NEW TRAUMA CARE 

SYSTEM

DOD Should Fully 

Incorporate Leading 

Practices into Its 

Planning for Effective 

Implementation

Report to Congressional Committees

March 2018

GAO-18-300

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-18-300, a report to 

congressional committees

March 2018

NEW TRAUMA CARE SYSTEM

DOD Should Fully Incorporate Leading Practices into 

Its Planning for Effective Implementation

What GAO Found

The Joint Trauma System (JTS) implementation plan submitted to Congress by

the Department of Defense (DOD) in August 2017 includes a description of the 

four elements required by the National Defense Authorization Act (NDAA) and an 

overview of implementation activities. For example, it indicates how the Army’s 

current JTS Defense Center of Excellence will become part of DOD’s new JTS.

However, the plan and other supplemental planning documents prepared to date

do not fully incorporate leading practices for planning as identified by prior GAO 

work. GAO has previously found that implementation plans incorporating these 

leading practices—goals, strategies to achieve goals, risks that can affect goals, 

and plans to assess progress toward goals—help ensure organizations achieve 

their objectives. For each of the four required elements, GAO found that these

leading practices either were partially incorporated or had not been incorporated:

• Element 1—Serve as the reference body for all trauma care provided 

across the military health system. DOD documents include specific goals, 

such as consolidating data from multiple trauma registries. They also include 

some strategies to achieve the goals, such as identifying lead offices and 

time frames to complete specific actions. However, the documents provide 

limited details on actions DOD plans to take, and do not indicate how DOD 

plans to address risks or assess its progress.

• Element 2—Establish standards of care for trauma care services. DOD

documents include a goal to develop, publish, and assess clinical practice 

guidelines that serve as standards of trauma care. These documents also 

describe how the new JTS will continue to produce, update, and monitor

adherence to the guidelines. However, they do not fully indicate plans to 

address risks, such as ensuring effective dissemination.

• Element 3—Coordinate the translation of research from DOD centers of 

excellence into standards of clinical trauma care. DOD planning 

documents do not incorporate any leading practices for this element. DOD 

officials told GAO that clinical standards incorporate relevant research and 

that officials responsible for trauma care standards routinely interact with 

officials responsible for research. Officials expect this practice to continue

under the new JTS.

• Element 4—Coordinate the incorporation of lessons learned from 

trauma education and training partnerships into clinical practice. DOD 

planning documents do not incorporate any leading practices for this 

element. According to officials, DOD must first establish a separate 

directorate responsible for partnerships with civilian trauma centers before 

determining how to incorporate lessons from partnerships into the new JTS.

According to DOD, the JTS implementation plan is a general overview of 

implementation activities, and planning efforts are ongoing. By not fully 

incorporating leading practices in its planning documents, DOD may be missing 

opportunities to ensure that the JTS is effectively implemented, to provide more 

effective trauma care across the military, and to help reduce trauma-related 

deaths and disabilities.

View GAO-18-300. For more information, 

contact Debra A. Draper at (202) 512-7114 or 

draperd@gao.gov.

Why GAO Did This Study

Traumatic injury is a major cause of 

death and disability in the military, but 

improved trauma care has the 

potential to improve these outcomes. 

DOD has worked to improve trauma 

care over time, such as by 

establishing a Joint Trauma System

Defense Center of Excellence to

examine trauma care and share best 

practices.

To improve trauma care across DOD, 

the NDAA for Fiscal Year 2017

directed DOD to establish a new JTS 

within DOD’s Defense Health Agency.

The NDAA requires that the new JTS 

include four specified elements, and

also required DOD to submit to 

Congress an implementation plan that 

included the four elements. The 

NDAA also included a provision for 

GAO to review DOD’s planning for the 

new JTS. 

GAO assessed whether the 

implementation plan includes the four 

required elements and the extent to 

which DOD’s planning efforts to date

reflect leading practices from prior 

GAO work, such as identifying goals 

and strategies to achieve those goals.

To conduct its work, GAO assessed 

DOD’s implementation plan and other 

supplemental planning documents

identified by DOD, and interviewed 

DOD officials.

What GAO Recommends

GAO recommends that DOD 

incorporate leading practices in its

planning to guide implementation

efforts. DOD agreed with the 

recommendation.
Page i GAO-18-300 DOD Trauma Care System

Letter 1

Background 4

DOD’s Joint Trauma System Implementation Plan Includes the 

Four Elements Required by the NDAA, but Does Not Yet Fully 

Incorporate Leading Practices for Planning 5

Conclusions 11

Recommendation 11

Agency Comments 12

Appendix I Comments from the Department of Defense 13

Appendix II GAO Contact and Staff Acknowledgments 15

Tables

Table 1: Four Key Leading Practices for Planning Identified in 

Prior GAO Work and Related Federal Internal Control 

Standards 3

Table 2: Extent to Which DOD Joint Trauma Planning Documents

Reflect Leading Practices Identified by Prior GAO Work 6

Contents
Page ii GAO-18-300 DOD Trauma Care System

Abbreviations

DOD Department of Defense

DHA Defense Health Agency

CPG Clinical Practice Guidelines

JTS Joint Trauma System 

JTS DCOE Joint Trauma System Defense Center of Excellence

DODTR Department of Defense Trauma Registry 

NDAA National Defense Authorization Act for Fiscal Year 2017

This is a work of the U.S. government and is not subject to copyright protection in the 

United States. The published product may be reproduced and distributed in its entirety 

without further permission from GAO. However, because this work may contain 

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necessary if you wish to reproduce this material separately.
Page 1 GAO-18-300 DOD Trauma Care System

441 G St. N.W.

Washington, DC 20548

March 19, 2018

The Honorable John McCain

Chairman

The Honorable Jack Reed

Ranking Member

Committee on Armed Services

United States Senate

The Honorable Mac Thornberry

Chairman

The Honorable Adam Smith

Ranking Member

Committee on Armed Services

House of Representatives

Traumatic injury is a major cause of death and disability within the 

military, but more effective trauma care has the potential to increase 

survivability and reduce disabilities after injuries. For example, 

Department of Defense (DOD) researchers found that approximately 24 

percent of all servicemembers who died in combat from 2001-2011 could 

have survived if improved and more timely medical care were made 

available.1 Over the last two decades, DOD has worked to improve the 

care it provides to servicemembers and others, with a goal of reducing 

deaths and disabilities caused by trauma. Previous efforts included the 

establishment of a Joint Trauma System, a Defense Center of Excellence 

(JTS DCOE) within the U.S. Army, which has been responsible for 

providing organized and coordinated capability for injury prevention, care, 

and rehabilitation support of DOD trauma initiatives across the Military 

Health System. A 2016 report by the National Academies of Sciences, 

Engineering, and Medicine noted widespread improvements over time in 

both military and civilian trauma care, but also acknowledged 

 1

B.J. Eastridge and others, “Death on the Battlefield (2001-2011): Implications for the 

future of combat casualty care,” Journal of Trauma and Acute Care Surgery, vol. 73, no. 6 

(2012). 

Letter
Page 2 GAO-18-300 DOD Trauma Care System

inconsistencies in care that continue to result in preventable injuries and 

deaths.2

To improve trauma-related care across DOD, the National Defense 

Authorization Act (NDAA) directed DOD to set up a new joint trauma 

system (JTS) within its Defense Health Agency (DHA) that includes 

required elements such as serving as a reference body for trauma care 

provided across the military health system, and establishing standards of 

trauma care at military medical treatment facilities. The NDAA also 

required DOD to submit an implementation plan for this effort and 

included a provision for us to review this plan. In this report, we examine 

the extent to which DOD’s planning efforts include the required elements

and incorporate leading practices for implementation planning identified in 

our prior work.3

To do our work we reviewed DOD’s August 2017 implementation plan 

and interviewed DOD officials about the existing JTS DCOE and the 

plans and status of implementing each of the required elements. 

Additionally, we reviewed and assessed the implementation plan and 

supplemental planning documents identified by DOD against leading 

practices for planning identified in our prior work.4 Specifically, we 

identified four leading practices that agencies may include when planning 

for program implementation: (1) goals for the program, (2) strategies to 

achieve goals, (3) risks that can affect goals, and (4) plans to assess 

progress toward goals. We also used Standards for Internal Control in the 

Federal Government to assess DOD’s efforts.5 (See table 1 for more 

 2

National Academies of Sciences, Engineering, and Medicine, A National Trauma Care 

System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable 

Deaths After Injury, Washington. DC: 2016.

3

Our leading practices for sound planning are derived from prior work related to planning. 

We have found that implementation plans that include these leading practices help ensure 

organizations achieve their goals and objectives. See, for example, GAO, Military 

Readiness: DOD Needs to Incorporate Elements of a Strategic Management Planning 

Framework into Retrograde and Reset Guidance, GAO-16-414 (Washington, D.C.: May 

13, 2016); and Managing for Results: Implementation Approaches Used to Enhance

Collaboration in Interagency Groups, GAO-14-220 (Washington, D.C.: Feb. 14, 2014). 

4

In our review, we asked DOD officials to identify documents that supported the 

development of the JTS implementation plan and documents being used to support 

implementation planning. When referring to both DOD’s implementation plan and these 

other documents, we use the term “planning documents.”

5

GAO, Standards for Internal Control in the Federal Government, GAO-14-704G 

(Washington, D.C.: September 2014).
Page 3 GAO-18-300 DOD Trauma Care System

detail on these leading practices.) We then determined whether DOD’s 

planning documents for each of the four elements required by the NDAA 

fully incorporated, partially incorporated, or did not incorporate the leading 

practices for planning.

Table 1: Four Key Leading Practices for Planning Identified in Prior GAO Work and Related Federal Internal Control Standards

Key leading practice Description of leading practice and related federal internal control standards 

Goals A specific set of policy, programmatic, or management goals for the program being planned. Goals 

should correspond to the objectives that an organization has set for its program and develop with 

greater specificity how an organization will carry out its objectives.

Strategies to achieve goals A description of how goals contained in the implementation plan are to be achieved. Key strategies 

may include (a) the identification of actions needed to achieve goals, (b) identification of lead 

offices responsible for executing these actions, (c) development of project milestones to guide the 

execution of actions, (d) development of a cost estimate for the actions, and (e) description of skills 

and technology resources needed to execute the actions.

Risks that can affect goals Key factors that can affect the achievement of the goal. These include external factors, as well as 

conditions or events that would affect the organization’s ability to achieve its goals. According to 

federal internal control standards, for a risk to be fully addressed through planning, the agency 

should (a) identify the risk, (b) plan to analyze its significance, and (c) plan to respond to the risk.

Plans to assess progress 

towards goals

Assessments that monitor and evaluate the progress made towards achieving an intended goal. 

According to the federal internal control standard for monitoring, plans to assess progress towards 

goals should include (a) an established baseline for performance, (b) a system for ongoing 

performance monitoring, and (c) a process for evaluating the results of ongoing performance 

monitoring.

Source: GAO | GAO-18-300

Note: Leading practices for planning are derived from our prior reports. See, for example, GAO, 

Military Readiness: DOD Needs to Incorporate Elements of a Strategic Management Planning 

Framework into Retrograde and Reset Guidance, GAO-16-414 (Washington, D.C.: May 13, 2016); 

and Managing for Results: Implementation Approaches Used to Enhance Collaboration in 

Interagency Groups, GAO-14-220 (Washington, D.C.: Feb. 14, 2014). In addition, federal internal 

controls provide a framework consistent with the leading practices for planning. See GAO, Standards 

for Internal Control in the Federal Government, GAO-14-704G (Washington, D.C.: September 2014).

We conducted this performance audit from June 2017 to March 2018 in 

accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.
Page 4 GAO-18-300 DOD Trauma Care System

Since the mid-2000s, DOD and the military health system have worked to 

decrease trauma-related morbidity and mortality by improving trauma 

care in DOD’s military treatment facilities and by conducting research on 

providing trauma care. As part of these efforts, the Army established the 

JTS DCOE, which serves to provide advice on trauma care across the 

military.6

The JTS DCOE performs several functions to improve trauma care, 

including

• overseeing the DOD Trauma Registry (DODTR)—a database that 

captures trauma data from the time servicemembers are injured on 

the battlefield to when they are treated by providers in the United 

States. The JTS DCOE uses DODTR data to conduct performance 

improvement activities and to identify gaps in medical capabilities to 

direct ongoing and future combat casualty care research, trauma skills 

training, and combat casualty care. The JTS DCOE also provides 

data from the registry to collaborating military and civilian personnel 

conducting medical research.

• managing the development, monitoring, and review of Clinical 

Practice Guidelines (CPGs). These guidelines, developed by subject 

matter experts using data from DOD’s trauma registry, are created to 

inform medical professionals of best practices based on medical 

evidence, with a goal of minimizing inappropriate variation in medical 

practice and improving care for trauma injuries, specifically when 

military servicemembers are deployed. The development of CPGs is 

an ongoing process that takes place during times of war and peace, 

according to DOD officials.

• developing and providing training curriculum for first responders to 

trauma-related injuries.7 The JTS DCOE seeks to identify lessons 

learned from trauma care that can be used as part of this training, to 

help improve the medical readiness of trauma care providers.

 6

The JTS, established by the Army in 2006, was named a Defense Center of Excellence 

in 2013.

7

The training curriculum provided by the Joint Trauma System is called the Tactical 

Combat Casualty Care curriculum.

Background

U.S. Army’s Joint Trauma 

System Defense Center of 

Excellence
Page 5 GAO-18-300 DOD Trauma Care System

To create a formalized, consistent trauma system across DOD, the NDAA

required that a new JTS be operated under the direction of DHA. DHA 

officials expect to begin initial operation of the new JTS in July 2018. 

Additionally, DOD plans to realign the existing JTS DCOE and its current 

functions under DHA. Section 707 (a)(2) of the NDAA required DOD to 

submit an implementation plan to Congress for the new JTS in June 

2017, 180 days after the NDAA was enacted. The NDAA also includes a 

provision for us to review DOD’s plan within 180 days after DOD 

submitted it to Congress, and for DOD to implement the new JTS 90 days 

after we submit our review. The NDAA required that the new JTS and 

DOD’s implementation plan include the following four elements:

1. serve as the reference body for all trauma care provided across the 

military health system,

2. establish standards of care for trauma services provided at military 

medical treatment facilities,

3. coordinate the translation of research from DOD’s centers of 

excellence into standards of clinical trauma care, and

4. coordinate the incorporation of lessons learned from trauma education 

and training partnerships pursuant to section 708 of the NDAA into 

clinical practice.

The implementation plan submitted by DOD to Congress on August 7, 

2017 includes a description of the four elements required by the NDAA. It 

also provides an overview of the implementation activities, including 

realigning the U.S. Army’s current Joint Trauma System Defense Center 

of Excellence to become part of the new system within DHA.

Although the implementation plan includes the four required elements, 

neither it nor DOD’s supplemental planning documents prepared to date 

fully incorporate leading practices, which we have previously identified. 

These leading practices, such as the establishment of goals and the 

identification of strategies to achieve those goals, play an important role 

in enabling an organization to achieve its objectives. We found that 

DOD’s planning documents, prepared to date, incorporate only some of 

the leading practices. (See table 2).

NDAA Requirement for a 

New DOD Joint Trauma 

System

DOD’s Joint Trauma 

System 

Implementation Plan 

Includes the Four 

Elements Required 

by the NDAA, but 

Does Not Yet Fully 

Incorporate Leading 

Practices for Planning
Page 6 GAO-18-300 DOD Trauma Care System

Table 2: Extent to Which DOD Joint Trauma Planning Documents Reflect Leading Practices Identified by Prior GAO Work

Legend:

Fully incorporates leading practice ●

Partially incorporates leading practice ◐

Does not incorporate leading practice ○

Source: GAO analysis of Department of Defense documentation. | GAO-18-300

Note: GAO analysis in this table is based on leading practices derived from prior work. See, for 

example, GAO, Military Readiness: DOD Needs to Incorporate Elements of a Strategic Management 

Planning Framework into Retrograde and Reset Guidance GAO-16-414 (Washington, D.C.: May 13, 

2016).

DOD officials acknowledged that the agency’s plans are presently 

incomplete because this process is ongoing. They stated that DOD is 

continuing to plan for implementing all four elements of the JTS—

including efforts to incorporate leading practices. DOD’s planning 

documents that have been prepared to date and our assessment of each 

of the four elements are described below.

DOD’s planning documents incorporate goals associated with this 

element, but only include partial information about the strategies, 

associated risks, and plans to assess progress. Without including more 

complete information about plans to serve as a reference body for trauma 

care, it is unclear how well prepared DOD is to implement this element.

Goals: According to a planning document, DOD has two goals for 

JTS to serve as a reference body:

Leading practices for planning

Required Elements of Sec. 707(b), NDAA 

FY17 

Goals Strategies to 

achieve goals

Risks that can affect 

goals

Plans to assess 

progress

toward goals

Element 1: Serve as the reference body for all 

trauma care provided across the military health 

system

● ◐ ◐ ◐

Element 2: Establish standards of care for 

trauma care services provided at military medical 

treatment facilities

● ◐ ◐ ●

Element 3: Coordinate the translation of 

research from the centers of excellence of the 

Department of Defense into standards of clinical 

trauma care

○ ○ ○ ○

Element 4: Coordinate the incorporation of 

lessons learned from trauma education and 

training partnerships into clinical practice

○ ○ ○ ○

Element One—Serve as a 

Reference Body for 

Trauma Care
Page 7 GAO-18-300 DOD Trauma Care System

1) consolidating disparate trauma registries into the 

DODTR. According to DOD officials, there are currently 

about 70 disparate registries, some of which collect 

trauma-related information for various entities across DOD.

2) developing a common trauma lexicon—a dictionary of 

common trauma care terminology to assist in the 

assessment of trauma-related injury data.

Strategies: In addition to defining goals, the documents also 

include some strategies to achieve those goals, such as specific 

actions that DOD plans to take and target dates for accomplishing 

these actions. For example, the documents outline plans to take 

action to define key terms such as “preventable death,” “nonsurvivable injury,” “potentially survivable injury,” and others by a 

target date of July 2018. The documents also identify DHA as the 

lead office within DOD that is responsible for executing and 

achieving this action.

The planning documents do not yet fully reflect the strategies 

needed to accomplish these goals. For example, although the 

documents discuss actions and milestones associated with goals 

for this element, they do not yet provide complete information on 

the resources and costs needed for implementation. The 

documents state that DHA will conduct an organizational analysis 

to determine what organizational structure, staffing needs, and 

other resources are needed for implementation at a later date. 

They also state that funding levels for DHA’s operation of the 

DODTR will be based on the existing JTS DCOE funding levels. 

However, another planning document indicates that the 

infrastructure for the DODTR’s existing host network—operated by 

the United States Army Institute of Surgical Research—would be 

insufficient to support the planned JTS and DODTR expansion, 

and that integrating even a single additional registry or component 

of a registry into the DODTR would require an adjustment to the 

funding for the system. Given that the planned activities for the 

new JTS would require an expansion beyond the scope of the 

current JTS DCOE responsibilities and activities, additional 

planning for equipment and network support costs may be 

necessary to ensure that the new JTS has sufficient resources to 

meet its goals.
Page 8 GAO-18-300 DOD Trauma Care System

Risks: The planning documents identify risks that could affect the 

JTS’s ability to serve as a trauma reference body, but the 

documents do not yet specify how DOD plans to assess or 

respond to these risks. For example, although one of the planning 

documents identifies potential shortfalls in the DODTR host 

network’s ability to support an increased number of users—which 

are expected as the various disparate registries are 

consolidated—none of the documents yet address the estimated 

impact of this risk on DOD’s goals or how it plans to respond to 

the risk. Not planning for assessing and responding to risks could 

increase the likelihood that they become problematic, and 

negatively affect DOD’s goal for the JTS.

Plans to Assess Progress: The planning documents do not yet 

fully indicate how DOD plans to assess progress made towards 

the goals for consolidating registries or developing a lexicon of 

common trauma terms, as would be consistent with leading 

practices. The documents include a description of a baseline for 

performance related to DOD’s goal to develop a lexicon of 

common trauma terms, but they do not yet include plans to 

monitor the progress made towards this goal or to assess the 

results of monitoring. Additionally, the documents do not yet 

establish a performance baseline, a system to monitor progress, 

or a plan to assess the results of monitoring for DOD’s other goal 

for this element—to consolidate registries into the DODTR. 

Without a fully-developed system for assessing the 

implementation’s progress—practices which are consistent with 

federal internal control standards for risk assessment—DOD may 

be unable to determine progress toward the goals it has identified 

for this element.

DOD’s planning documents incorporate goals and plans to assess 

progress, but do not yet fully incorporate leading practices related to 

strategies and risks.

Goals: According to the documents, DOD’s goal for this element 

is twofold:

1) to develop, publish, and assess standards of care in 

DOD’s CPGs.

Element Two—Establish 

Standards of Trauma Care 

for Military Services
Page 9 GAO-18-300 DOD Trauma Care System

2) to determine if the CPG development process can be 

improved. DOD publishes CPGs to provide trauma care 

providers with recommended practices for the provision of 

care, based on available evidence. According to DOD 

documents, the CPGs minimize variations from evidencebased best practices, which help to save lives.

Strategies: DOD’s planning documents describe how the new 

JTS will continue to produce, update, and monitor adherence to 

CPGs and designates JTS as the office that is primarily 

responsible for leading these efforts. Although DOD’s planning 

documents include information needed for the JTS to establish 

standards of care through CPGs, they do not yet fully reflect the 

strategies necessary to achieve DOD’s goal. DOD officials 

indicated that the new JTS will develop, publish, and assess 

CPGs using the same process used by the existing JTS DCOE. 

DOD officials told us that CPGs are currently reviewed on an 

annual basis and updated once every two years, on average. 

According to DOD officials, this frequency exceeds standards 

established by leading civilian organizations. Once updated, 

officials disseminate CPGs by posting them on a website, sharing 

them with DOD officials responsible for training trauma care 

providers, and discussing them at weekly conference calls on 

combat casualty care. Officials also told us that the existing JTS 

lacks authority to require that trauma care providers adhere to 

recommendations made in CPGs. In addition, DOD’s planning 

documents acknowledge that the existing process lacks sufficient 

mechanisms to ensure timely updates and effective dissemination, 

but do not yet indicate what plans are needed to make 

improvements in these areas. Without additional planning to 

improve mechanisms for CPG development and dissemination, 

DOD faces uncertainty regarding the new JTS’s ability to ensure 

that the CPGs it produces are up to date and effectively 

disseminated to military trauma care providers, which may 

ultimately impact the trauma care that it provides.

Risks: The planning documents identify risks associated with the 

development and dissemination of trauma care CPGs, such as an 

inconsistent process for dissemination. However, they do not yet 

include information on determining the potential effects of these 

risks, nor do they include how DOD expects to respond, which are 

both leading practices for risk assessment and are consistent with 

federal internal control standards. Without additional planning, 
Page 10 GAO-18-300 DOD Trauma Care System

DOD may not be fully prepared to address risks related to 

updating and disseminating CPGs.

Plans to Assess Progress: The planning documents include 

detailed information about how DOD uses performance measures 

for each CPG to assess progress in provider adherence to trauma 

care standards. The documents also establish a baseline for 

provider performance, a system for ongoing performance 

monitoring, and a process for evaluating the results of 

monitoring—performance measurement activities that can help 

the department track progress towards the goal it has established 

for this element.

One of the planning documents provides a general overview of how DOD 

plans to coordinate the translation of research from its centers of 

excellence—including the JTS DCOE and other trauma care centers of 

excellence—into trauma care standards, but the planning documents 

have yet to incorporate any of the four leading practices, including goals, 

strategies, risks, or plans to assess progress.8 According to DOD officials, 

the current JTS DCOE routinely translates research into trauma care 

standards by creating and updating these standards to incorporate the 

findings and results of relevant research. DOD officials also told us the 

current JTS DCOE routinely interacts with the various DOD organizations 

responsible for trauma-related research, such as by holding weekly 

discussions on trauma care issues. Officials stated that they do not 

expect these interactions to change as the JTS DCOE transitions to the 

new JTS. However, the planning documents do not yet provide any detail 

about how these interactions will inform clinical standards. Without 

including detailed information in the planning documents on how DOD 

expects to coordinate the translation of research into trauma care 

standards, it is unclear whether the JTS will be fully prepared to ensure 

that clinical standards are up-to-date and based on the most relevant 

evidence from research. This is critical to ensuring the effectiveness of 

the trauma care provided.

 8

DOD operates seven centers of excellence, including the JTS DCOE. Other centers of 

excellence that may conduct trauma-related work include the Defense and Veterans Brain 

Injury Center and the Extremity Trauma and Amputation Center of Excellence.

Element Three—

Coordinate the Translation 

of Research into Trauma 

Care Standards
Page 11 GAO-18-300 DOD Trauma Care System

The planning documents for this element do not yet incorporate any of the 

four leading practices, including goals, strategies to achieve goals, risks, 

or plans to assess progress. Officials indicated that planning for the 

implementation of this element will be incomplete until DOD establishes 

the new Joint Trauma Education and Training Directorate responsible for 

establishing these partnerships. Section 708 of the NDAA states that 

DOD may enter into partnerships with civilian trauma centers to provide 

trauma care providers with maximum and continuous exposure to a high 

volume of critically injured patients. According to DOD officials, planning 

for incorporating lessons learned will begin after the directorate reaches 

initial operating capacity, which they anticipate in 2018. DOD officials also 

told us that the JTS will collaborate with the directorate for trauma 

education and training partnerships, once it is established, to plan the 

translation of relevant lessons learned into clinical practice. Because

planning for this element is still incomplete, it is unclear whether DOD will 

be prepared to use information from these clinical partnerships to improve 

the effectiveness of the trauma care it provides to injured service 

members.

In an effort to reduce preventable deaths and disabilities due to trauma, 

and as required by the NDAA, DOD is planning for the implementation of 

its new JTS. Specifically, the department has submitted its 

implementation plan to Congress as required and has developed other 

supplemental planning documents that describe how it plans to address 

the four required elements of the new system. Incorporating these 

elements is a critical step for DOD as it works to improve trauma care 

consistently across the military health system. Although the NDAA 

requires that DOD begin implementation in 2018, DOD’s planning is 

ongoing, and its planning documents do not fully incorporate leading 

practices that can help ensure the success of its efforts. As it moves 

forward, DOD has the opportunity to update its efforts and planning 

documents to fully incorporate these leading practices. By not doing so, 

DOD may be missing an opportunity to ensure that its efforts to 

implement a new JTS are effective and to help reduce trauma-related 

deaths and injuries across the military.

To fully implement the four required elements of the new Joint Trauma 

System, the Director of the Defense Health Agency should fully 

incorporate leading practices—including establishing goals, planning 

strategies to achieve goals, identifying and addressing risks, and 

Element Four—

Incorporate Lessons 

Learned from Trauma 

Education and Training 

Partnerships

Conclusions

Recommendation
Page 12 GAO-18-300 DOD Trauma Care System

assessing progress—in its planning to guide implementation efforts. 

(Recommendation 1)

We provided a draft of this report to DOD for comment. DOD provided 

written comments, which are reprinted in appendix I, and technical 

comments, which we incorporated as appropriate. In its written 

comments, DOD concurred with our recommendation to fully incorporate 

leading practices in its planning to guide JTS implementation efforts. 

DOD’s written comments also referred to technical concerns regarding 

the timeliness of its updates to clinical practice guidelines. Specifically, 

the comments indicate that DOD updates these guidelines more 

frequently than standards established by leading civilian organizations. 

Our report includes a description of DOD’s processes for developing and 

updating these guidelines, including the frequency of the updates, and we 

added a statement regarding DOD officials’ comparison of this frequency 

to civilian standards.

We are sending copies of this report to the appropriate congressional 

committees, the Secretary of Defense, and other interested parties. In 

addition, the report is available at no charge on the GAO website at 

http://www.gao.gov.

If you or your staff have any questions about this report, please contact 

me at (202) 512-7114 or draperd@gao.gov. Contact points for our Offices 

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Debra A. Draper

Director, Health Care

Agency Comments
Appendix I: Comments from the Department of 

Defense

Page 13 GAO-18-300 DOD Trauma Care System

Appendix I: Comments from the Department 

of Defense 
Appendix I: Comments from the Department of 

Defense

Page 14 GAO-18-300 DOD Trauma Care System
Appendix II: GAO Contact and Staff 

Acknowledgments

Page 15 GAO-18-300 DOD Trauma Care System

Debra A. Draper (202) 512-7114 or draperd@gao.gov

In addition to the contact above, Will Simerl (Assistant Director), Carolyn 

Garvey (Analyst-in-Charge), Sarah Sheehan, Jennie Apter, and 

Jacquelyn Hamilton made key contributions to this report.

Appendix II: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments

(102164)
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