Leading the Defense Health Agency

The Military Health System (MHS) is integral to the U.S. national security strategy. It provides a diverse offering of healthcare services, logistics, public health and research training, and supports the armed forces and their families. Today, the U.S. Department of Defense is transforming the MHS to improve how it operates and delivers health and care. The reform efforts focus on organizational, infrastructure, and manpower changes and the Defense Health Agency, DHA, plays a critical role in ensuring these reforms are successful.

Lt. General Ronald Place, M.D., director of DHA joined me on The Business of Government Hour to explore the agency's strategic priorities, how it is working to create a more integrated Military Health System, and what DHA is doing to combat the COVID-19 pandemic. The following is an edited highlight of our discussion, complemented with updated and additional research.

I have four key strategic priorities for DHA: great outcomes, ready medical force, satisfied patients, and fulfilled staff. These priorities flow from and support the MHS quadruple aim of readiness, better health, better care, and all achieved at lower costs. It is all about truly driving value throughout the MHS.  Focusing on achieving great outcomes means making sure that every service member is medically ready to do their job, then using that knowledge and expertise for all beneficiaries. Outcomes also relates to fielding what we call a ready medical force, which means having deployable medical teams and project that far forward, and then take care of whatever medical mission sets that are there.

We need to ensure those who use our services, who come to the MHS for care or who accesses care outside using Tricare get the care they need. It also means focusing on patient-related or patient-reported outcome measures. My fourth priority is ensuring DHA has a fulfilled staff. Our staff matters. We are in the field of healthcare because we want to make a difference. How are we making a difference? How are we fulfilling ourselves? How can we build teams to collectively deliver medical readiness to our force? How can we build teams that are ready to deploy? In addressing these questions, we must keep our staff and their needs front and center. If we do that, then we will make a real difference as a team.

DHA is a relatively young agency just under seven years old. I transitioned into this role to focus on my four priorities that support the MHS quadruple aim. While pursuing these priorities, I am also leading an organization in transition. Four new organizations, or more accurately four markets, have transitioned into DHA since I took over leadership. They are the National Capital Area region, Texas, Florida, Mississippi Coast, and Central North Carolina. The idea is to extent the shared services model across these organizations with the idea that each of those markets share patients, staff, budgets, and administrative support functions. My major responsibilities to is transition, and really transform, DHA from its legacy of managing the Tricare Health Plan and Management Activity to an organization that manages the Tricare program, but also leads the healthcare delivery inside of its hospitals, medical centers, and clinics.

I would say also that my biggest challenge is leading the integration and merging of these four markets (with more to come) managing people, merging cultures and operations, and doing this in the mists of a global pandemic.  

DHA is an integral part of U.S. Department of Defense’s COVID-19 pandemic response. This has required a joint synchronized effort across the department. DHA is focused on keeping our service members, their families, and our staff healthy and safe.

• Testing. In March, when the pandemic started DHA had a grand total of fifteen laboratories and perhaps the ability to do a few hundred tests for COVID. Today [August], we do about 60,000 tests a week; we can do it in 126 different laboratories across the Department of Defense and around the world. Since the start of the pandemic, DHA has done more than 700,000 laboratory tests for COVID-19.
• Predictive Modeling. DHA has a COVID-19 hospital impact model. We use statistical modeling to predict where resources may be needed most across the MHS enterprise. This information allows us to move resources where it is needed most in an more efficient manner.  

The pandemic has also required us to change the way we delivery health and care.

• Telehealth. We rapidly transitioned from about 80,000 telehealth appointments across the Military Health System per month to more than 500,000 telehealth appointments across the DOD every single month.
• Shifting Operations. In late March, we postponed elective and invasive procedures for the safety of staff and to protect the supply line of PPEs. We were preserving inpatient bed capacity in case of a surge. We were also making staff available to augment communities hardest hit by COVID-19. This policy lasted for several weeks with it being lifted in late May 2020 based on key indicators.  
• Changes to TriCare Benefits. We changed the Tricare benefit to allow for expanded use of telephone access for telehealth support for applied behavioral analysis which is part of our autism care demonstration project. We changed the way we made lab testing available.
• Success of the Nurse Advice Line. When it comes to getting advice we have successfully used our Nurse Advice Line. Prior to the pandemic, we averaged about 2,000 calls per day. At one point in April, we were receiving 10,000 calls per day. This advice line was able to answer questions and direct callers to the right place according to symptoms.

We are effectively using the antimicrobial stewardship application. The app provides clinicians with guidelines and evidence-based recommendations for the treatment of infectious diseases. The goal is to reduce the chance of failed therapy, optimizing healing, and reduce cost by limiting the prescription of the wrong drug. The app was developed collaboratively among DHA teams including this Antimicrobial Stewardship Program Working Group, our J6 teams, so our information technology team, and the connected health branch who are really the gurus when it comes to making these applications.  It is an app that is updated routinely as clinical information changes on the best ways to treat a particular infectious disease. The app gives general guidelines for how to treat common infectious diseases. It is organized by condition, organism, and specific to the COVID-19. As research continues and more evidence is collected, the guidelines in the app are updated accordingly. With this app, we are providing our practitioners with the latest protocols and ways to treat infectious diseases such as COVID-19.

Staying on COVID-19, we also created a clearinghouse for information about COVID-19 patients’ medical and service histories, journeys with the disease, and clinical outcomes to help it improve treatment quality and keep Defense Department guidance for COVID-19 care current. We are using continuous process improvement with the data within the system to continuously update the guidance that we give to the field on best modalities on how we care for our patients. This registry sees patients in two ways. It aims to understand their personal and medical histories leading up to their battles with COVID-19. The history encompasses characteristics as age, sex, medical issues deployments, current medical problems and medications, and their history of surgeries. The registry aims to understand what actually happened to the patient.

Fundamentally, we are focused on standardizing how services are delivered. We are working on standardizing our processes with the end goal of improving our health outcomes.

I’ll give you a couple of examples. The maternal child clinical community is a unique but large population. We assess how medicine is practiced in this area. We look at health outcomes. We use that information to improve the clinical practice guidelines in this clinical community with the goal of achieving better outcomes. To do this, we adopted the care pathway developed by the Navy Medical Center in San Diego and expanded that approach throughout the MHS. Adoption of this pathway resulted in more than 3% decrease in peripartum infections, almost 15% decrease in cesarean sections, and 14% decrease in neonates having to be admitted into a neonatal intensive care unit. By developing clinical pathways from the grassroots where it is really happening, finding those best practices, standardizing it across the entire system, we are getting better outcomes.

We have also done this in behavioral health involving the prescription and use of benzodiazepines. They are frequently prescribed and have pretty significant adverse effects. Analyzing data culled from our behavioral health data portal we identified patterns of over prescribing this drug. We informed the clinical practice guidelines to indicate the key conditions for the use of this drug. It would also indicate an alternative drug to practitioners that would be a better intervention for the conditions presented. Over the last two years, we found that we cut the use of benzodiazepines by just under 50% which ultimately prevents bad outcomes from happening to patients. Using data and the best practices being done on the front line by clinicians we can identify the most effective clinical approaches and standards how they are used with an expressed goal of improving health outcomes across the MHS.

We are in a period of tremendous change and transformation. The consequence of this change is uncertainty. We are in the mist of implementing a new electronic health record, which is a huge change that impacts how we delivery care on multiple levels. The Military Treatment Facilities transition from the Services to DHA is also a major transformation. There is also the department’s decision to possibly decrease the number of uniformed medical staff and potentially increase the number of civilian staff, or rely more on the managed care support contractor, that's a significant change to how we operate.  When you put all that together and add the pandemic, the totality of unknowns for our patients and staff is enormous.

Thousands of books have been written on and about leadership. As a student of leadership, I’ve figured out some things.  

Humility is critical especially in the delivery of healthcare. None of us is perfect and nothing that we do leads to perfection. Communicating is also integral at all levels. It is the number one challenge in almost all large organization. I think our challenge as leaders within the MHS is to effectively communicate what's happening, why it's happening, and what it means for individual members of our team. Respect is also important. As an American, it is very interesting that most of us demand to be respected always. Yet many of us make others earn our respect. The demand versus earn dynamic leads to what I have termed the “respect gap”. We need to give others the benefit and make sure that through our actions, words, and efforts we respect everyone else around us. In so doing, it is much easier to be an effective team. Whether in the Department of Defense, the Marine Corp, Army, Navy, or Air Force, teams are what win battles. Teams are what win wars. Similarly, healthcare delivery teams are the ones who maintain wellness. Healthcare teams are the ones who return people to their optimum level of health.