A National Trauma Care System Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury (2016) / Chapter Skim
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7 Leveraging Leadership and Fostering a Culture of Learning
7 Leveraging Leadership and Fostering a Culture of Learning
Pages 301-336
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Similarly, high-quality civilian trauma care within the United States bridges numerous federal, state, and local agencies; prehospital and tiered inpatient systems; professional organizations; and academic societies. In such a cross-cutting and interconnected endeavor, knowledgeable and effective leadership at all levels is essential to success.
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. This elevation of medical training to a tactical priority on par with a unit's capability to shoot, move, and communicate drove the regiment to establish a casualty response system integrating tactical combat casualty care (TCCC)
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Over 80% of what DC Fire and EMS does daily is prehospital care and there are three people on the EMS "leadership side": only two have any significant experience in the practice of prehospital emergency medicine.
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and private health systems, remains a problem in civilian trauma care. The expansion of competing for-profit trauma centers in the civilian sector also threatens outcomes for injured patients (Johnson, 2015)
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Transparency for the purposes of performance improvement is not possible, however, without a standard set of performance indicators. Equally important, as discussed above, is a culture in which fear -- of disciplinary action, liability, or embarrassment -- is not permitted to impede continuous learning (Garvin et al., 2008; IOM, 2007b)
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both provide national-level quality improvement programs that facilitate transparency through external benchmarking. The ACS Trauma Quality Improvement Program (TQIP)
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A 2011 assessment of the military's trauma system included the following observations about performance improvement processes in theater: • The trauma performance improvement and patient safety process is fragmented. The awareness, implementation and integration of struc tured [performance improvement]
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Civilian Sector In the civilian sector, the trauma performance improvement process -- supported by a trauma registry -- is a hallmark function of trauma centers, second only to trauma patient care. This process entails monitoring compliance with evidence-based practice, care delivered, and system performance 2 Personal communication, J
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Neal, American College of Surgeons, to E Cornett, the National Academies of Sciences, Engineering, and Medicine, regarding the National Trauma Data Bank and Trauma Quality Improvement Program, April 12, 2016.
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. Box 7-3 E MS COMPASS Launched in October 2014, EMS Compass is part of a 2-year cooperative agree ment between the National Association of State EMS Officials and the National Highway Traffic Safety Administration Office of EMS.
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Thus the military cannot compare its trauma system with those found in the civilian sector and vice versa. In addition, civilian trauma systems cannot compare their performance with that of other civilian systems.
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Similarly, public reporting would inform community and policy leaders regarding geographic differences and potential gaps in the care and outcomes among trauma patients. PROMOTING AND REWARDING HIGH-QUALITY TRAUMA CARE Transparency is arguably one of the most powerful levers for effecting change in practices and improvement in trauma care outcomes, but as discussed in Chapter 3, high-performing learning systems apply an array of stimulants to encourage and reward continuous quality improvement.
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Civilian Sector In the civilian sector, measures and financial incentives play a large role in current health care reform initiatives. For decades, the civilian sector operated under a largely fee-for-service payment system.
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. Trauma care is not encompassed within current health care reform efforts. CMS, as the nation's largest payer organization for trauma care,5 has significant influence over how such care is delivered through the use of health care payment policies, and thus is well positioned to lead the development of innovative approaches to improving trauma care while lowering costs.
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Trauma system elements critical to continuous quality improvement (data collection systems, performance improvement programs) could be considered conditions of participation for all components of the care continuum.
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With regard to leadership for trauma care, the committee observed the same fundamental challenge in the military and at the national level: no one owns trauma care. Fragmentation, silos, competing political interests, ambiguity of leadership, and conflicting aims are far too common in trauma care in both the military and civilian sectors and across the care continuum.
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, stable, and distributed uniformly across the combatant commands and services. In the absence of standardization of a formal trauma system across all combatant commands, the many lessons learned over the course of the wars in Afghanistan and Iraq and the improvements made in combat casualty care may be lost.
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. Responsibility for the training and delivery of combat casualty care remains widely distributed across the Assistant Secretary of Defense for Health Affairs, the Defense Health Agency, the services, and the combatant TABLE 7-1 Recent Recommendations on the Need for a Single Point of Accountability Responsible for Combat Casualty Care and Military Medical Readiness Key Findings Recommendations Rotondo et al., 2011 The United States Military Joint Trauma System Assessment "The Joint Trauma System (JTS)
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Defense Health Board, 2015 Combat Trauma Lessons Learned from Military Operations of 2001–2013 "Despite vast improvements in the military trauma A senior-level organization should be established care system achieved over the past decade, no as the lead agency. This agency should "continually unifying agency has oversight over all aspects of assess the system's structure, function, resources, the combat casualty care system." The Defense and outcomes," and be able to recommend Health Board concurs with assessment of earlier policies that would standardize trauma care across reports regarding the need for a lead agency for DoD.
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. The consequences of the lack of ownership for combat casualty care include ineffective investment in trauma readiness and variation within and across combatant commands.
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This authority extends to medical personnel; as a result, it is line leader ship, not medical leadership, that maintains control over joint personnel, training, and equipment assigned to support the delivery of combat casualty care in theater (Roles 1-3)
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As always, with that responsibility must come the relevant authorities and resources -- when those are unlinked, the responsibility lacks relevance. Further, as exemplified by the 75th Ranger Regiment, the culture of accountability will have to shift such that there is widespread understanding and acceptance among medical and nonmedical leadership that line commanders have a primary role in and must be engaged in the readiness of their forces to deliver optimal combat casualty care.
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had applied tourniquets early. Lesson Line leadership needs to make the delivery of combat casualty care a priority and be held accountable for ensuring that medical and nonmedical service members under their command are trained and equipped to execute TCCC guidelines.
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As in the military, the trauma care system in the civilian sector has witnessed a strong record of inaction or inadequate action in response to 8 While not comprehensive, a list of trauma-related associations is noted on the National Trauma Institute website: http://www.nationaltraumainstitute.org/home/trauma_related_ organizations.html (accessed May 23, 2016)
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The present committee agrees with and supports previous assessments regarding the need for defined leadership for trauma and emergency care within HHS that serves to promote the integration of services across the continuum of care, from prehospital to rehabilitation and post-acute care. 9 Civilian trauma care differs from military trauma care in that it is more fully part of a larger emergency response system that provides care for many other time-critical health problems (e.g., stroke and myocardial infarction)
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. Through its research and deliberations for this study, the committee determined that the only feasible solution is to forge a significant and ambitious partnership between the military and civilian sectors such that the civilian sector can serve as a reservoir and innovative engine for trauma care knowledge and a training platform for the military trauma care workforce during the interwar period.
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Related findings: • both the military and civilian sectors, performance transparency at In the provider and system levels is lacking. • Military participation in national trauma quality improvement collab oratives is minimal; only a single military hospital participates in an ACS TQIP benchmarking program.
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. A notable difference between the military and civilian sectors is the extent to which the military has invested in training nonmedical personnel so that they are able to provide buddy care or self-aid.
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Related findings: • Promotion incentives for military medical personnel are misaligned; current promotion structures do not encourage or reward the growth of clinical trauma-focused expertise. • Within the military leadership structure, there is no overarching au thority responsible for ensuring medical readiness to deliver combat casualty care.
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CONCLUSION: Despite the tremendous societal burden of trauma, the absence of a unified authority to encourage coordination, collaboration, and alignment across and within the military and civilian sectors has led to variation in practice, suboptimal outcomes for injured patients, and a lack of national attention and resources directed toward trauma care. Related findings: • lack of integration of military and civilian trauma care has im The peded a highly functioning military trauma care system and the full transfer of lessons learned between the two sectors.
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Paper presented to the Committee on Military Trauma Care's Learning Health System and Its Translation to the Civilian Sector, Meeting Two, July 23-24, Washington, DC. Champion, H
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: Implications for the future of combat casualty care. Journal of Trauma and Acute Care Surgery 73(6 Suppl.
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Paper commissioned by the Committee on Military Trauma Care's Learning Health System and Its Translation to the Civilian Sector. nationalacademies.org/TraumaCare.
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Paper presented to the Committee on Military Trauma Care's Learning Health System and Its Translation to the Civilian Sector, Meeting One, May 18-19, Washington, DC. Pappas, C
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Paper presented to the Committee on Military Trauma Care's Learning Health System and Its Translation to the Civilian Sector, January 15, Washington, DC. Winchell, R
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