Defense Health Care: Availability and Quality Measurement of Women's Health Care Services in U.S. Military Hospitals
Published: 2016-06-23T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: DOD provides health care services to active-duty servicemembers, their dependents, and others, in part through direct care provided at military hospitals and clinics located on military bases. Women represent a significant percentage of the population eligible for MHS services, comprising nearly half of the 7 million adults eligible for coverage at the end of fiscal year 2014.
In recent years, DOD’s study of the quality of care in the MHS raised questions about the quality of health care at military hospitals, including the quality of women’s health care services. The Carl Levin and Howard P. “Buck” McKeon National Defense Authorization Act for Fiscal Year 2015 included a provision for GAO to describe the availability of women’s health care services at military hospitals, particularly maternity care, and the measurement and monitoring of the quality of these services.
This report describes: (1) the extent to which women’s health care services are available to servicemembers and other beneficiaries at domestic military hospitals; (2) how the MHS selects quality measures for women’s health care services provided at military hospitals; and (3) the quality measures that the MHS has selected for women’s health care services and how they are used to improve the quality of care. GAO reviewed documentation, information, and data provided by DOD and the military services, on women’s health care services available as of July 2015, and interviewed officials from DOD, the military services and NCR, and six hospitals (selected based on military service, geographic diversity, and volume of deliveries).
section_title: What GAO Found
paragraphs: Almost all of the domestic military hospitals in the Department of Defense’s (DOD) Military Health System (MHS) offered general women’s health care services, including general maternity, neonatal, and gynecological care, with fewer offering specialty care services. Specifically, according to officials from the three military services and the National Capital Region (NCR) (which includes two military hospitals in the Washington, D.C. area), 37 of the 41 domestic military hospitals offered a basic or specialized level of maternity and neonatal care services, although fewer offered more specialized levels of these services. All of the 41 hospitals offered general gynecological care, including contraceptive services and cervical cancer screenings, while fewer offered more specialized care, such as treatment for gynecological cancers, according to officials.
According to MHS officials, the MHS selects quality measures for women’s health care services based on assessments and input from advisory groups at multiple levels of the MHS, including at the department, military service, and hospital levels. Members of these advisory groups participate in the activities of national clinical organizations and educate their colleagues within the MHS about new developments in health-care quality assessment, including new quality measures. According to officials from the MHS and all three services and NCR, coordination of the selection of quality measures for women’s health care services across the military services and NCR has increased in the past several years, including for the selection of measures to include in a perinatal quality measures “dashboard,” which is being developed to provide more timely quality information to providers during the patient’s stay in the hospital.
In 2015, the MHS collected data for 90 quality measures related to maternity, neonatal, and gynecological care, a number of which related to areas that had been identified nationally as being problematic and associated with high rates of maternal morbidity. In maternity and neonatal care, for example, data was collected on elective deliveries (where the birth is facilitated, such as with medication or surgical cesarean section, without a medical indication). For gynecological care, the MHS collected data for quality measures related to prevention, such as screenings for breast and cervical cancer, and gynecological surgery, such as morbidity rates within 30 days following surgery. The MHS, the military services and NCR, and individual military hospitals used the data collected to identify areas for quality improvement and implement related improvement activities. For example, MHS officials told GAO that the MHS’s 2015 Perinatal Quality Initiative was implemented across all military hospitals in response to a finding that postpartum hemorrhage rates were higher in military hospitals compared to certain civilian hospitals. This initiative included training for hospital staff, clinical simulation drills, and using quality tools to help providers prepare for and carry out steps to minimize the risk and negative outcomes of the condition. Officials reported that after implementation of the initiative, postpartum hemorrhage rates decreased, on average, across the MHS.
section_title: What GAO Recommends
paragraphs: GAO is not making recommendations in this report. DOD reviewed a draft of this report and provided technical comments, which GAO incorporated as appropriate.

section_title: Letter
paragraphs: Women represent a significant percentage of the population served by  the Department of Defense’s (DOD) Military Health System (MHS); as of  the end of fiscal year 2014, nearly 3.5 million of the 7 million adults  eligible for coverage in the MHS were women. This system provides a full  range of health care services to active-duty military servicemembers, their  dependents, and others, through both direct care (provided at military  hospitals and clinics located on military bases), as well as through care  purchased from civilian health care facilities. While the system as a whole  provides a full range of health care services, the specific services  available at each military hospital (including women’s health care  services) vary depending in part on hospital size and staffing levels.  When needed health care services are not available at a military hospital,  the patient is referred to either another military hospital or a civilian  hospital for care.
In recent years, questions have been raised about the quality of care,  including women’s health care, provided at military hospitals. For  example, in 2014, DOD conducted a study of the quality of care in the  MHS, and found significant variability in the performance of military  hospitals on certain measures of quality related to maternity, neonatal,  and gynecological care. The study also found that military hospitals had  comparatively poorer performance on some of these measures than other  health care systems, and raised questions about the consistency of care  in the MHS.
According to health care researchers, for any health system—including  the MHS—assessing the quality of care provided in its hospitals is key to  identifying potential problems and then to taking the appropriate steps to  mitigate the risks to patients. For example, to ensure that women receive  high-quality health care, it is essential that health systems such as the  MHS select and systematically monitor relevant quality measures.  Moreover, researchers also note that it is important that the measures  selected are based on a hospital’s particular care delivery practices and  needs, which may change over time in response not only to changes in  the needs of an individual hospital, but also to evolving national trends in  clinical care.
The Carl Levin and Howard P. “Buck” McKeon National Defense  Authorization Act for Fiscal Year 2015 included a provision for GAO to  describe the availability of women’s health care services at military  hospitals, particularly maternity care, and the measurement and  monitoring of the quality of these services. In this report, we describe: (1)  the extent to which women’s health care services are available to  servicemembers and other covered beneficiaries at military hospitals; (2)  how the MHS selects quality measures for women’s health care services  provided at military hospitals; and (3) the quality measures the MHS has  selected for women’s health care services, and how, if at all, they are  used to improve the quality of care for its beneficiaries.
To describe the extent to which women’s health care services are  available to members of the military services and other beneficiaries at  military hospitals, we obtained data and information in July 2015 about  the women’s health care services provided at each domestic military  hospital. Specifically, we obtained from the military services (Army,  Navy, and Air Force) and the National Capital Region (NCR) information  about the levels of maternity and neonatal care provided at each  hospital. The levels of maternity and neonatal care ranged from the most  basic (Level I) to the most specialized (Level IV). In addition, we  obtained information on the availability at each hospital of certain general  gynecological services, and specialized services associated with the  treatment of gynecological cancers. We also interviewed officials from  the military services and NCR about referrals of women to other hospitals  when needed services were not available. Further, we obtained data from  the MHS on the number of women, aged 18 or older, served in fiscal year  2014, including the number of inpatient hospitalizations and the number  of hospitalizations specifically related to maternity and reproductive  health. We reviewed related documentation about these data, interviewed  knowledgeable MHS officials, and determined that these data were  sufficiently reliable for the purposes of our reporting objective.
To describe how the MHS selects quality measures for women’s health  care services, we analyzed related policies used by DOD, including the  MHS and each of the military services and NCR, and interviewed officials  representing each to learn about quality measure selection, and how  information is shared among different levels within the MHS. In addition,  we conducted site visits to six military hospitals selected to ensure we  included those representing each of the three military services, as well as  a mix of urban and rural geographic locations, and variation in the number  of deliveries. At each of these hospitals, we conducted interviews with:  the hospital’s leadership; clinical leadership for women’s health care  services; clinical providers such as obstetricians, certified nurse  midwives, and nurses; and quality management staff. Through these  interviews, we obtained information about the role of military hospitals in  selecting quality measures. Because the hospitals we visited were not  selected randomly, they do not constitute a representative sample of all  domestic military hospitals, and the information obtained from these  interviews cannot be generalized to other hospitals. We also interviewed  representatives of national health care quality organizations about the  processes that other hospital systems use to select quality measures.
To describe the quality measures that the MHS has selected and how, if  at all, these measures are used to assess and improve the quality of care,  we reviewed documentation about which quality measures the MHS, the  military services, and NCR selected, and interviewed officials  representing each about how they use the measures to assess and  improve the quality of women’s health care services. We also conducted  a literature search and interviewed representatives of national  organizations that focus on women’s health to gain an understanding of  what types of quality measures are available and how they are used.  We also interviewed officials at the hospitals we visited and obtained  information about how hospital officials and staff use the measures to  assess and improve the quality of women’s health care services at the  hospital level. For the purposes of this report, we focused on two types of  quality measures—process measures and outcome measures—that are  designed specifically for clinical services and medical conditions related  to women’s health care.
We conducted this performance audit from May 2015 to June 2016 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 based  on our audit objectives.
subsections: section_title: Background
subsections: section_title: The Military Health System
paragraphs: The MHS is operated through collaboration between the military services,  the Office of the Assistant Secretary of Defense for Health Affairs, and the  Defense Health Agency (DHA). The MHS governance structure includes  representatives from each of the military services and DOD. Within this  structure, the Medical Operations Group oversees the provision of health  care services, including the oversight of health care quality. (For  additional information about the MHS governance structure, see appendix  I.)
In 2015, the MHS’s direct care system included 41 domestic military  hospitals across the military services and the NCR. These hospitals  varied widely in the number of inpatient beds—a general indicator of  hospital size and scope of services—with the majority of these hospitals  being relatively small, having 50 or fewer inpatient beds. (See table 1.)  The hospitals spanned the country from very populated areas, such as  the Washington, D.C. region, to very remote areas, such as the Mojave  Desert region in southeastern California. (See appendix II for the location  of domestic military hospitals.)
Women represent a large share of the population eligible for MHS  services. For example, as of the end of fiscal year 2014, 49 percent of all  eligible MHS health care beneficiaries aged 18 or older were female, and  among active-duty servicemembers and their dependents served by the  MHS, females represented 43 percent. (See table 2.)
Health care services for women represent a significant percentage of the  care provided by domestic military hospitals. For example, in fiscal year  2014, maternity and neonatal care services—as represented by the two  major diagnostic categories related to 1) pregnancy and childbirth and 2)  newborns—accounted for the largest and the second largest number of  direct-care hospitalizations reported across all domestic military hospitals.  These two categories combined represented about 40 percent of  hospitalizations. (See table 3.)
section_title: Using Quality Measures to Assess and Improve Women’s Health Care Services
paragraphs: Recommendations to improve the quality of care at hospitals—including  both civilian and military hospitals—are generally developed after  assessing care over time using various quality measures. Over the past  two decades, based on such assessments, health services researchers  and national organizations that focus on women’s health, among others,  have identified areas of concern related to women’s health care services  in U.S. hospitals. Those findings have led to recommended changes in  clinical practice to achieve better outcomes. For example, researchers  found that there were increasing rates of elective cesarean sections— surgeries for which there is no clear medical indication that a cesarean  section is necessary—and that this clinical practice may be associated  with increased rates of morbidity for both the mother and baby. In  response to this finding, the American College of Obstetricians and  Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine  issued a recommendation that obstetricians only perform cesarean  sections when there is a medical indication for them. In addition, in  response to findings of increased rates of postpartum hemorrhage and  other types of maternal morbidity, the National Partnership for Maternal  Safety, which started as a collaborative effort of more than 25  organizations including national women’s health organizations, has  developed resources—such as recommended checklists and other  clinical decision-making tools—to help providers prevent common causes  of postpartum hemorrhage and other types of maternal morbidity.
Health systems and hospitals use quality measures to assess  performance relative to national recommendations and compared to other  systems and hospitals. Each health system and hospital may select from  a variety of measures for women’s health care services to assess the  quality of care they provide, and to initiate efforts to improve the delivery  of care. Among those measures, process measures may examine  whether a certain service is performed, while outcome measures may  identify the result of treatment. Some quality measures for women’s  health care services have been developed, endorsed, recognized, or  used by relevant national organizations. (See table 4 for examples of  key national organizations with roles in health care quality measurement.)  Quality measures for women’s health care services that are used or  recognized by national organizations have changed over time and  continue to evolve.
Health systems and hospitals—including both military and civilian  hospitals—generally develop improvement strategies based on their  performance on selected quality measures. Quality improvement involves  making systemic changes within an organization often requiring multiple  types of change, such as using new quality tools, training health care  professionals, and improving coordination among clinical providers.  These approaches are aimed at making recommended changes in clinical  practice. Within the MHS, resources are available to military hospitals for  conducting quality improvement activities, including for women’s health  care services, such as training in systems aimed at optimizing patient  care by improving communication and teamwork skills among health care  professionals. In addition, each of the military services has policies in  place requiring hospitals to conduct quality improvement activities.
section_title: Almost All Domestic Military Hospitals Offered General Women’s Health Care Services, with Fewer Offering Specialty Care Services
paragraphs: As of July 2015, almost all of the 41 domestic military hospitals offered a  basic or higher level of maternity and neonatal care services, although  fewer offered more specialized levels of these services, according to  military-service and NCR officials. All 41 hospitals offered general  gynecological care, including contraceptive services and cervical cancer  screenings, while fewer hospitals offered more specialized gynecological  care, such as treatment for gynecological cancers. When needed  women’s health care services for active duty military servicemembers are  not available at a military hospital, the provider is to try first to refer the  patient to another military hospital.
Maternity Care Services. According to officials from the three military  services and NCR, as of July 2015, 37 of the 41 domestic military  hospitals offered maternity care services, with most hospitals offering  either a basic level or specialized level of care (levels I and II), and fewer  offering maternity care at subspecialty or higher levels (level III or higher).  Specifically, they reported that 16 of the 37 domestic military hospitals  that offered maternity care offered only a basic level of care (level I), 13  offered a specialty level of care (level II), 5 offered a more specialized  subspecialty level of care (level III), and 3 were considered even further  specialized regional perinatal health care centers with full maternity care  capabilities (level IV). (See table 5 for the number of military hospitals by  levels of maternity care.)
Neonatal Care Services. As of July 2015, most domestic military  hospitals offered neonatal care services, with the majority offering only  basic well newborn nursery (level I), and fewer offering more specialized  neonatal intensive care units (level II or higher), according to officials from  the military services and NCR. Specifically, they reported that 37 of the 41  domestic military hospitals offered neonatal care services. Of these 37  hospitals, officials noted that 23 offered level I neonatal care services, 7  offered level II, 7 offered level III, and none offered level IV. (See table 6  for the number of domestic military hospitals by level of neonatal care.)
In general, hospitals with more specialized levels of maternity and  neonatal care tended to be larger, whereas those hospitals that offered  only basic levels of maternity and neonatal care tended to be smaller. In  the interactive graphic linked to below, we provide a map that shows the  location of each domestic military hospital, as well as each hospital’s total  bed size and the highest levels of maternity and neonatal care services  offered. (See figure 1 for an illustration of maternity and neonatal care  services provided by domestic military hospitals via the interactive map  available at the website.)
Gynecological Care Services. For the gynecological care services  included in our review, most domestic military hospitals offered general  gynecological care, and fewer offered more specialized care. Specifically,  officials from the three military services and NCR reported that all 41  hospitals offered contraceptive services, including contraceptive  counseling and intrauterine device (IUD) insertion and removal, all 41  offered cervical cancer screenings to check for changes in the cells of the  cervix that could lead to cancer, and 38 offered mammography  screenings to check for breast malignancies. Fewer, 30 of the 41  hospitals, offered osteoporosis screenings to check bone density,  according to officials.
Although most domestic military hospitals offered general gynecological  care, far fewer offered more specialized care, particularly surgical,  medical, and radiation treatment for gynecological cancers, such as  ovarian, cervical, and uterine cancer. Specifically, officials from the three  military services and NCR reported that 14 of the 41 hospitals offered  surgical treatment for gynecological cancers, 12 offered medical  treatment, and 9 offered radiation treatment. (See table 7.)
Referrals for Women’s Health Care Services. When needed women’s  health care services for active duty military servicemembers are not  available at a military hospital, the provider is to try first to refer the patient  to another military hospital (keeping the patient in the direct care  system). Military service and military hospital officials told us that this  was done in order to facilitate continuity of care. Officials from the three  services and NCR told us that because all military hospitals use the same  electronic health records system, a referral within the direct care system  helps facilitate continuity of care, because the receiving military hospital  automatically has access to the patient’s health records. Officials at one  hospital we visited also noted that referrals within the direct care system  are less expensive than purchasing care from civilian hospitals. If the  patient cannot be referred to another military hospital (for example,  because there are none nearby with the capacity or services needed), the  provider will make a referral to a civilian hospital through the purchased  care system. In this case, medical records are provided to the patient to  take with her to the receiving hospital, and with patient approval, faxed to  the receiving civilian hospital.
Regardless of whether the referral is made through the direct care or  purchased-care system, the extent of communication with the receiving  hospital about the referral often depends on the acuity of the case,  according to military service officials. For example, in cases such as a  complicated pregnancy or a preterm infant, the provider will typically call  or e-mail the receiving provider, discuss the patient’s health status, and  schedule an appointment for the patient. In more routine care cases, such  as an uncomplicated pregnancy, the referring provider is less likely to  reach out to the receiving provider and more likely to instead provide the  relevant contact information to the patient to make the appointment  herself.
section_title: The MHS Draws on Expertise of Internal Advisory Groups and National Clinical Organizations to Select Quality Measures
paragraphs: According to MHS officials, the MHS selects quality measures for  women’s health care services based on assessments and input from  advisory groups at multiple levels of the MHS, including at the  department, military-service, and hospital levels. Department- and  military-service-level advisory groups track clinical developments in health  care and identify quality measures for the MHS and the services to use.  Specifically, members of these advisory groups participate in the activities  of national clinical organizations and educate their colleagues within the  MHS about new developments in health-care quality assessment,  including new quality measures. Based in part on this participation and  expertise, these members recommend quality measures to their advisory  groups for consideration. Officials told us that members of hospital-level  women’s health advisory groups provide their perspectives about quality  measures and data through regular monthly or bi-monthly meetings  hosted by military-service-level clinical specialists. MHS officials  explained that the selection of quality measures for women’s health care  services is also partly influenced by recommendations from the  organizations that collect quality measure data for the MHS. For example,  the National Perinatal Information Center (NPIC) periodically makes  recommendations to the MHS about quality measures to add or  discontinue for the quality performance reports that it generates for the  MHS. According to MHS and military service and NCR officials,  coordination of the selection of quality measures for women’s health care  services across the military services has increased in the past several  years.
MHS advisory groups related to women’s health care services that are  involved in selecting quality measures are described below.
Department-level advisory groups. MHS officials reported that at the  department level, there are four advisory groups involved in selecting  quality measures that include measures for women’s health care  services. The Clinical Quality Integration Board (CQIB) is responsible for  the overall assessment of clinical quality across the entire MHS,  coordinates with multiple MHS advisory groups that focus on different  clinical areas, and regularly reports about quality issues to the MHS  Medical Operations Group. Under the CQIB are three advisory groups  that focus on quality measures that include measures for women’s health  care services—the Perinatal Advisory Group (PAG), the Clinical  Measures Working Group (CMWG), and the National Surgical Quality  Improvement Program (NSQIP) Working Group. Figure 2 depicts these  advisory groups. Each of these groups has representatives from the  military services and formally reports to the CQIB on an annual or  biannual basis.
MHS officials told us that each of these department-level advisory groups  selects and reviews quality measures. For example, the PAG, which  coordinates the MHS’s efforts to improve the quality of maternity and  neonatal care, annually reviews quality measures. In 2014, the PAG  added two quality measures that looked at newborn complications and  first-time cesarean deliveries. In addition, officials from MHS, all three  services, and NCR reported that coordination of the selection of quality  measures for women’s health care services increased in the past several  years. For example, the PAG, using coordinated efforts across the three  military services and NCR, is selecting perinatal quality measures to  include in a “dashboard” that will be used throughout all domestic military  hospitals. The dashboard is intended to provide more timely quality  information to providers during a patient’s hospital stay. MHS officials said  that the CMWG and NSQIP Working Group have similar processes  focused on broader clinical topics, of which women’s health care services  are a subset.
Military-service-level advisory groups. Each of the three military  services reported one or more advisory groups or offices responsible for  advising their respective service about women’s health issues, including  those associated with the quality of care and measures. These groups  are composed of, or collaborate with, military clinicians and experts in  women’s health care, some of whom are officially appointed as subject  matter experts (or consultants), in clinical areas related to women’s health  care services, such as obstetrics and gynecology, certified nurse  midwifery, maternal-infant nursing, and family medicine. Military service  officials explained that some members of these groups are also members  of the department-level advisory groups, such as the PAG. This dual  membership helps facilitate an exchange of information between the  department- and military-service-level advisory groups. These individuals  may recommend quality measures or tools for discussion at meetings of  the military services. In addition, military service officials told us that  members of these groups communicate regularly with women’s health  clinical providers at individual hospitals through such means as e-mail,  memos, or conference calls, including discussion of quality data and  measures. Table 8 describes these military-service-level advisory groups,  as reported by MHS officials.
Hospital-level advisory groups. Each military hospital also has a group  or department that is responsible for the quality of women’s health care  services. Navy officials told us that Navy military hospitals have a  Women’s Health Services Committee, and the responsibilities of this  committee include reporting on quality measures to Navy’s Women’s  Health Continuum of Care Advisory Board. Army officials said that Army  hospital Perinatal Advisory Boards coordinate perinatal quality, safety,  education, patient satisfaction, and outreach efforts. According to Air  Force officials, in Air Force hospitals, responsibility for the quality of care  is held by clinical departments, such as the Women’s Health Department  or the Obstetrics Department. NCR officials said that in NCR hospitals,  the Obstetrics/Gynecology Department holds this responsibility. Members  of these hospital-level groups participate in conference calls and  meetings sponsored by their military-service-level advisory group or  subject matter experts to learn about trends in clinical care and quality  measurement. According to Air Force officials, these meetings also  provide an opportunity for hospital staff to make recommendations about  quality measures related to women’s health care services.
section_title: The MHS Selected 90 Quality Measures for Women’s Health Care Services in 2015 and Used Them in a Variety of Quality Improvement Activities
paragraphs: In 2015, the MHS selected 90 quality measures for women’s health care  services, which were collected across all three services and NCR. In  2015, the MHS, the military services and NCR, and military hospitals  used quality data to assess performance, identify areas for quality  improvement, and implement quality improvement activities, both across  the MHS and within individual military hospitals.
subsections: section_title: In 2015, the MHS Collected Data on 90 Quality Measures for Women’s Health Care Services in Military Hospitals
paragraphs: In 2015, the MHS collected data for 90 quality measures related to  maternity, neonatal, and gynecological care. A number of these  measures were related to current issues in women’s health care services,  such as maternal morbidity and elective deliveries. In addition to these  90 quality measures, the military services and NCR reported taking other  steps related to quality measurement for women’s health care services.
Maternity and neonatal care quality measures. Seventy-three of the 90  women’s health care services quality measures that the MHS collected  data on in 2015 were related to maternity or neonatal care, and included  measures related to areas that had been identified nationally as being  problematic, such as high rates of maternal morbidity and elective  cesarean sections and low rates of breastfeeding. For example, it  collected data on certain perinatal measures, which provided information  on rates of elective deliveries, cesarean sections, breastfeeding,  bloodstream infections in newborns, and administration of antenatal  steroids. In addition, it collected data on measures that captured various  types of maternal morbidity, including measures that linked outcomes for  mother and baby. For example, one measure demonstrated the possible  linkage between the birth trauma experienced by babies and births  obstructed by shoulder dystocia. (See table 9 in appendix III for a  summary of maternity and neonatal care quality measures collected  across the MHS in 2015.)
Gynecological care quality measures. Seventeen of the 90 women’s  health care services quality measures that the MHS collected data on in  2015 were related to gynecological care, including surgery and preventive  screening. Gynecological surgery measures included 14 measures from  the National Surgical Quality Improvement Program (NSQIP), which  identified the rate of different types of adverse outcomes within 30 days  following surgery. For example, NSQIP measures provided information  on morbidity rates for overall gynecological surgeries, as well as for  certain procedures, such as hysterectomies. In addition, in 2015, the  MHS collected data on three women’s health care services quality  measures related to gynecological preventive screening. These measures  were part of the National Committee for Quality Assurance’s (NCQA)  Healthcare Effectiveness Data and Information Set, commonly referred to  as HEDIS, and provided information on the rates of chlamydia, breast  cancer, and cervical cancer screenings provided. (See table 10 in  appendix III for a summary of gynecological quality measures collected  across the MHS in 2015.)
Additional quality measurement activities reported by the military  services. The military services and NCR reported taking additional steps  related to quality measurement for women’s health care services. For  example, in fiscal year 2015, the Navy collected data on five additional  quality measures to monitor its military hospitals’ compliance with the  Department of Veterans Affairs and DOD Clinical Practice Guideline for  Pregnancy Management. One example was measuring compliance with  the “nine-visit pathway,” a standard that a patient should have had nine  prenatal visits (allowing for seven to eleven visits, two visits more or less  than nine). Navy officials reported that they collected and reviewed this  information twice in 2015 to determine areas for improvement. In addition,  Air Force officials reported that in order to allow for more timely  monitoring of certain measures, Air Force hospitals collect and analyze  data for five measures on a monthly basis, so that they would have the  data sooner than would be available through NPIC’s quarterly  performance reports on these measures. Finally, officials from all three  military services and NCR reported that some of their military hospitals  opted to collect data on additional quality measures in 2015. Specifically,  one or more military hospitals within each of the services collected data  on three of the Joint Commission’s Surgical Care Improvement Project  measures that described the use of antibiotics for hysterectomies.
section_title: The MHS, the Military Services and NCR, and Individual Military Hospitals Used Quality Measures to Identify and Implement Quality Improvement Activities
paragraphs: In 2015, the MHS, the military services and NCR, and individual military  hospitals used information from the data they collected through quality  measurement efforts to identify and implement quality improvement  activities. The MHS reviewed data on quality measures across all military  hospitals and identified areas in need of improvement. The military  services and NCR implemented MHS-wide quality initiatives to improve  their performance on these quality measures. For example, according to  MHS officials, the MHS 2015 Perinatal Quality Initiative was implemented  across all military hospitals in response to a finding that postpartum  hemorrhage rates were higher in military hospitals compared to certain  civilian hospitals. This initiative addressed various processes of care,  including training for military hospital staff, conducting postpartum  hemorrhage simulation drills, and implementing quality tools. One of the  tools was a quality bundle to guide providers in responding to cases  involving postpartum hemorrhage. According to MHS officials, the DHA  PAG developed this tool by combining and modifying tools from ACOG’s  Safe Motherhood Initiative, the Council on Patient Safety in Women’s  Health Care, the California Maternal Quality Care Collaborative, and the  Air Force. Additionally, officials reported that in February 2015, the  military services and NCR implemented the use of postpartum  hemorrhage prevention and management carts that contained equipment,  supplies, protocols, documentation, and medication used to manage  postpartum hemorrhage. The MHS also took steps (beginning in 2014) to  improve the medical record coding related to postpartum hemorrhage,  ensuring more standardized coding of these events across all military  hospitals. After the implementation of the Perinatal Initiative and coding  standardization, the MHS’s average postpartum hemorrhage rate  decreased from 5.03 percent in 2014 to 3.05 percent in June 2015, and  was lower than the average for all of NPIC’s hospital clients (3.61  percent) during the first half of 2015.
Additionally, according to military service and NCR officials, individual  military hospitals often use quality measurement data to identify and carry  out quality improvement activities. Officials at each of the military  hospitals that we visited described a variety of such activities for women’s  health care services that they conducted. For example, officials at an  Army hospital that we visited told us that they conducted a quality  improvement project to respond to data that indicated relatively high rates  of third and fourth degree lacerations in deliveries. They conducted a  review of all related medical cases, shared data with obstetricians,  provided training, and adopted a quality tool called “Safer Passages”—a  tool that highlighted 13 steps to guide labor and help reduce the risk of  perineal trauma, such as eliminating midline episiotomies from their  clinical practices. Hospital officials reported that these steps resulted in  decreased rates of episiotomies and third and fourth degree lacerations,  and increased rates of successful vaginal deliveries. Additionally, one  Navy hospital that we visited implemented a “pregnancy passport” quality  improvement project in 2015 in response to data on low compliance rates  with the nine-visit pathway. The passport provided detailed information  for each prenatal care visit—time frames, discussion topics, medical  procedures, and follow-up services needed with the radiology and  pharmacy departments. One reported outcome of this effort was  improved continuity of care because the hospital’s scheduling staff was  able to use the primary obstetrician’s information listed on the passport  when scheduling patients’ upcoming appointments, which resulted in  more patients seeing the same provider throughout the course of their  pregnancy.
section_title: Agency Comments
paragraphs: We are not making recommendations in this report. We provided DOD  with a draft copy of this report for review and comment. DOD provided  technical comments, which we incorporated as appropriate.
We are sending copies of this report to the Secretary of Defense and  appropriate congressional committees. In addition, the report will be  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 IV.
section_title: Appendix I: Governance Structure of the Military Health System and Management of Military Treatment Facilities
paragraphs: According to a DOD report, Military Health System Review, the Military  Health System (MHS) can be described as a federated health system,  with responsibility for the delivery of care being shared among the Office  of the Assistant Secretary of Defense for Health Affairs, the military  services, and the Defense Health Agency (DHA). The Office of the  Assistant Secretary of Defense for Health Affairs reports to the Under  Secretary of Defense for Personnel and Readiness, who in turn reports to  the Secretary of Defense, whereas the medical commands for the Army,  the Navy, and the Air Force report through their Service Chiefs to their  respective Military Department Secretary and then to the Secretary of  Defense.
Military treatment facilities, including hospitals and clinics, are under the  direction and control of the military services, which maintain the  responsibility to staff, train, and equip those commands to meet mission  requirements. Decision making within the MHS reflects collaborative  activities by a number of bodies with representation from each service  and the DHA throughout the decision-making process. (Figure 3 depicts  the governance structure and management of military treatment facilities  within the MHS.)
section_title: Appendix II: Location and Number of Beds of Domestic Military Hospitals by Military Service
paragraphs: In 2015, the Military Health System’s direct care system included 41  domestic military hospitals across the three military services (Army, Navy,  and Air Force), and the National Capital Region (NCR). These hospitals  ranged in the number of inpatient beds—a general indicator of hospital  size and scope of services. The hospitals spanned the country from very  populated areas, such as the Washington, D.C. region, to very remote  areas, such as the Mojave Desert region in southeastern California. The  four figures below show the location and number of beds of domestic  military hospitals by military service.
section_title: Appendix III: Quality Measures for Women’s Health Care Services Collected by the Military Health System in 2015
paragraphs: In 2015, the Military Health System collected data for 90 quality measures  related to maternity, neonatal, and gynecological care. The tables below  list the 73 quality measures for maternity and neonatal care (see table 9)  and 17 measures for gynecological care (see table 10), whether the  measure is a process or outcome measure, and whether certain key  national organizations recognize the measure.
section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
paragraphs: Debra A. Draper, Director, (202) 512-7114 or draperd@gao.gov.
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Gerardine Brennan, Assistant  Director; Amy Andresen; Jennie Apter; Melissa Duong; Mary Giffin;  Jacquelyn Hamilton; Rich Lipinski; Melanie Papasian; Vikki Porter; Ernest  Powell; Jessica Smith; and Eric Wedum made key contributions to this  report.