text: Background U.S. Army’s Joint Trauma System Defense Center of Excellence 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. 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. 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. NDAA Requirement for a New DOD Joint Trauma 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 2. establish standards of care for trauma services provided at military 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. 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 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). 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. Element One—Serve as a Reference Body for Trauma Care 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: 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,” “non- survivable 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. 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. Element Two—Establish Standards of Trauma Care for Military Services 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. 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 evidence- based 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, 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. Element Three— Coordinate the Translation of Research into Trauma Care Standards 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. 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. Element Four— Incorporate Lessons Learned from Trauma Education and Training Partnerships 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. Conclusions 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. Recommendation 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 assessing progress—in its planning to guide implementation efforts. (Recommendation 1) Agency Comments 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 of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix II. Appendix I: Comments from the Department of Defense Appendix II: GAO Contact and Staff Acknowledgments GAO Contact Staff Acknowledgments 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.
target: 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. 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.