Public Health Accreditation of Army Preventive Medicine Departments: Improving Military Medical Treatment Facility Practice to Impact Force Readiness.

ASSURING QUALITY IN THE MILITARY HEALTH SYSTEM

In 2014, the U.S. Secretary of Defense identified access, safety, and quality in the Military Health System (MHS) as key priorities.[1] Accreditation formally recognizes the MHS’s commitment to quality[1] and demonstrates that MHS activities and staff meet nationally recognized requirements for quality and standardization.[1] Currently, accreditation and certification programs exist in the MHS for health care services, such as primary care, laboratory and blood banks, radiology and nuclear medicine, medical and surgical subspecialties, and advanced medical and dental education.[1] However, there is no accreditation or certification for military public health. In 2014, U.S. Army Medical Command (MEDCOM) and one of its installation preventive medicine (PM)/public health (PH) departments recognized that pursuing third-party public health accreditation at the installation level may be desirable and feasible and also followed the trend set by many state, county, and city health departments. In July 2018, after a multi-year exploratory process and pilot project, MEDCOM published an operation order (OPORD) directing 28 Army PM departments at the installation level to initially apply for public health accreditation by the end of Fiscal Year (FY) 2025 with the goal of having all accredited by the end of FY2027.

This paper provides an overview of public health accreditation and its potential applicability to Army and other military PM/PH departments, highlights the Army public health accreditation demonstration project at Fort Riley, Kansas, outlines the Army Public Health Performance Improvement/Accreditation (PI/A) Initiative, and posits that public health accreditation of Army installation PM/PH departments, and perhaps those of other military services (Navy and Air Force), is a meaningful strategy that directly supports the Department of Defense (DOD) and MHS priorities of access, safety, and quality and Army Medicine’s goal to become a high-reliability organization (HRO). Further, the authors discuss that public health accreditation may be a useful and objective framework by which the Defense Health Agency (DHA) can determine consensus for Tri-Service (Air Force, Army and Navy) public health as required under the National Defense Authorization Act (NDAA) for Fiscal Year 2019.[2]

OVERVIEW OF PUBLIC HEALTH ACCREDITATION

The ultimate goal of public health accreditation is to improve and protect the health of the public.[3] In the early 2000s, the Institute of Medicine[3,4] and the Centers for Disease Control and Prevention[3] recommended accreditation as a strategy for achieving stronger public health infrastructure,[3,4] which led to the development of a national public health department accreditation program.[3] The Centers for Disease Control and Prevention and the Robert Wood Johnson Foundation with the support of national public health organizations formed the Public Health Accreditation Board (PHAB), a non-governmental organization, to develop and execute voluntary, national public health department accreditation.[3] Since the program launched in fall 2011, PHAB has awarded national public health department accreditation to 235 health departments and one integrated local public health system in 45 states and the District of Columbia.[5] As of August 2018 over 70% of the U.S. population (over 219 million people) is now served by a nationally accredited health department with more accredited departments on the way.[5]

Public health accreditation of Army PM/PH departments aligns well with other DOD and MEDCOM accreditation and certification efforts, such as The Joint Commission accreditation of health care in Army MTFs, the organizations to which Army PM departments currently belong. Army PM departments have a primary role to ensure Force readiness and are similar in function to county and city health departments for the installation communities they serve. Further, application of a national public health department accreditation program in Army PM/PH departments ensures that the full spectrum of MEDCOM activities, including PM/PH, are accredited by an external third-party, and are better positioned to become an HRO. This national public health department accreditation program specifically embodies the three imperatives of HROs as proposed by Chassin and Loeb[6] in the following ways:

Leadership commitment: Conforming to the national public health department performance standards (the basis of public health accreditation) and achieving public health accreditation requires an ongoing and long-term leadership commitment to achieve and maintain a culture of quality. The PHAB accreditation applicants must obtain their governing entity’s/MTF Commander’s support and the PM department director’s/chief’s approval to pursue and sustain accreditation.[7]

Culture: The PHAB accreditation program is intended to help build a culture of continuous quality improvement[3] in public health departments across the array of public health functions set forth in the 10 Essential Public Health Services framework (Table I).[8] The Essential Public Health Services are also outlined in Army Regulation 40-5, Preventive Medicine.

TABLE I.

The 10 Essential Public Health Services

1: Monitor health status to identify and solve community health problems

2: Diagnose and investigate health problems and health hazards in the community

3: Inform, educate, and empower people about health issues

4: Mobilize community partnerships and action to identify and solve health problems

5: Develop policies and plans that support individual and community health efforts

6: Enforce laws and regulations that protect health and ensure safety

7: Link people to needed personal health services and assure the provision of health care when otherwise unavailable

8: Assure competent public and personal health care workforce

9: Evaluate effectiveness, accessibility, and quality of personal and population-based health services

10: Research for new insights and innovative solutions to health problems

The 10 Essential Public Health Services are the set of public health activities that all communities should provide.[8]

Robust process improvement: To meet national public health department performance standards and achieve public health accreditation, a health department must demonstrate that it has and uses an updated and comprehensive quality (process) improvement plan.[7] The accreditation program also requires applicant public health departments to use a performance management system.[7]

The Army Public Health Accreditation Demonstration Project at Fort Riley, Kansas

In 2013, the PM department at Irwin Army Community Hospital (IACH), the Fort Riley, Kansas MTF, formally declared its intent to apply for voluntary national public health department accreditation through PHAB and in April 2014, MEDCOM designated the Fort Riley PM Department as the Army demonstration site for national public health department accreditation. In 2016, the Fort Riley PM Department became the first military PM department to apply for this national accreditation. In addition to formally supporting the Fort Riley PM Department’s pursuit of public health accreditation, the demonstration project also required the U.S. Army Public Health Center (APHC) to provide direct subject matter expertise and technical consultation on performance improvement actions and accreditation preparation to the Fort Riley PM Department. As part of the demonstration project, the APHC conducted a systematic, multi-year case study to capture details of the Fort Riley PM Department’s accreditation preparation process, challenges, lessons learned, resources required, and outcomes to inform potential public health performance improvement and accreditation pursuit at other Army PM departments in the future.

As the military’s first public health accreditation applicant, Fort Riley’s PM Department demonstrated its commitment to improve processes and enhance performance to meet national public health department standards and improve the quality of the 10 Essential Public Health Services for the installation. This act alone is a first and important step. Results of the APHC-led public health accreditation case study at the Fort Riley PM Department also showed that by preparing and applying for accreditation, even prior to receipt of its accreditation decision from PHAB, the department and IACH achieved multiple positive outcomes (APHC unpublished data). The following reflections from Fort Riley PM Department personnel illustrate some of these initial findings:

I think we are more aware now that we make a difference when we get out and we work together with other partners and I think it’s improved our function, communicating with Riley and Geary Counties off post. Within the community, as a military organization I’m working with other health departments and actually the State as well, because we were… making it [a] more active process to get together and schedule meetings and make sure that we are constantly communicating with our partners and just developing contacts and talking and building relationships with those people so that if we did have something that was going on, we already had those in-roads. So that’s how things have really…changed for the better (APHC, unpublished data)

We are starting to see dialogue between public health and clinical operation in the hospital. Start looking at “okay, well, what can we do as far as access to care?”, so we’re seeing pockets [of improvements] (APHC, unpublished data)

Well, it’s been improvement in that we’re consistent with our practice. We’re focused because our milestones to goal post… so if you’re driving for a goal that has evidence-based practice behind it you know…that you’re doing a better job (APHC, unpublished data)

Further, the IACH Commander and PM department personnel specifically used the public health accreditation standards to explore and develop new approaches to its work ultimately marking a deliberate and new effort to better leverage public health expertise and perspectives. Unlike county and city health departments, the MHS is an employer-based provider and payer of care, whose employer is an expeditionary Army where readiness for war is a critical population health and public health outcome. As such, the Army profession places demands on Soldiers and families that deserve special consideration, including temporary single parent households, deployment-related stress, frequent moves, and other socioeconomic conditions that indirectly and directly determine health. Negative conditions within Army families can directly affect mission accomplishment; if a Soldier is not “ready” at home, a Soldier will not be “ready” in combat. Similar to all populations, enhancing and sustaining the health, well-being, and performance of Soldiers and their families is influenced by multiple factors and determinants of health separate and distinct from what is accomplished within the walls of an MTF or other health care facility. Using public health accreditation as a catalyst and the accreditation standards as a lens by which to examine priority issues, IACH facilitated collaboration among multiple stakeholders on the installation and in the local community, including the First Infantry Division, Fort Riley Army Community Services, the Fort Riley Community Health Promotion Council, US Army Garrison Fort Riley, Geary County Health Council, Riley County Public Health Department, Via Christi Hospital, and Stormont Vail Health System to create an integrated program to improve population health services, clinical care, and ultimately the quality of life for women, infants and children. Although not typically considered a key readiness priority, in 2016 the Army directed the full integration of women allowing all Soldiers, regardless of gender to serve in any military occupational specialty for which they are qualified. Attrition and retention rates of pregnant Soldiers can directly impact unit readiness and IACH and Fort Riley leaders also recognized that poor pregnancy and infant outcomes were affecting Soldier readiness and retention. Whether the mother is a Soldier or a Soldier’s family member, such a program aims to improve unit readiness and enhance community resiliency to sustain that readiness more comprehensively than may have been achieved by IACH or a traditional health care model alone. This approach is especially actionable for Army MTF Commanders who are dual-hatted with responsibility for both the health care and public health services at a location. Although it may seem intuitive, this systematic shift to a population-oriented, public health approach was important and needed.

Based on the IACH and the Fort Riley PM Department’s experience, it is reasonable that Army PM departments’ pursuit and achievement of national public health department accreditation will provide a number of benefits to the department itself, the Army MTF, and the community it serves. These benefits include, but are not limited to, assuring a population health approach to addressing issues affecting Soldier readiness and family resilience, greater collaboration, improving communication, and identifying efficiencies in processes (APHC unpublished data).

IMPLEMENTING ARMY PUBLIC HEALTH ACCREDITATION

On July 13, 2018, MEDCOM published the Army Public Health Performance Improvement/Accreditation (PI/A) OPORD that is now being implemented across all four Army Regional Health Commands (RHC). Two Army PM/PH departments are slated to initially apply for public health accreditation by the end of FY2019 with four to five PM/PH departments to be identified in each subsequent FY through FY2025. The APHC has a team dedicated specifically to the PI/A initiative whose mission is providing training and technical consultation to PM/PH departments and their RHC and local partners. This type of consultation proved vital in the Fort Riley PM Department’s accreditation endeavor (APHC unpublished data).

The PM/PH department at Fort Bragg’s Womack Army Medical Center (WAMC) is one of the two PM/PH departments applying for public health accreditation in FY19. The PM department began pursuing public health accreditation ahead of the MEDCOM OPORD based on the MTF Commander’s previous experience with public health accreditation at Fort Riley. On October 1, 2018, WAMC transitioned from MEDCOM oversight to the DHA as part of the first phase of the consolidation of health care operations in the military services. Going forward, the experience at WAMC may provide important lessons learned for other Army PM/PH departments about how the MTF’s transition to DHA oversight may or may not affect pursuit of public health accreditation, among other things.

PUBLIC HEALTH ACCREDITATION IN OTHER MILITARY SETTINGS

This paper largely focuses on public health accreditation within Army PM/PH departments as this is the only military service known to be instituting it at this time. There is no reason to believe that using public health accreditation as a quality and performance improvement strategy is limited to the Army setting or that the observed and purported benefits of public health accreditation in the Army would not be achieved on Air Force, Navy, or joint installations. This idea is especially important given that the NDAA for Fiscal Year 2019[2] changed the future of military public health significantly. The Act specifically states that the DHA will create a subordinate organization known as Defense Health Agency Public Health effectively acquiring responsibility for public health across all military services. Although the details of how this transition will occur and what military public health will ultimately look like are unknown at this time, the authors believe that the national public health accreditation standards can serve as a practical, objective framework for DHA to use in developing consensus across the Air Force, Army, and Navy for Tri-Service public health and be a valid way for DHA to ensure quality public health services military-wide going forward. Further, the Army’s requirement of public health accreditation for its Army PM/PH departments and its systematic evaluation of this initiative can provide lessons learned that may be useful to all military public health.

CONCLUSIONS AND CONSIDERATIONS

Ultimately, national public health accreditation is purported to strengthen the delivery of public health services and programs, improve understanding of and responsiveness to community needs and assets, increase consistency in practice, support more efficient and effective use of resources, and improve overall population health outcomes.[9] Although the impact of this accreditation is still unfolding, state and local (civilian) health departments report several specific benefits that they’ve experienced already as a result of achieving accreditation including:

Enable identification of department strengths and weaknesses[4] to address gaps

Document capacity to deliver core public health functions[4]

Improve cross-organizational (i.e., within organization) collaboration[10]

Promote transparency and accountability within and outside of the department[3]

Stimulate quality and performance improvement[4,10,11]

Improve communication[4]

Strengthen the department’s culture of quality improve-ment[4,10,11]

The Fort Riley PM Department’s accreditation process revealed that many of these benefits and others were seen despite not yet receiving the department’s final accreditation designation (APHC unpublished data). Additional analysis of the Fort Riley PM Department case study data and future evaluation work there or at other Army PM departments will determine whether these benefits continue or change over time. The case study also revealed several challenges and barriers to pursuit of public health accreditation that are outside of the scope of this paper and that can also provide key information on how MEDCOM may plan to systematically address these Enterprise-wide rather than leave them to each installation’s PM/PH department to solve.

As Army MTFs and other Army agencies continue to support Soldier and installation community readiness and resilience, the pursuit of third-party public health accreditation is a natural step to advance the quality and effectiveness of the PM/public health missions and improve MTFs’ capabilities to address the complex issues that threaten Soldier readiness. Public health accreditation gives Army MTF Commanders and other leaders a specific way to better leverage the capabilities of the Army PM department, consider population-based approaches to issues affecting Soldiers, families and other beneficiaries, and an ability to demonstrate the quality and commitment of the PM department to those it serves in a more visible and credible way. Although Navy, Marine Corps, and Air Force installations may vary somewhat in their scope of practice, there is also reason to explore how public health accreditation can achieve similar benefits for these agencies, their respective installations and joint installations, while serving as an objective framework by which those at DHA charged with determining consensus for Tri-Service public health can effectively and neutrally meet congressional intent for military public health in the coming years. Those who protect our nation’s freedom and their family members deserve this level of practice and accountability across all areas of health care and public health services.