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

Summary: 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). 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. GAO is not making recommendations in this report. DOD reviewed a draft of this report and provided technical comments, which GAO incorporated as appropriate.