but near-misses were well-documented, and recriminations were saved for the very rare intentional process. Such an environment is crucial to quality systems.12
In sum, the Navy experience shows that such quality can't be directed; it must be led. Paradoxically, sailorproofing Quality is not reducing technology of healthcare; in fact it probably means increasing technology. But, it means making quality simple by keeping it central and pivotal for every team member all the time. This is not especially hard for most providers (generally we didn't go into medicine intending to do a bad job caring for patients). Thus, such quality is within the reach of any healthcare organization. It costs money, surely. But we know too well the cost of the status quo.
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