Like everything in government, military medicine is a vast bureaucracy. As such, military medicine is inherently resistant to change; sometimes it seems that people work four times as hard to get one-fourth of the work done. Nonetheless good people do good things every day, and slowly the prow of this lumbering battleship gets pointed in the right direction. I have spent over 23 years in military medicine, including 18 months as a liaison in Washington at the Department of Health and Human Services, and have learned a few things along the way. This paper is intended to help my staff, others currently in military medicine, and perhaps even those after us, get good things done in the US military health system.
Step One – The Idea
Nothing gets better unless someone thinks of it first. This requires the desire to think about how to improve a situation, an extensive though not exhaustive understanding of the current situation, and time to think. Every part is vital; we have all suffered through legions of ideas presented by well intentioned people who did not understand the situation they were trying to fix, or hadn’t thought clearly about their proposed solution. Occasionally someone with little or no knowledge of a situation has a great idea about how to improve it, but this is rare. Once we have an idea we need to think it through on our own, identify risks and benefits in the short term, and try to anticipate longer term effects.
For example, a patient may want longer appointments with her physician to get more complaints addressed for the same investment in time and money. A health care administrator may want shorter appointments to maximize profits. It would be easy to assume that the patient is right and the administrator is wrong, since in medicine we try to put patient needs first. However, if a doctor sees patients in the clinic eight hours per day and each appointment is 15 minutes long, he can see 32 patients. If the appointments are 30 minutes long he can see 16 patients. Unless there is excess capacity in the system as a whole so that the other 16 patients can get care from someone else, they will go without. The question then becomes, if our medical ethic is to do the most good for the most people, does the benefit of longer appointments for this patient outweigh the other patients’ need to get care at all?
Another key question is “does this idea align with the overall strategy of the service, the department, and the organization as a whole? If so, proceed. If not, it should be taken up in another venue. Writers write good novels that are rejected because they are submitted to non-fiction publishers. Don’t make this mistake. Every initiative has a concept of operations (CONOPs) which outlines what the initiative is intended to do and this is the right time to formulate an informal CONOPs.
Most ideas will not survive this step, and that is not a bad thing. Rejection of an idea does not mean rejection of the idea maker, and no one has consistently good ideas. The lesson is not that people should stop having ideas, but to have them and think them through.
Step Two – Analysis
After the idea generator has carefully considered his or her idea and still deems it worthy to pursue, formal analysis begins. In research, investigators do a literature review to see if others in their field and with similar obstacles have had the idea before. If they did, what was the result? In business, process improvers seek other companies that struggle with the same problem to discover what they are doing about it. This is called benchmarking. Governments, non-profits and others worth their salt do the same thing. In a world of seven billion people and thousands of organizations facing similar obstacles, it is unusual for an idea to be completely new.
Once these innovators have completed the literature review and the benchmarking, it is time to see if the idea might work in their specific situation. Kaiser Wilhelm II of Germany, having devoured Alfred Thayer Mahon’s Influence of Sea Power on History, loved the idea of building a blue water navy to challenge Great Britain in the years prior to World War 1. He imitated the British and even surpassed them in some areas; investing billions of German goldmarks, only to discover during the war that his Kaiserlichemarine still could not defeat the Royal Navy. The Kaiser had reviewed the most current literature and benchmarked against the best in the world, but did not make sure that what he discovered would not carry over to his specific situation.
First, the project team further refines the CONOPs. Also, most organizations use business case analyses (BCA) to determine how an idea might fare in their specific situation. There are many formats for these depending on the needs of the organization, and so individual formats will not be discussed here. However, most BCAs consider only or primarily the financial aspects of an idea. In reality the analysis must consider the desires of all, or at least most, of the stakeholders in an organization. In military medicine BCAs might address the following:
1. Financial – Will this idea make money, lose money, or break even? Consider the short, medium and long term.
2. Educational – Will this idea help our employees, our patients, and/or our other stakeholders perform better in their responsibilities or expectations?
3. Research – Will this idea contribute significantly to the body of knowledge in this field? Is research one of the key missions of this organization?
4. Quality – Will our patients and families receive better care? Will our staff have better working conditions? Will our other stakeholders benefit in some tangible way?
5. Mandate – Is our higher headquarters or some other entity with authority over us mandating that we do this?
If we don’t include all of these factors, and more depending upon the situation, in our BCA, we will overlook some worthwhile initiatives and harm our organization. The environment is constantly changing and every institution must adapt to these changes. This is the time to further develop the CONOPs.
Part of any analysis is deciding how processes will flow. For example, to decide whether or not to fund a residential treatment center (RTC) for substance abuse, innovators had to figure out who would be admitted to the RTC and how. They had to envision how the patient’s care would occur, how long it would be, and the characteristics (how many, what type) of staff would be required. Innovators had to conceive the process for discharge and follow up long before the first patient ever darkened the door. Research and educational opportunities needed to be considered, as well as quality of care issues. Metrics and methods to implement the RTC had to be devised, as did metrics and methods to maintain the RTC once it was fully operational. In short, the idea makers have to construct their ideas completely in their minds and on paper (or computer screen) long before it becomes reality. In the Seven Habits of Highly Effective People, Steven Covey argues that every project must begin with the end in mind. First comes the mental creation, and only later comes the physical creation. As the team figures out how they think the processes will look, they need to prepare flowcharts for each process and explanations of each step. These will be useful to comprehensively think through the processes and explain them to others.
It is unusual for one person to have the skills, time and other resources to do all of this by themselves, so the idea-creator has to enlist the help of others. Even if the idea-generator can do the entire analysis, he shouldn’t – he needs a team to get political momentum if nothing else. Until the others have caught the vision, the innovator must use personal connections or whatever other resources he has to sell the idea. If the idea is truly good and the analysis shows that it might work, the project will gain a life of its own. Eventually a team will coalesce which will work on the project and advocate for it.
Analyses take time, energy, focus and skills and so the supervisors of those analyzing the project will need to allow their people to do it. Information briefs are used to inform leaders about a project and, implicitly but not explicitly, their approval to continue working on it. Plan these briefs carefully and show progress – no one wants a good project killed because it was communicated poorly to a leader who then withdrew the resources to keep evaluating it.
Step 3 – Decision
Once the analysis is completely done, the innovator has to sell the idea, which has now become a project, to the decision maker. This person or group will vary depending upon the scope of the project and the resources required. The clinic chief will decide on a project to change work processes in a single clinic, and the chief executive officer or the board of directors will decide on a project to build a new hospital for the health care system. In the later case, however, several lower level leaders will usually have to support the project before it even makes it to the boss. Every organization is unique, but the key point is that every project champion and her team have to shepherd their project through every step of the appropriate chain to get it approved and implemented.
The process is similar at every decision making level:
1. Decide who needs to be influenced and how to influence them.
2. Identify who is likely to support the project, who is likely to oppose the project, and why.
3. Begin to informally socialize the project with likely supporters, see if they actually support it, and gauge their enthusiasm. Lukewarm support will kill a project at least as effectively as outright opposition.
4. Encourage enthusiastic supporters to become more enthusiastic and to influence their less enthusiastic peers. Ask them who else at their level will support the project, how strongly, and who will oppose it. One person will need to become a champion.
5. Float the idea carefully with those will are likely to oppose it. If they are against it, ask why and take their feedback seriously. They may be right, and ideas that looked good on the surface, even after analysis, have been appropriately killed by intelligent opposition. Improving the project on the basis of criticism from opponents is also a good way to turn opponents into supporters.
6. Provide information briefs about the project to interested and important players, including the ultimate decision maker.
7. Make the reasonable and intelligent changes suggested by supporters and opponents as long as those changes do not ruin the project altogether. Fight for the important stuff and be flexible on the unimportant stuff.
Once the project team believes that they have a critical mass of supporters and have effectively addressed the concerns of the opposition at each level, they should prepare a decision brief for the decision maker. Send the brief to the decision maker ahead of time so he or she can review it at leisure. Never ask a leader for a decision on something that he or she has never seen before; the answer is likely to be no. The leader will probably send the decision brief to trusted associates and subordinates so it can be useful to get their buy in ahead of time. The project team should do everything they can to make approval a foregone conclusion.
The decision brief is a key document. Subject to individual variations in a command or organization, it should include the following information:
1. Slide 1 – Title of the Presentation (name of the issue), briefer and date
2. Slide 2 – Mission as received
3. Slide 3 – Mission analysis – Current Situation (METT-TC) narrative and metrics
4. Slide 4 – Mission analysis – Desired End State (METT-TC) narrative and metrics
5. Slide 5 – Mission implicit and explicit tasks
6. Slide 6 – Summary of Courses of Action (COAs)
7. Slide 7 – COA 1 including supporting metrics
8. Slide 8 – COA 1 advantages and disadvantages (in all of the areas noted below)
9. Slide 9 – COA 2 including supporting metrics
10. Slide 10 – COA 2 advantages and disadvantages (as COA 1)
11. Slide 11 – COA 3 including supporting metrics
12. Slide 12 – COA 3 advantages and disadvantages (as COA 1)
13. Slide 13 – Additional COA supporting metrics
14. Slide 14 – Additional COA advantages and disadvantages (as COA 1)
15. Slide 15 – Decision matrix
16. Slide 16 – Recommended COA
17. Slide 17 – Questions
18. Backup slides – hidden and not included in presentation unless requested
19. Decision Matrix – Side by side comparisons of the courses of action, ranked from 1 to 3 as the most to least desirable.
d. Logistics and Facilities
e. Finance and Money
f. Public affairs/customer relations
This list is longer than many commanders want their decision briefs to be, but it is comprehensive. Slides 2 and 5 will often be back-ups, the COA slides will often be combined into one slide per COA, and slides 13 and 14 may not be needed at all. As with all communication, presenters will tailor the brief to the needs of the audience.
The Mission Analysis slides deserve comment. The military uses the acronym METT-TC to assist staffers in comprehensively analyzing missions given to them by their commander (or higher commands).
1. Mission – as provided
2. Enemy (forces opposing mission accomplishment) – in health care, this may refer to competitors, pathogens, or failure of the staff to follow certain practices such as hand washing.
3. Troops (resources available to accomplish mission) – in health care, this usually refers to the people available to address the problem. If the mission is to decrease hospital acquired infections, “troops” will include staff members, patients, family members, and others working together to prevent infection transmission.
4. Terrain (environmental factors affecting mission) – in health care, the physical environment, the fiscal environment, the regulatory environment, the political environment, and others are included. In the example of hospital acquired infections, multi-patient rooms are a risk factor for infection that would be included under “terrain”.
6. Civil considerations (maximizing benefit and minimizing damage to peripherally involved parties) – health care systems have many stakeholders besides the staff, the patients and their families. Payers such as employers, governments, and the local communities also play important roles in the life of their local hospitals and clinics.
A common mistake with decision briefs is to make them too general. Decision makers cannot make decisions based on vague generalities such as “decrease hospital acquired infections”. They want specifics such as “this initiative will decrease the incidence of staph aureus and other common percutaneously acquired infections by 20% in the adult medical-surgical ward in six months after implementation at a cost of $41 per inpatient bed day.” Everyone knows that hospital acquired infections are a bad thing; leaders need to know exactly what to expect, how to measure it, how much will it cost, and similar specifics. The project team should rehearse among themselves and prebrief supportive members of their chain of command (or authority) to get constructive feedback. Canvas your team to ensure that the final decision brief will be the right message presented by the right messenger using the right method at the right moment to the right audience. Make sure that the team carefully considers everyone who will be in the room, who are they and what do they need?
After the project is approved at each level, go on to the next level until the last decision maker has given the thumbs up. Don’t ask for any decisions prematurely or without the appropriate preparation because once a leader has said no it is very hard to reverse it. To reverse one’s own decision is seen as inconsistency at best and weakness at worst. It forces the decider to admit to having possibly made a mistake, and human psychology makes that hard to do. Far better to get the initial yes.
Step 4 – Implementation
Far too often when we get the decision that we want we pop the champagne corks and think our work is done. Popping the corks is fine for an evening or perhaps a weekend, but then the real work begins. The implementation plan should have been completed during the Analysis phase and edited during the Decision, so the initial way forward should be mapped out. However, as the Prussian Field Marshall Helmuth von Moltke (1800-1891) observed “no battle plan ever survives contact with the enemy.” Change is a fearsome opponent, and will not surrender easily. People that the project team thought were allies will disappoint them, either with opposition or with indifference, and some ideas which smelled like a rose on the drawing board begin to smell like something else in practice.
Five types of documents are important to starting a new program.
1. CONOPs (final)
2. Action plan – this specifies who will do what, when and where they will do it, and with whom. How to do it may be specified or unspecified depending upon the situation.
3. Timeline – the written action plan needs to be visually laid out on a timeline with milestones so that those involved can grasp at a glance what needs to be done, when, and how it fits into the overall project. The military uses stoplight colors (red, yellow, green) to identify the status of milestones.
a. Red – Major obstacles or delays; task will not be achieved by the time indicated.
b. Yellow – Moderate obstacles or delays; task may not be achieved by the time indicated.
c. Green – Minor or no obstacles or delays; task should be completed by the time indicated.
4. Process flowcharts – As the initiative is implemented, the expected process flowcharts which were drawn in the Analysis phase will be modified to conform to reality on the ground. Each point on the chart should be explained. In accompanying text.
5. Issuances, including policies, charters, orders and other documents – For large projects, or those generated by a higher command to a lower one, these documents guide the subordinates in how to implement the new system.
One common pitfall in implementing a new project is failing to consider important aspects of the project. In offering a new service such as joint replacement services in a community hospital, for example, project leaders usually remember to make sure that there are patients who need the surgery and surgical staff who can do the surgery. They may not remember, however, that people need to be trained to buy the implants, suppliers need to be found, and a host of seemingly little things need to be done to get this off the ground. As the proverb says:
“For want of a nail the shoe was lost; for want of a shoe the horse was lost; for want of a horse the knight was lost; for want of a knight the battle was lost; for want of the battle the kingdom was lost – all for the want of a nail.”
The smallest oversight can derail a project, and nothing can be left to chance. Therefore the US Department of Defense uses the acronym DOTMLPF to guide comprehensive thinking on any issue.
1. D – Doctrine (how we do what we do – big picture)
2. O – Organization (how we are organized to accomplish our mission)
3. T – Training (how we teach others to accomplish the mission at the tactical level – Army foxhole, Navy deck plate, Air Force flight line, medical bedside or clinic)
4. M – Material (what things we need to accomplish our mission)
5. L – Leadership (who are our leaders and how do we prepare them)
6. P – Personnel (who do we need to complete the mission, and where/how do we get them)
7. F – Facilities (real property, buildings, etc. that contribute to our mission accomplishment)
Looking at initiatives in this light is essential to remembering the major details necessary to implement any program.
The last thing to consider when implementing a project is how to measure the implementation. The timeline is necessary but not sufficient. People need to be hired, equipment needs to be purchased, space needs to be finalized, training needs to be done and documents need to be written. All of those must be done on time and within budget, and each must be monitored with appropriate metrics to judge progress. When hiring people for the Patient Centered Medical Home, we tracked money budgeted and people hired, ensuring that when the personnel budget for implementation was zero, we had 100% of our staff on board. When implementing secure messaging between patients and providers, we tracked what percentage of our enrolled patients was signed up to use the system.
Step 5 – Monitoring
Once a project is implemented, the project team can relax; but only for an evening or a weekend. The final stage, monitoring, goes on for the life of the project. Decision makers need to know the outcomes of their decisions, and all stakeholders want to know how their organization is doing. Metrics should be reported regularly, often monthly, and should be manageable. Management often wants more metrics than they actually use, and each request for information requires someone’s time. Effort that they spend preparing metrics in reports could be spent in other activities, such as taking care of patients. Also, metrics must measure outcomes that people care about, not merely on how well an organization does a process. Metrics must also focus on outcomes that are important.
Patients who come to emergency departments for heart attacks often develop abnormal electrical activity in their hearts. This abnormal activity often preceded sudden cardiac arrest. When I first started medical school we were taught to give lidocaine, an anti-arrhythmic medication, to all heart attack patients, hoping to prevent abnormal electrical activity and thereby prevent sudden death. It made sense, at least until science caught up with practice. Good research showed that patients without abnormal heart electrical activity who received anti-arrhythmics in such circumstances were more likely to die, not less, than patients who did not. We found that we were measuring the wrong thing; the outcome that we wanted was healthier patients, but the outcome that we had been measuring was a healthier looking electrocardiogram tracing.
Metrics must be tied to the topics mentioned in the Analysis section:
1. Financial – Is the project making money, losing money, or breaking even? Consider the short, medium and long term.
2. Educational – Is the project helping our employees, our patients, and/or our other stakeholders perform better in their responsibilities or expectations?
3. Research – Is the project contributing significantly to the body of knowledge in this field? Is this research contributing to accomplishing the key missions of this organization?
4. Quality – Are our patients and families receiving better care? Does our staff have better working conditions? Do our other stakeholders benefit in some tangible way? If so, how?
5. Mandate – Is our higher headquarters or some other entity with authority over us pleased with this project? Are we accomplishing what they intended?
There are many other possible metrics, but the number can be quickly overwhelming. No more than 30 metrics can be routinely followed and adequately addressed for most organizations.
It has taken over 4,000 words to tell a simple story. Getting positive change in military medicine is hard, but it can be done. Though all large bureaucracies seem impenetrable, and the US military bureaucracy is one of the largest, hard-working people with good ideas, courage and perseverance can and will do great things for our country. More importantly, we will do these things for our patients. No one who has ever held the hand of a grandmother as she passes into eternity, or comforted the father of a fallen warrior, or cared for a mother and her terminally ill child, can stop trying to do better. Hopefully, this paper will help future American warriors and healers get things done in military medicine.