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HRO Corner: Insights from Navy’s First Chief Quality Officer on HRO Transformation

Picture of a high reliability organization screensaver that displays on all Navy Medicine computers communicating importance of high reliability and patient safety. Foreign object debris walk downs help eliminate potential runway hazards. This sense of vigilance is similar to that required for highly reliable health care. This screensaver was developed to communicate the importance of high reliability and patient safety as part of a high reliability organization screensaver series that displays on all Navy Medicine computers.

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Navy Medicine has several structures in place to support the Military Health System’s goal of zero preventable patient harm through continuous process improvement, committed leadership, and a culture of safety. Both the Navy Medicine High Reliability Organization (HRO) Operating Model and the Clinical Community construct guide and support knowledge sharing and inter-connectedness, while leadership roles including the chief quality officer (CQO) and the chief medical officer (CMO) drive HRO transformation efforts across all levels of the enterprise.

The Navy Medicine HRO Operating Model is a patient-centered framework, which identifies the relationships and functions necessary to ensure staff are connected and supported. Clinical Communities unite networks of subject matter experts and stakeholders around specific clinical areas, such as, women and newborn, surgical services, and dental, to improve patient outcomes. The Postpartum Hemorrhage Bundle, for example, illustrates a Women’s Health Clinical Community process improvement initiative.

Photo of Rear Adm. Bruce L. Gillingham leads Navy Medicine’s transformation to a high reliability organization as deputy chief of Bureau of Medicine and Surgery Readiness & Health, and Navy Medicine’s first chief quality officer.Rear Adm. Bruce L. Gillingham leads Navy Medicine’s transformation to a High Reliability Organization as Deputy Chief of the Navy Bureau of Medicine and Surgery Readiness & Health, and Navy Medicine’s first Chief Quality Officer.

Following identification of significant variation in local responses to postpartum hemorrhaging, Navy Medicine sought to decrease patient risk and potentially unsafe patient outcomes through the Postpartum Hemorrhage Bundle. This collaborative patient safety initiative identified procedures to standardize clinical practices, equipment, medication, and supplies available for every delivery. Navy Medicine developed the toolkit by using the Swarming via Communicate, Anticipate, Identify, Resolve, Share process, designed to develop solutions for pressing patient safety issues.

The Navy Bureau of Medicine and Surgery (BUMED) CQO role was developed to lead quality and safety initiatives, foster a greater understanding of high reliability, and champion the application of data driven solutions across the military health enterprise in close collaboration with the other Services and the DHA. The CMO role spans headquarters (BUMED), the regions, including Navy Medicine East and Navy Medicine West, and the military treatment facilities. The CMO leads HRO transformation efforts by enhancing quality and safety, and driving clinical and non-clinical process improvement.

The Navy Medicine Patient Safety Monitor Dashboard visualizes patient safety data across the Clinical Communities to inform and measure process improvement initiatives. Additional patient safety tools include, the Harm Evaluation and Risk Assessment, an IT solution that informs data-driven application of best practices to reduce preventable harm; and Clinical Surveillance System, a semi-automated, web-based hospital acquired infections surveillance dashboard that enables predictive analytics.

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Reporting Infection Prevention and Control Data to the Centers for Disease Control and Prevention using the National Healthcare Safety Network 12-005

Policy

The purpose of this memorandum is to update Health Affairs Policy 08-020, which implemented the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) within the Military Health System (MHS).

Navy BUMED Instruction 6010.28: Healthcare Resolutions Program

Policy

This instruction establishes Navy Medicine strategic policy for the promotion of organizational transparency and full disclosure following unanticipated or adverse outcomes of care; to assist the enterprise in "doing the right thing" when there are unanticipated outcomes of care, treatment and services; to train and coach providers in disclosure techniques and to resolve complex healthcare issues at the earliest opportunity, outside a legal venue, with equitable resolutions for patients, providers, and the organization.

Navy BUMED Instruction 6010.23: Participation in the Military Health System Patient Safety Program

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This instruction requires all shore-based commands providing medical and dental services, providing care, or participating in the health care delivery system to support the MHS Patient Safety Program.

Navy BUMED Instruction 6010.21: Risk Management Program

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This instruction establishes policy and assigns responsibility for organizational risk management activities. It defines minimal requirements for proactive and reactive responses in naval medical and dental treatment facilities.

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