the military personnel subcommittee
will reconvene
and MS ellis is back . Alright the
spices here . Let's see . We left off
with miss escobar . We will now go to
MS Spice from Oklahoma for five minutes .
Would you like to pass for a moment
madam chair if that would be okay ?
Sure of course . We'll go to mr doctor
Westrup ,
Give it two seconds .
She's right . All right Miss by she
recognized for five minutes . Thank you
madam Chairwoman and I want to say
first of all uh to the lucky family ,
my condolences to all of you . Um I
can't imagine um getting that knock at
the door so please know that my heart
and prayers go out to both of you Um
and Mr Joe Barbara You and I had the
chance to speak briefly as the mother
of a 21 year old myself . I cannot
imagine um that the suffering that you
go through and how traumatic that's
been for your parents um and certainly
your story is incredibly important
for us to all here so that no other
service member has to endure the type
of pain that you have , I have endured
over these last months and years before
we sort of . I I ask a couple of
questions I think to Miss Silas , I do
want to ask , can you talk a little bit
about your recovery um from
the infections that you had . Yes of
course . Um So I was in the icu at
Fort Sam Houston uh Brooke Army Medical
Center for 100 days . um I did have
43 surgeries . I was discharged from
the hospital in May towards around
Memorial Day weekend . Um
I learned how to walk on a prosthetic ,
um did a lot of strength training and
stuff from my leg . It took me until
about March , so almost a year to
finally walk and be able to come home
to my family and friends . Um
Yeah , it's
the the wounds Taken over two years
to heal and they still got the scars
will never look anything like normal
ever again in my life , but they're
still healing honestly . To this day ,
they're still so very fragile my leg is
and um I still go to pt every
week for my right leg as I have nerve
damage on my right leg where I can't
really walk correctly because of my
ankle . Um And yeah , that's pretty
much it , Thank you for that . Um
This question is actually um to Miss
Silas . The G . A . O . Report stated
some facilities which have cases that
resulted in payments . Silas Silas
Silas . My apologies . Um The G . A . O .
Report has stated that some facilities
have had cases that have resulted in
payments um that have exceeded the time
required for those reviews . Can you
elaborate on the process in which
should be um you know implemented to
improve the delays and was Fort Benning
included in the review on this G . A .
O . Report ? Well ,
first I can't identify the military
treatment facilities that we included .
Our view . It was something that we
negotiated with our clients as part of
this review because it's important to
have some confidentiality so that folks
um the staff that we're talking to um
will be forthcoming in the information .
So um I can say that we did include of
the four facilities . Two of the
facilities were on the west coast and
one was on the east coast and one was
in the south . Um In terms of the
patient patient safety events that
resulted in um payment . Um
Those reviews are conducted by D . H .
A . Once the military treatment
facilities have determined that there
hasn't been a uh standard
of care matt D . H . A . has kind of
what I call two bites of the apple to
conduce some additional reviews . Um
and they have 270 days to conduct these
reviews . And um what we found as I
mentioned in my testimony about half of
the 12 cases that we included in our
review exceeded that 270 today
timeframe . Um and the range of days
that we found for those cases was from
420 days to up to 746 days .
Um And the clocks for those starts um
As soon as the payments have been made
either to the patient or the families
And quick follow ups , you mentioned
that you you reviewed four facilities
um Are the rest of these facilities
across the country being evaluated in
some way shape or form ? And are they
being graded on their performance by
these metrics ? Not as part of our
review . We limited our review to the
floor selected military treatment .
Only four . Um We made the selection
based on um one limiting it to so that
we're able to conduct the review in a
reasonable amount of time . Um We had
to look through a number of records for
to look at um all three types of
procedures . Um but we did try to
ensure that you know at least with the
providers , we looked at a sample of
100 providers . It was a non generalize
double sample . We took a sample of 25
providers from each of the four
military facilities and then for the
focused professional evaluations and
the patient safety events . We selected
the total number of patient safety
events that occurred at those four
facilities . Great thank you madam
chair . My time has expired . I yield
back The gentlewoman yields back . The
gentleman from California . Mr Sonja is
recognized for five minutes . Thank you
madam Chair and thank you to the
ranking member for having this hearing
and being so tenacious as you always
are . Mr Del Barra and Barbara and
family . Thank you for being here in
your courage . Dad , thank you for just
telling me your story as well . Mr
Lucky Derek . Thank you and your wife
and your family for having my staff be
part of your life . We talked about
this often . So tell me
how long was it before Daniella gets
sick and when she saw a doctor
uh Danielle
had been going back and forth to
medical I believe from
10 From 10
32 ah
man From 10 3 to 10 from
10 3 - 10 9 . She had been going back
and forth to medical and she
kept being turned away and I believe on
the the day she died . Uh
I need a few minutes was I as I
remember the story she was in for five
months . She was on the ship for two
weeks . 10 days , two weeks . Yeah she
was on she was on the ship for two
weeks and she became sick and she kept
going back and forth to medical for
several days until the day she died .
And that's when they figured out that
she had died I guess So Daniel um
Tell me tell my colleagues the story
about when she was lying on the ground
and one of the medical office one of
the medical shipmates said
Danielle was trying to get to medical
but the Corman would not help
her . So her sailor Brothers and
sisters . Speaker two to medical
because he could no longer walk . And
she basically laid on the floor . If
that wasn't for her Sailor Brothers and
sisters that's where she would have
died right there on the floor . So
you've you've heard from some of her
friends were on that ship at your house .
I was lucky enough to meet one of her
best friends . Tell us their side of
the story does not is not consistent
with the Navy side of the story of what
happened factually . Well I believe
Danielle was being evacuated
to another destination . But the
person who we spoke to said that she
they didn't see her get off the
aircraft . So
basically she died on the Reagan .
That's that's that's all . Um So you
mentioned in your opening testimony and
one of the things I think we need to
change on this is she was not in a
medical facility onshore in the United
States of America . So your claim was
denied because she was on a US Navy
ship . Is that correct ? That's correct .
And that's one of the things that needs
to be changed in this . That's correct .
The congress intended to bring justice
and accountability . The military
malpractice . However , D . O . D .
Went and narrowly interpreted your
intent by denying our victims that were
harmed on ships outside of the U . S .
This is not fair .
How did you feel when you found that
out ? I mean you sent your daughter out
to serve in the military and then on
this seems like a technicality . That
makes no sense . You couldn't seek
justice . No this could have been
prevented . This could have been
prevented . If they would have gave her
medical treatment . But even after that ,
your ability to seek justice with your
attorney has been difficult . It's been
very very difficult . Do you
know of any repercussions to the people
who were in the chain of command , Who
denied , were they promoted ? Do they ?
I'm pretty sure someone has been uh
how should I say this ?
No uh
promoted . That's correct . I believe a
lot of them has been promoted including
the captain of the Reagan Captain
Donnelly . I believe they have been
promoted and the other service members .
I believe they may still be in the
military to continue their career while
my daughter lost her life and her
career . Thank you . Mr . Lucky . My
time's up at your back . Thank you
madam Chair . Gentleman's time has
expired . The gentleman from Ohio Dr
went strip is recognized for five
minutes . Thank you . I just want to
express my condolences Mr Del Barba and
hello your family and our lucky family .
Um I just I just I want to say
that I thank you for being here today
and know that the effort will be
made from this end as best we can to
make sure that all of our troops always
have the right providers in the right
places with the right credentials and
the appropriate complement of all the
tools that they need treat people at
all times . So God bless you all your
in my thoughts and prayers . Now you're
back . The gentleman yields back . The
gentle lady from California MS Jacobs
is recognized for five minutes . Well ,
thank you so much madam chair and I
want to thank all the witnesses for
being here and telling what are not
easy stories to have to relive . And
I'm so sorry that you have to keep
doing it to get us to take action . MS
Silas , in a recent jail report that
was published on september 17th 2018
reported that MHS largely uses separate
measures for direct and purchased care
on its dashboards and tracks the
quality of care delivered by civilian
providers and purchase care in the
aggregate rather than individually .
The MHS lacks the information . It
needs to make comparable assessments of
the quality of care delivered across
the MHS as a whole to your knowledge .
Is this report still accurate ? And
what if anything has the military
health system done to overcome this
information gap ?
So to my knowledge , um I believe that
some of the recommendations are still
open from that review . I can't speak
directly to the particular
recommendations . Um But I am familiar
with some of the findings from that
report but I'm glad to take this for
the record and get back to you about
the status of the recommendations on
that and what progress has been made .
Thank you . I appreciate that . And um
one other question for you is in
reviewing these medical treatment
facilities . Clinical quality
management efforts . Has G . Io
discovered any reasons why facilities
are not consistently adhering to D . H .
A . Procedures . Okay . Yeah I mean
based on our preliminary observations
again this work is ongoing . It seems
to appear again that there's a lack of
clarity in the procedures . For example
we found that it's um some of the
language that's used in there in the
procedures are is not consistent . Um
There's also a lack of definition in
some of the facility staff um had
different interpretations of what was
initiation of a potential compensable
event and what was the the end of a
potential compensable event review . Um
And then there was just a general kind
of lack of awareness and a lack of
understanding of the procedures . Okay
thank you . Well I will look forward to
your answer for the record on my first
question and Madam chair . I yield back
The gentlewoman yields back . I'll now
ask questions for five minutes . Mr Del
Barba . Is it true that at one
point you were so depressed that you
attempted to take your life ? Mhm . No .
Yes . Uh November 12 , 2019 .
Which was um same year as the accident
happened and when
you were um
seeking care , your drill
sergeant was reluctant to take you . Is
that correct ? Yes correct .
So one of my drill sergeants
was notified by my peers in the
barracks that I was not feeling good
and that I needed to go to the hospital .
He proceeded to tell this battle buddy
that has he already got a sick call and
the battle buddy said yes a couple of
times and he said well there's nothing
we can really do and this was a 24 to
40 hours before my body went into
septic shock . So if I remember
correctly on friday you
went to sick call and complain about a
sore throat and pain in your legs . So
um thursday I went to sick call and
complain about a sore throat and pain
in my legs . I was swab for strep .
There's two types of swabs . They do .
One comes back Rapid test about 5-10
minutes . The other one takes 24-40
hours rapid test came back negative the
next day that 24 to 48 hour test came
back positive . However in the system ,
whoever wrote that note said , notified
monday in the morning and this was on
friday . They waited , they wanted it
was in your record at that . It was in
my record . Yes . And then on sunday
you went to the er and the doctor
showed showed you enough time , three
minutes to say that you were fine and
evidently didn't even look at your
record because it would have been in
your record , correct ? Yes , correct .
Um I did I went to the er doctor on
sunday february . Uh I want to say it
was february 9th 10th , february 10th .
Excuse me . Um And I saw the doctor
for each clutch clocked in and clocked
out for three minutes . Um That was the
time and he told me I was fine and that
my legs were sore , do the running and
he just prescribed me throat lozenges
for my sore throat . That is such gross
incompetence and it doesn't take
a Q AI for three years to determine
that that's gross incompetence .
Now , if I'm if
I'm not mistaken , if I'm not mistaken .
Um you also
were um mistreated by the
drill sergeant who forced you to go up
the stairs at the hospital , is that
right correct ? So um I mean
I I experienced a lot of bullying and
harassment from the drill sergeants um
that sunday when I went to the doctor
at sick call um there was it wasn't the
emergency room but it was up a flight
of stairs . My legs did feel like
sandbags and they were hurting , they
were in so much pain that I wanted to
take the elevator up . But you know ,
we as privates were advised to take the
stairs . So I literally had to have my
battle buddy carry not carry me on my
shoulder , but I had to put a lot of
weight on his shoulder just to get
those flights of stairs to be seen for
three minutes by this doctor and after
you were diagnosed with strep , was
there an outbreak ? Yes , correct . Uh
So on Tuesday february 19th martin Army
hospital Surgeon general . Lieutenant
Colonel Ethan Miles contacted my
parents . I was in a coma at this time .
Uh 56 positive cases in my company
bravo company 405 positive cases in two
brigades at Fort Benning . Fort Benning
requested requested an order of 10,000
units from Fizer at the estimated cost
of $1.7 million . Fighter told ford
bending . They only had 60,000 units
available for the entire world .
Christopher Private Christopher Hus who
was also in my company . He died
January 22 due to Sepsis . He had a
heart attack
again . Um Does your remarkable young
man and um this is such a gross
disservice to you and your family and
I hope that our colleagues who are here
listening to you recognize that there's
there are changes that have to be made .
Mr . Lucky . Um Did the Navy ever take
responsibility for their failures ? No ,
not at all . Did the Navy tell you if
they made any changes in response to
Daniel's death ? We haven't heard
anything from the Navy . Alright , just
for the record . Mr . Lucky . Um
There's something called legislative
intent and since I was the author of
the legislation , the intention was to
recognize that when you're not in a war
zone when you're at a military medical
facility , whether it's in the
countess or if it's in europe or if you
are on a ship , um you
should be receiving quality care .
If there is malpractice associated with
that care and you're not in a war zone ,
then you should be eligible for
compensation under the state school act
that was my intention . That's what
passed the House and the Senate and
became law . So if we have to clarify
that in the NBA this year we will
attempt to do that . MS
um Silas , am I pronouncing it right or
wrong ? Silas ? Yes , it's Silas .
Silas , thank you for your outstanding
work . I want to ask you a question If
it's been over 270 days and there is
a Q . A . i . There might even be too
cute guys that that are not in sync But
it's over 270 days . Is there a
requirement that it be reported to the
national database ? You're
muted ? I think . Oh can you hear me
now ? Okay . Yes , that's correct .
They need to be reported to the
national practitioner databank and
what's the the penalty of ? It's not
I'm not sure . I don't think there is a
penalty for it . Um Yeah . Okay . You
also referenced that In your review ,
you found selected facilities did not
adhere to the D . H . A . requirements
for these 19 potentially compensable
events . Event reviews in two key areas .
First , at the initiation of the
reviews , the selective facilities did
not document their consideration of
whether to remove the providers from
care and take adverse privilege .
Privileging action against any of the
providers in your review . So it wasn't
documented and you have no reason to
believe that there was action taken .
Is that correct ? That's correct . I
mean based on our review is the only
way because we're reviewing documents .
Um the only way that we know that any
consideration was taken is that it
needs to be documented and and it
should be documented in the file and
for all of those reviews , we did not
have any documentation of that
consideration of taking an adverse
privileging , privileging action or
pulling that provider offline . And
whether it was actually a com
compensated Evette or an a
potentially compensable event , it
should be documented
and there should be an effort made to
assess whether or not the provider
should be removed from providing care .
Exactly . Because even the patient
safety events that result in payment ,
they start out as a potential
compensable events so that that
consideration should always be taken .
Alright . I thank you . I have exceeded
my time . Um we will now
thank all of our witnesses who have
done a remarkable job under I think
very painful circumstances . I think
you've heard from every member on this
committee that we are deeply troubled
by um the events were saddened by
the loss of Daniel's life . It was an
unnecessary loss of life . It was not a
complicated , complicated set of
circumstances and to mr dale Barbara ,
um what you've endured is
just unforgivable and
uh I just hope the rest of your life is
everything you wanted to be and I hope
by virtue of both of your experiences
here today . Um that the military is
going to recognize it has an obligation ,
has an obligation to communicate with
the families and the service member who
had been injured or there's about a
loss of life . There has to be more
transparency . And we've got to make
sure that we have quality care
provided to our service members . Um ,
it's just fundamental to everything
that we believe in . So again , I thank
you . Um we're now gonna recess for
just a few minutes to allow our next
panel . Excuse me , Can I read this
place ? Mr . Lucky , yes , I have this
here . This is the the Corpus Men's
Hospital pledge . I solemnly
swear myself before God
and these witnesses , These corpsman
raised their right hand .
I solemnly pledge myself before God and
these witnesses to practice faithfully .
All of my duties as a member of the
hospital corpsman . I hold the care of
the sick and injured to be a privilege
and a secure trust . And I will assist
the medical officers with loyalty and
honesty . I will not normally permit
harm to come to any patient . This is
what they did to my daughter . I will
not partake nor administer any
unauthorized medication . I will hold
all personal matters pertaining to the
private lives of the patients in strict
confidence . I dedicate my heart , my
mind and strength to work before me .
I'll show do all within my power to
show myself an example of that
is honorable and good . Throughout my
naval , my naval career . My daughter's
career was taken from her while these
people here continue with their lives
in their career . Thank you .
Thank you . Mr . Lucky . Thank you both .
We are now going from our 2nd panel .
Lieutenant General Ronald Place ,
Director of the Defense Health Agency .
Lieutenant R . Scott Dingle , Surgeon
general of the Army , Rear Admiral ,
Bruce , Gillingham , Surgeon General of
the Navy . Lieutenant General robert ,
I . Miller , Surgeon General of the Air
Force . Welcome .
Mhm .
Lieutenant General Place . Do you want
to begin ? Chairwoman spear ranking
member Gallagher , distinguished
members of this subcommittee . I'm
honored to represent the Defense Health
Agency and it's dedicated military and
civilian medical professionals in the
military health system . In describing
our comprehensive enterprise approach
to ensuring high quality of care in the
military health system . The NHS
However , before doing so , I've added
some handwritten comments if I could
because I think it's important for me
to address Mr Del Barba And the Lucky
family . Your testimony today was
compelling and heartbreaking . It's
clear that you've suffered tremendous
losses and I apologize for those losses .
I take it very seriously when they're
bad outcomes from the medical care
provided within our system . I'm deeply
committed to ensuring we learn from
your losses so we can better our health
care system so we can have fewer losses .
My goal is to make this health system
stand as one of the finest , if not the
finest in the nation and those who
serve their country should expect that .
I say this not only is the leader of
the defense health agency , but as a
husband , a father of two currently
serving service members and grandfather
has found family also receives their
care in our system . You have my word ,
madame Chairwoman . The DHS now
exercises authority , direction and
control over all MTs . Worldwide
quality starts with the individual
medical personnel . We recruit and on
board every day . The credentialing and
privileging process serves as the
foundation for high quality and safe
care by ensuring qualified and
competent staff deliver care in a
manner consistent with their education
and training the D . H . A . Overseas
accreditation and certification for
hospitals and clinics as well as
specially specific certifications and
quality assurance programs . In fact ,
the D . O . D . Participates in
multiple civilian accreditation
programs and has held to the same
standards as our private sector
healthcare colleagues . I mentioned
just a few of those programs here .
While my written testimony provides a
more comprehensive list . The D . H . A .
Manages an enterprise level contract
with the Joint Commission for all MTs
and all D . O . D . M . T . S . Are
fully accredited at the specialty level .
The MHS participates in numerous
voluntary healthcare collaborative that
helped drive improvement , allow us to
compare our performance with others .
These include the national surgical
quality improvement program . This quip
a collaborative led by the american
college of surgeons . The National
perinatal Information Center and pick
the consortium of more than 80 health
systems with high volume obstetric care .
The list goes on and on from
laboratories to blood banking pharmacy
programs and so much more for patient
safety . R . D . H . A . Programs
similarly incorporates strategies and
practices from the private sector and
uses widely accepted measures for
performance . Over the last four years ,
the duty has seen improved patient
safety performance . Again , specific
performance improvements were noted in
the testimony submitted by the
department while I'm confident in our
processes for ensuring high quality
care and proud of our performance as
measured against peers in american
medicine . The department also has
clear policies and procedures in place
when patient safety incidents occur .
The department has taken steps to
methodically implement Section 7 31 of
the Fy 2020 N . D . A . Which amended
the military claims Act by allowing
members of uniformed services or their
representatives to file claims for
compensation for personal injury or
death caused by the medical malpractice
of a . D . O . D . Healthcare provider
in an empty F . And those claims where
a claimant disagrees with the
determination . We have an appeals
process with appeals board members who
have no prior connection with the cases
they're reviewing in cases where a
military medical malpractice claim .
Active duty , disability or death
payment is made . Additional reviews
are required by the D . H . A
headquarters including an external peer
review and specialty consultant review .
Following these additional reviews , I
am responsible for rendering a final
provider determination and reporting
decisions . The department is grateful
for the support and oversight from this
subcommittee on patient safety and
quality of care programs in the
military health system . We're
confident that recent changes put in
place within the NHS properly respond
to both the spirit and letter of
legislatively directed changes and will
continue to closely manage these vital
programs on behalf of the service
members and families were privileged to
serve . I appreciate the opportunity to
appear before you today and I look
forward to your questions . Alright ,
Lieutenant General Dingle , chairwoman ,
spear ranking member Gallagher and
distinguished members of the
subcommittee . Thank you for the
opportunity to speak to you on behalf
of our armies health professionals .
The committee's investment combined
with the army's deliberate emphasis on
patient safety enhances medical
readiness and I thank you . I
appreciate the first panel expressing
their personal stories and testimonies
it resonated because people are our
number one priority . My unwavering
commitment as the 45th Army surgeon
general is to ensure the health and
safety of our soldiers and families
first and foremost , maintaining the
confidence at military treatment
facilities or at our operational sites
requires a dedicated total Army
medicine force . This is about taking
care of our people together with the
Defense health Agency . We will , we
will accomplish these goals By focusing
on advancing towards zero preventable
harm and the delivery of medical care
As a key enabler . Army medicine is
committed to our high reliability
organizational mission in the
operational environment and the core
competencies of patient safety in
conjunction with the Defense Health
Agency . We are advancing toward zero
preventable harm through training and
oversight across the continuum of
healthcare to maximize reduction of
medical risks . Army medicine is also
synchronized with the Defense Health
Agency to meet the needs of the
operational force . From the fox hole
to the fixed facility . Army Medicine
follows one Clinical Quality Management
Standard . The military departments ,
operational units and the medical
treatment facilities are inextricably
linked . The medical treatment facility
is the premier readiness platform for
our medical personnel to hone and
sustain the mission essential clinical
skills needed to perform their duties .
Downrange my enduring responsibility is
unchanged to exercise my duties as the
Army Secretary , senior medical Advisor
and medical Integrator . By certifying
army healthcare capabilities are
trained and ready . Are the medicines
focus has pivoted to the operational
medicine but we will ensure operational
standards are in accordance with the
policies , guidelines and procedures .
Patient safety is essential for a
strong , healthy and resilient army and
is the most critical indicator of our
readiness to deploy , fight and win our
nation's wars . In closing Army
medicine is committed to people First
we remain vigilant as we strive towards
reduced preventable medical errors . I
appreciate the subcommittee's work and
the continued support to our soldiers ,
families and your long standing support
to Army and the army medicine . Army
medicine is army strong . I look
forward to your questions .
Thank you , Chairwoman spear first and
most importantly , Mr Lucky and Mr Del
Barba , thank you for your powerful
testimony . I know this wasn't easy and
that we are grateful for the courage
you demonstrated . I learned a lot
listening to your statements and as the
leadership of the military health
system we needed to hear from you to Mr
Lucky and the Lucky family , you
suffered a profound loss with Daniel's
tragic death . I know you continue to
grieve . I want you to know that we
Daniels . Navy family mourn her passing
as well . The loss of a shipmate and
family members heartbreaking and
impacts all of us who serve in
America's Navy Madam , Chairwoman ,
ranking member Gallagher members of the
subcommittee , thank you for conducting
this hearing on patient safety and
quality of care . You rightfully hold
us accountable to provide service
members and families healthcare that is
high quality , safe and accessible
please . No , we never waver from our
commitment to protect the health of
those who go in harm's way as part of
our solemn obligation to the sailors
marines and their families . We are
continuing our strong commitment to
high reliability within navy medicine
appropriately in conjunction and
collaboration with the Defense health
Agency , Army and air Force , high
reliability practices are critical for
success and high risk Navy environments
such as submarines aircraft carriers
and diving operations in order to
enable teams to avoid the detrimental
impacts of mistakes . We have emulated
their example within the military
health system because we recognize that
the three H . R . O . Pillars ,
leadership , engagement , continuous
process improvement and a culture of
safety directly translates to better
outcomes and the sustained delivery of
high quality paper patient care for me .
This commitment to HR was deeply rooted
in my early professional development .
As a pediatric orthopedic surgeon , I
was mentored by highly regarded Navy
orthopedist Captain john Webster who
demonstrated high reliability in all
aspects of patient care . In my view ,
he was ahead of his time into playing
key principles of safety and quality in
the operating room . But he also
recognized that he couldn't do it alone .
He knew that patient care and the
relentless pursuit of better outcomes
and fewer errors is interconnected and
complex and involved teams of people ,
people working together in a culture of
trust cooperation and mutual respect
for a common purpose and I should add
all empowered to speak up about issues
impacting the safety of the care we
deliver . I have seen the powerful
impact of high reliability throughout
my career as a surgeon operating in
commands such as Naval Medical Center
san Diego in combat where I lead a
surgical shock trauma platoon in Tacoma
Rock During the 2nd Battle of Fallujah
in command of military medical
treatment facilities with large medical
staffs and as the fleet surgeon guiding
the provision of care on the naval
operational forces Now in my current
role as the Navy surgeon general ,
These experiences inspire me to broaden
and deepen our efforts to eliminate
preventable patient harm for Navy
medicine . High reliability represents
a commitment to safety , quality
resiliency and operational success
wherever , wherever naval forces
operate . To this end , we established
the Navy Medicine Quality and Safety
Leadership Academy specifically
equipped our leaders with a charro
tools to communicate , anticipate ,
identify , resolve and then ultimately
rapidly share and apply the lessons
through the enterprise . Our providers
are expertly trained and we hold them
accountable for the care they provide .
We do rigorous work including provider
credentialing , privileging patient
safety reporting and other critical
components . Following the requirements
specified in the clinical quality
management program as well as in
compliance with other applicable Navy
directives . We recognize that we
cannot completely eliminate all errors ,
either human or systemic , but we must
be persistent . Are rigorous self
assessment , rapid cycle feedback and
high velocity learning to continuously
improve as a high reliability
organization privileged to care for our
nation's war fighters and their
families . We can never be content .
Gentlemen , spare , thank you for your
leadership in this area and look
forward to your questions . Good
afternoon , chairwoman , spear ranking
member , Gallagher and distinguished
members of the subcommittee . It's an
honor and a privilege to appear before
you today as a surgeon general of the
Air Force and Space Force to discuss
Air Force medicine , clinical quality
management processes and functions to
include patient safety and health care
risk management . Before I continue , I
also want to thank Mr Del Barbara and
Mr lucky for their testimony , I want
to reiterate my commitment to patient
safety for all military health system
beneficiaries . We started our journey
towards becoming a high reliability
organization in 2015 when my
predecessor , Lieutenant General Mark
Edgar , launched the trusted care
program . Even now , high reliability
remains the foundation for the care we
provide . Additionally , we remain
partnered with the Defense Health
Agencies . High reliability efforts .
Together our processes ensure a culture
and practice of safeguarding patient
safety in the operational and non
operational environments . Today I
would like to highlight two aspects of
that collaborative partnership towards
quality and safe patient care . First ,
the FMS clinical Quality Management
transitioned to the D . H . A . And
second , the FMS operational Quality
program . Due to the D . H . A .
Transition , the Air Force Medical
Operations Agency , Legacy Clinical
Quality Quality Management Office
transitioned from a large organization
that supported 76 military treatment
facilities all downrange facilities and
patient transport missions to a
streamline office supporting the
operational environment . Currently our
clinical quality management division
falls within the Air Force medical
readiness agency or Acura and has been
renamed after Maria Operational Quality .
This support now focuses on our
deployed facilities and air medical
transport capabilities . I'm happy to
report the Air Force operational
facilities comply with D . H . A .
Clinical quality management Procedural
manuals . Additionally , the Air Force
quality policies have been updated to
align with the D . H . A . Procedural
manuals . The Akron operational quality
division is focused on development ,
implementation and sustainment of
clinical quality management procedures
and guidance for safe and quality
healthcare and operational environments
are patient safety and health care .
Risk management teams use proactive
assessments to reduce risk and harm
across the enterprise as well as afford
an analysis of events to identify gaps
in health care , delivery and
mitigation strategies to prevent future
harm , mitigation and reduction of risk
in the delivery of operational health
care is paramount . Proactive
management of safe and quality care
includes review of joint patient safety
reports from our downrange and patient
transport environments to develop and
improve processes to reduce the
potential for harm in the deployed
environment regardless of location . If
a patient safety event occurs , the
event is entered into the joint patient
safety reporting system . These can be
events that could have caused harm and
did not reach the patient or one that
caused harm by reaching the patient .
In either case , an event review occurs
through an analysis of the healthcare
delivery process with the aim of
identifying the gaps that contributed
to or directly caused the event .
Additional healthcare risk management
activities involved a review of the
care that was delivered . If the
standard of care review identifies
potential misconduct , a significant
deviation from the standard of care or
other significant concerns , then an
adverse action to hold the involved
provider accountable is pursued in
summary FMS remains committed to being
a high reliability organization and is
committed to maintaining the quality
and safety of care delivered in the
operational environment . Our program
focuses on risk mitigation ,
transparency and delivery of trusted
care anywhere . We work hand in hand
with the defense health agency ,
culture of learning and safety is
paramount to the success of our
operational quality program . R . A . F .
M . S . Team is working to ensure our
airmen and guardians get the safe ,
high quality health care they deserve
and I remain dedicated to safeguarding
that diligence as their surgeon general .
I look forward to your questions .
Thank you . Thank you all . I'll um
resist asking my questions until the
end . Um ranking member Gallagher ,
you're recognized for five minutes and
I would like to yield my time to the
gentleman from Ohio dr Wernstrom dr wen
strip your recognized . Thank you madam
Chair and thank you ranking member for
the opportunity to participate in this
today . And I want to thank our
witnesses here today for being here .
Um I uh personal point of
personal privilege if I can . General
Dingle , I want to thank you for your
opening up the opportunity for the
service members uh to be able to
converse with you uh with my expansion
of your consultant program and I want
to , I want to thank you for that . I
think it's been a great opportunity for
us and for the for army medicine . Um
you know , the Mh , as a vital
component of our National Security
Strategy , there's no doubt about it .
It needs to be . And the Defense Health
Agency is a critical element of the MHS .
It was established as part of a larger
effort to reorganize military
healthcare programs and and services .
We've learned a lot in the last couple
of years as well . I think through
covid population medicine is extremely
important in the military . We need to
preserve that . And there are concerns
that the Congress has tasked D . H . A .
With increasing responsibility despite
it's being limited by its construct as
an integrated Combat support agency .
And I've been working on this issue for
several years now . Um you know , even
after leaving this committee , but as a
surgeon who serve reserve and active
personal experiences as as a surgeon
conversations I've had with active and
retired officials , uh some that sat in
your seats um experiences in private
practice uh grown some concerns with
MHS transition . I think a lot of
people have looking at further changes
in the MHS . I think we need to ensure
that we're able to provide . Um What we
often hear is the medical medically
ready force and a ready medical force
operationally and all the while
preserving population health for
service members , their families at
home and abroad retirees for that
matter . Uh So we want to make sure
that we are not sacrificing readiness
for population health and make sure
that we can do the best of both . Ah
So through the experiences and
listening to many stakeholders , I
think that we
could greatly benefit the MHS and all
the patients in their care with a
functional specified command is what I
call it . And if I could , I would like
to submit for the record some of what
we have worked on involving the
military health system and possible
reforms to it . Uh certainly this isn't
cut and dried . Um but it offers a
specified command , three star command
that I think would potentially make us
all more functional across everything
that we're trying to achieve . And I
certainly would want input on that from
each and every one of you as I have
sought some of that already . As you
know , um you know , I know that some
of the concerns that we have came from
Congress and I remember it a hearing
with uh previous surgeon general , your
predecessor , General Dingle where we
were discussing as we , one of the
members was reading a letter from
combatant commanders saying this is
going to be difficult for us to really
challenge that . We're worried about
this . And General West said , well
we're just doing what Congress asked us
to do and that's why I want to engage
from this end because if we're asking
some things to do maybe good intentions
that aren't necessarily the best for us ,
you know , where do we go from there
and how do we make a difference to make
your life easier and more productive .
In many ways we want flexibility . We
want the services to be able to weigh
in a compass across all compositions .
We have joint situations , we have
service specific situations , reserve
flexibility or you backfill ru
operational , are you both ? And uh
certainly respecting the value of R . M .
T . F . S . And I think that's an
important thing . So we want to enhance
also opportunities between military and
civilian um operations where we can
learn to train each other and we see a
lot more of that happening today ,
which I think has been very , very
helpful . Um I guess in the time that I
have , I'll just go with one question
with the understanding that each
service has unique needs . How would
you describe for us ? That's the level
of ownership you have over the
personnel and medical training
readiness within each of your services .
Representative wisdom about I'll start
from the army , I own the soldiers ,
I'm responsible for their readiness ,
trained and ready for us . And I do
that through what we call individual
critical task list . So for every
specialty I am responsible to make sure
that that soldier can perform his or
her duty . Uh not just in the fixed
facility where we um sharpen the acumen
but also downrange in the operational
environment . So I do have control over
those soldiers to ensure the readiness
and in conjunction with the Defense
Health Agency . I leverage internal
training Cross Lebanon as well as
military civilian partnerships .
Thank you congressman . Similarly in
the Navy my responsibility is command
and control of all naval medical forces
um within our uh medical force um
and demanding training and equipping of
them to make sure they're ready to
perform . Downrange . Um We have found
that by establishing naval medical
readiness training commands within the
MTs to oversee those responsibilities
uh in conjunction with the D . H . A .
As a training range that that model is
working well albeit um some growing
pains . But we continued to collaborate
with the DHS to make that successful .
Thank you congressman and similar for
the Air Force . Um I would say that as
we focus on organized training and
equipping our force and especially our
medics um R . M . T . S . Are our
readiness planning training platforms .
It's the focus sometimes we do need to
uh go to civilian facilities as needed
uh supplement that training . But the
preference is always to work within the
military training facilities . Uh That
training starts at Mezey for enlisted
medics different for for the officers .
And and I would also like to comment
that it's more than just the active
duty . It's Total Force , it's the
Guard , its reserves and and you put
that whole team together which is
critical to make sure that we're
delivering that trusted care across
across the globe ,
they mentioned working with D . H . A .
I think that's an important component
of that company . Yes sir , as already
indicated by the three surgeons , the
services control the forces . We are in
dialogue about how they might help
within the MTs . But the services
control the forces . Yes .
Gentleman yields back . Uh the
gentleman from texas dr Jackson is
recognized for five minutes . Thank you .
Um I just want to briefly say as a
relatively new member of Congress and
and new to this subcommittee as such .
I'm looking for opportunities to make a
difference . And I'll tell you the only
physician on this subcommittee and as a
career Navy emergency medicine
physician , I think that this is an
area anything all these issues
involving military medicine is gonna be
one of the main areas that I'm that I
intend to focus on for my foreseeable
future here in Congress on on having a
big impact . I just think that
everybody needs to pick their niche . I
think that my uh this this will become
my niche in this subcommittee . And so
I say that because I uh you know , just
looking and Per per last year's budget ,
almost 8% of the D . O . D . funding
was dedicated to the military health
systems . That's quite a lot . And I've
been trying to you know , figure out
where where can I make an impact in
military medicine . And I start by
saying that I'm not doing it to to
shake anything up or to identify any
problems I'm doing it to uh as , as
somebody who comes from your community
to find ways that I can help you make
military medicine better for all of us
because just like general place was
saying , I too have family members
including a daughter , a son and a
daughter in law that are on active duty
as well . And I want their career to be
fulfilling and I want them to get the
medical care that they need in the
process and be ready to fight and do
what they have to do as well . So , uh ,
I I approach it in that regard and I've
had the , the uh , the honor to spend a
little time with General Miller and I
really enjoyed that sir . And I think ,
I think you've got a great attitude and
I think we're going to work together .
Well , I'm gonna enjoy working with you .
I I personally know Admiral Gillingham
pretty well and he's a , he's a , he's
an aggressive and well respected leader
in Navy medicine . I hope to get to
meet to get to know the two of you a
little bit better as time goes on . But
my question would be , I guess in
general , you know , I , uh , and , and
I'm trying to figure out exactly where
we're at in the general process because
I was , I was on active duty back in
2012 , 2013 , whenever DHS
came about and the the branches were
trying to figure out how , where
everybody fit in and how it was all
going to work and I know it was a mess
to start with and you know , right ,
you know , you would assume that it
would be with an organization the size
of , of military health care , you know ,
trying to come together and just
completely restructure . I know that
there was some growing pains early on .
I'm assuming that a lot of that stuff
has been overcome . I have been going
out and trying to be active and and
figure out exactly where I can have an
impact and what's broken and what I can
help fix from here . And I've been to
san Diego , I've been to walter reed .
I've been out to Brooke medical our
Brooke army Medical Center . So I'm
making my rounds and I'm gonna continue
to do that . I'm gonna continue to
visit as many MTs clinics and things as
I can to continue to ask people what's
working , what's not working as a
member of congress , what do you know ,
what would you like to see me work on ?
What would you like to see me help you
fix on and so forth ? But I ask you
guys that as well and I'm sure that the
stuff that , that that comes to your
level might be different than the stuff
that that's happening , you know , with
the , with the folks that are on the
ground , some of the doctors and nurses
that are , you know , um directly
taking care of patients . Uh , but I
will say that , you know , I still
think that there's a little bit when I
talk to folks , uh and and I'm hoping
that , you know , try to disarm people
as much as you possibly can when you go
into these situations . Especially , I
don't think of myself as a congressman
quite honestly , at this particular
point , I just when I get back in the
military M . T . F . I feel like , you
know , You know , that's this is where
I've been for the last 25 years . I
don't feel like , you know , I'm out of
place , but I think a lot of people are
hesitant to talk to me about certain
things . And I get a lot of people that
are just like , well , everything's
fine . We don't need any help , you
know , you know , but I get the sense
that everything might not be completely
fine , there may be issues , but I
don't know what they are . So , my
question to you all to start with would
be what's working and what's not
working with the transition and what is
a member of Congress on this
subcommittee that deals with military
health . Can I do to help you guys
facilitate your to to make military
medicine is absolutely to make it the
absolute best that it can possibly be
well represented . Jackson . Thanks for
the discussion and the question , uh ,
knowing how all the process works , the
legislative proposals have , you know ,
they're working their way through and
be and you'll see them . Um Yeah , I
think all of us will say that we are
working way better today than we did a
year ago and I think we'll say that
we're working way better a year ago
than we were three years ago and way
better three years ago , five years ago .
So I think you'll see a united
organization here between all of us and
the organizations that we lead . I
think that that that the best
discussions are often held informally
as a as a as a methodology of
organizational ideas exchanging . So I
think I I speak for myself when saying
I look forward to getting to know you a
little bit better as well and how we
can have those discussions but I don't
have specific things that I would
recommend that you address today along
those lines and represent Jackson . I
would add that . Um we are not where we
were and we are moving the ball down
the field . However , there are
challenges that we are learning and so
we're in the assessment phase because
this is new . Um we as as a team from
the director and all the surgeon
general's working together to implement
the law as well as diode policy . We
are learning Discovery learning as we
go through to include the initial
question for representing one strip
about readiness and as I assess the
readiness of soldiers . And so I I had
to welcome you know , the discussion um
you know um at the same time um
imperative that we give the opportunity
to uh do a D assessment internal as
well as external . And then as general
place mentioned we are using the
legislative proposal process uh through
the Department of Defense for the
initial ones . Thank you
Admiral . I'm a congressman Jackson for
that question . Um I would say us
specifically what's working I think um
Covid taught us the power of our
unified approach . Um The D . H . A .
Did a terrific job interacting in the
inter agency . Typically as we got
ready for vaccine distribution and then
working closely with with them , we
were able to translate that into our
unique operational environments . Um I
think that rapid cycle feedback uh that
uh General place has spoken about in
terms of the practice management
guidelines for the treatment of COVID ,
which is now in its 8th edition
demonstrates demonstrates the power of
having a you know , a large central
organization that can collate that
experience and then allow us to to
execute through our respective services .
So I to welcome the opportunity . I
think we'll be speaking next week . I
look forward to that sir and appreciate
your support and advocacy . The
gentleman's time has expired . Alright ,
um let me start off with
Admiral Gillingham , you heard um Mr
Lucky talked about the loss of his
daughter . What have we
learned from the loss of her life ?
What has the Navy done
differently because she received such
incompetent care . Thank you for that
question madam . Chairwoman . I can
assure you that Navy medicine
investigated the facts and
circumstances surrounding semen Lucky's
medical care that we examined lapses in
systems and protocols that we made
standard of care determinations but
that we developed improved processes
not just aboard Uss Reagan but but we
shared those throughout the fleet and
across our medical treatment facilities
and with the D . H . A . And that we
have addressed the accountability to
involve care providers . We have grown
as an organization due to that
unfortunate Travis . Can you be
specific about what changes have been
made in terms of providing medical care
on ships ? Certainly . Um We um
we developed a fleet wide sepsis
screening . Uh so when an individual
comes to sickle aboard ship , the
Corman can use that screening tool to
detect whether there are risk factors
for that individual to develop sepsis .
In addition then the treatment protocol
that follows should sepsis be
identified and that that has also been
shared with our MTs we implemented a
process , we call surge which is
supporting urgent responses across the
global enterprise . These are reviews
that go to a site if there has been an
event , even potentially near misses so
that we can learn the maximum from
those cases and apply that . And we
also have deployed the joint patient
safety reporting system across the
fleet and in our all of our operational
environments . Thank you . Lieutenant
General Dingle since um Don't
Mr Del Barbas incident . What changes
is the army made and how they care for
service members and training units
represents spear , you know , again ,
not to repeat what Rear Admiral
Gillingham said . You know , we have
conducted all of those investigations
in conjunction with the Defense Health
Agency , the lessons learned , the
clinical practice guidelines . Uh not
just at that location but across the
military health system we work through
and with the Defense Health Agency
because it is I understand all of that .
I want to know what you've done
differently . What's pretty clear to me
is that the likelihood for um whether
it's strep or sepsis is
much more likely in a setting where you
have people living very close together .
It appeared that in the case of Fort
Benning there wasn't enough antibiotics
to provide to the other service members .
So how are you anticipating that ?
Earth and Spirit ? If I can take that
for record , um I can give you much
more detail than the numbers and what
we have done as I synchronize that with
the Defense Health Agency . Alright .
In in all of your settings . Um spinal
meningitis is um much more prevalent
and spreads much more quickly in living
situations where people are close
together . It's um it happens in
college campuses um and it can happen
in a setting where you're on a on a
ship or in close quarters in the
barracks have all of the service
members upon um participating
in basic training receiving the
the actual shot . I guess it's a
vaccine . I'm not sure . And we are we
haven't started the minister and that
I'm sorry you have started doing that
man . We have stopped for a period at
that location and then re implemented
through the lesson learned from this
incident . So are are all
basic training recruits actually
receiving that kind of a vaccine ? Yes
ma'am . penicillin and how about in the
navy ? Yes ma'am . To my knowledge , we
are doing that . General miller Air
Force . Yes , ma'am also . All right .
Um
General place in your opening comments ,
you reference the goal of the
D . H . A . Is ready , reliable care .
And that struck me kind of um oddly
reliable is not quality ,
reliable is not comprehensive ,
Reliable , arguably could be three
minutes in the er So
why is that word used versus one that
kind of emphasizes quality . The use of
the word reliability is , is taken from
high reliability concepts to become a
high reliability organization and the
tenants of high reliability is , is
where that word is coming from . Well ,
I would recommend that you re evaluate
that
your we've all heard about the J . O .
Study . It's preliminary in nature .
The one question I didn't ask Miss
Silas is what grade would you give
These services based on the fact that
16% of the credentials of the
healthcare professionals are never
verify , never confirmed . Now that
falls under you . Lieutenant general
place , that's your responsibility .
You can delegate it . But the fact that
16% haven't been looked at should send
alarms , does it not send alarms to you ?
Congressman ? The alarm uh
is always on . I mean the the depth and
breadth of the requirements that uh the
GTO study is looking at is significant
and and quite honestly , I'll agree
with the preliminary results that she
described you . I think those are
accurate but I'm not sure that the
characterization that you're making is
as accurate as it could be . And here's
what I'm saying that one of the
examples and I happen to know some of
the preliminary results that she was
describing When it came to licensing
the specific case that she's talking
about . That particular provider had 10
licenses , 10 and eight of them were
primary source verified . Now is the
requirement to do all of the answer is
yes . Should we have done better . The
answer is yes . But I wouldn't infer
from that that there's no checking for
the licensor of the providers . Well ,
I mean the fact of the matter is I wish
she was still here . There were 100
cases pulled at four installations And
of those 100 Records , 16 of them had
not been verified . Now in this one
you're referencing that eight of the 16
licenses had been of this one person .
But I think the expectation is that
we're not credentialing , we are not
allowing anyone to provide health care
to our service members unless we have
verified their credentials . So if you
need more staff then you should tell us
do you need more staff to complete that
function ? Uh At this point I think it
would be premature to say that . And
that gets back to the the other comment
that she mentioned , the quality
requirements that we have now that I
signed out as one of my first acts as
the director of the Defense Health
Agency in october of 2019 was a market
expansion of the clinical quality rick
requirements massive . And we are still
in the process of implementing all of
them perfectly . And quite frankly , I
think the help of the G . A . O . To
help us see ourselves better where
we're not meeting those expectations .
My expectation is to be perfect . Okay .
So she's also said very clearly that if
A Q . A . I takes more than 270 days ,
you're supposed to report it to the
national practitioners Databank bank .
Have have you done that in all of these
cases ? No , ma'am . Not in all these
cases and why not ? Part of the reason
the clock starts when the payment is
made ? Not when we find out that it's
not right . That is actually not right .
It starts on day 270 whether you've
completed the Q . A . I . Or not .
I understand that . And there are cases
where you do not compensate but they
are compensated Ble but have not been
reviewed for whether or not that
practitioner should no longer be
providing services . I think we're all
interested in the same thing . We don't
want practitioners out there providing
services to our service members who um
either need more training or have
forgotten their training or just are
not good physicians or healthcare
professionals correct ? Yes , ma'am
agreed . So it seems like we should be
checking their credentials , we should
be reporting it to this um data bank
and we should be evaluating whether or
not they should be put on
administrative leave pending the
results of the cases . I mean when ,
when a police officer shoots his gun
and someone dies or is injured , they
are immediately put on administrative
leave . While there is an investigation
that's undertaken in many of these
cases , these practitioners continued
to practice and some were even promoted ,
correct ? I don't know the details of
all the cases were describing , but I
can see how that would happen . Yes ,
ma'am . Alright . Um
so my understanding is that whatever
the gao report finalizes , you are
going to embrace it and you're going to
make the changes necessary to comply
with it . Absolutely . Yes , ma'am ,
the the personnel performing these
guys , How are they selected ? How do
you ensure their independence from
command influence or personal loyalties
within their unit . Is that a question
for me ? They're not a part of units .
The headquarters people that I have are
are not associated with units . Okay ,
so the question is how do you guarantee
that this kind of review that's being
done is by persons that are independent
from different facilities ? Don't know
the provider that's being reviewed .
How do you make sure there's not a
conflict of interest ? Well , exactly ,
as you described at first , they're not
part of the same unit . And and the
panel that we use within our
headquarters is not associated with the
health care being delivered . Similarly ,
we use a uh commercial program , a
commercial company as an independent
second opinion for these cases as a as
another independent way of evaluating
them . So when do you send cases
for external reviews ? So the status ,
what's the determination is made if the
if the local level says status or
standard of care met um than those go
to an external peer review . If
standards are met ? If we say
internally in our evaluation of the
standard of care is met . Those are the
ones that are sent to an external peer
review . So it's not just well we all
got together and you know , we're all
together here . So no nothing to see
here . If we determine internally that
standard of care is met , then we send
it to an external peer review . How
many QA eyes has the department
completed over the past three years ,
Man ? Because of Title 10 . I can't
tell you that in this forum . I'm happy
to provide that to you . Um , offline
as your status as chairman . Okay .
Would you do that please ? Yes , ma'am .
And then also provide to us how many
found that the standard of care was not
met and how many providers were
reported to the national practitioners
database for failing to meet the
standard of care ? Yes , ma'am . I'll
give your staff for the specific
questions will provide that . All right .
Those are my questions . Anything else
anyone wants to add ? All right . We
thank you very much for your service
and for being here today , we've got to
get this right . Those two
results are untenable . I think . You
appreciate that . I hope that you will
redouble your efforts with that . We
stand adjourned .