New Trauma Care System: DOD Should Fully Incorporate Leading Practices into Its Planning for Effective Implementation
Released: 2018-03-19T00:00:00


Highlights: section_title: Why GAO Did This Study
paragraphs: 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.

section_title: What GAO Found
paragraphs: 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.

section_title: What GAO Recommends
paragraphs: GAO recommends that DOD incorporate leading practices in its planning to guide implementation efforts. DOD agreed with the recommendation.

section_title: Letter
paragraphs: 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. 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  inconsistencies in care that continue to result in preventable injuries and  deaths.

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.

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. 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. (See table 1 for more 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.

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.
subsections: section_title: Background
subsections: section_title: U.S. Army’s Joint Trauma System Defense Center of Excellence
paragraphs: 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.

section_title: NDAA Requirement for a New DOD Joint Trauma System
paragraphs: 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.

section_title: 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
paragraphs: 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.
subsections: section_title: Element One—Serve as a Reference Body for Trauma Care
paragraphs: 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.

section_title: Element Two—Establish Standards of Trauma Care for Military Services
paragraphs: 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.

section_title: Element Three— Coordinate the Translation of Research into Trauma Care Standards
paragraphs: 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.

section_title: Element Four— Incorporate Lessons Learned from Trauma Education and Training Partnerships
paragraphs: 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.

section_title: Conclusions
paragraphs: 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.

section_title: Recommendation
paragraphs: 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)

section_title: Agency Comments
paragraphs: 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.

section_title: Appendix I: Comments from the Department of Defense

section_title: Appendix II: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact

section_title: Staff Acknowledgments
paragraphs: 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.

Fast facts: DOD researchers found that about 24% of military servicemembers who died in combat from 2001-2011 could have survived if better and more timely trauma care had been available.

To help reduce preventable deaths and disabilities, DOD is planning for a new trauma care system. However, we found that DOD's planning documents do not fully incorporate certain practices, like clear goals and strategies, that could help the department more effectively implement its new system.

We recommended that DOD fully incorporate leading practices into its ongoing planning to help ensure the success of its efforts to improve trauma care.

Question-summary annotations: questions: question: To what extent does the plan incorporate leading practices?
answer: 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.
child_questions: question: Why is the inclusion of these leading practices important?
answer: 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.

question: Have the leading practices been incorporated?
answer: For each of the four required elements, GAO found that these leading practices either were partially incorporated or had not been incorporated:

questions: question: What goals do DOD documents include?
answer: DOD documents include specific goals, such as consolidating data from multiple trauma registries.
child_questions: question: To what extent do these documents have plans for reaching these goals?
answer: They also include some strategies to achieve the goals, such as identifying lead offices and time frames to complete specific actions.
child_questions: question: How thorough are these plans?
answer: 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.

question: What is the DOD’s first leading practice?
answer: Element 1—Serve as the reference body for all trauma care provided across the military health system.

questions: question: What is the second of four leading practices of the DOD?
answer: Element 2—Establish standards of care for trauma care services.

question: How do DOD documents set trauma care standards?
answer: DOD documents include a goal to develop, publish, and assess clinical practice guidelines that serve as standards of trauma care.
child_questions: question: How do these documents address the new JTS?
answer: These documents also describe how the new JTS will continue to produce, update, and monitor adherence to the guidelines.

question: What aspects of these plans are underdeveloped?
answer: However, they do not fully indicate plans to address risks, such as ensuring effective dissemination.

questions: question: How did the NDAA for FY2017 attempt to improve DOD trauma care?
answer: 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.
child_questions: question: What did the NDAA require regarding the new JTS?
answer: 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.

question: How did the NDAA involve GAO?
answer: The NDAA also included a provision for GAO to review DOD's planning for the new JTS.