PI initiative yields impressive turnaround

Teamwork, persistent monitoring key

Not too long ago, Irwin Army Community Hospital, in Fort Riley, KS, had an obvious quality issue; more than 30% of its "board" results — results used to determine if there are adequate medical reasons to "separate" a soldier from the military — were being returned, which in many cases required a repeat of the process.

Now, the facility is basking in the glow of receiving a top U.S. Army Surgeon General's award — the "Excalibur" — for its success in improving its process and decreasing the rate of returned board packets. "Currently, we have the best return rate in our region, at 3.7%," says Mark Rivera, chief of the patient administration division.

"The physical evaluation board [PEB] is a process to serve the soldier and the army — for a soldier injured in the line of duty," Rivera explains. "When they have a condition that fails retentions standards, they can't go on with a military career. The military has a process by which the soldier is evaluated and awarded a pension."

At the medical treatment facility, or MTF, level, a physician will evaluate the soldier and complete a medical report stating he or she either met or failed retention standards. Then, physical evaluation board liaison officers, or PEBLOs, gather the required documentation for the medical evaluation board, or MEB. This includes clinical, administrative, and performance data.

Once that is completed, the packet is sent to the Fort Lewis PEB, which reviews all boards for the region. "They adjudicate and determine if the soldier is fit or unfit," says Rivera. "If they are fit, they return to duty; if unfit, they determine if they are eligible for compensation and the percentage of disability. This comes to us, and we advise the soldier of the findings." For those facilities that submit boards to the Fort Lewis PEB, Rivera adds, the returns are expected to be no more than 10%.

For what reasons are these boards returned? "If the packet is missing information, or if additional physical conditions need to be addressed before the higher echelon can make a decision, they kick it back to us," says Deanna Wolnik, chief of quality management in the clinical operations division. "The packet might be missing some administrative information related to the soldier or their medical condition, or it may not have contained enough justification by the providers."

When boards are returned, she adds, "it results in delays in processing the service member, which is a disservice to them; potentially, we have to redo the board or parts of it, so it is sent back to the physicians, which results in added costs to the facility and the government."

Addressing the problem

In order to address the situation, "we brought a team together that included the deputy commander of clinical services of the hospital; our MEB physicians; our MEB nurse; the physical therapy clinic; the behavioral health clinic; the PEBLOs; and our contact representative support staff as well. It was definitely multidisciplinary," says Rivera. The team came up with several recommendations.

One of those recommendations involved after-action reviews. "In the past, when a we got a case returned, that return letter went to whoever's case it was — one PEBLO," says Rivera. "They'd have to fix it, and they did not always communicate with the other PEBLOs and doctors. So, say something had been missing that dealt with a back disability. The very next month, a different PEBLO might get a return for the same reason."

Now, he says, depending on the reason for the return, "the right team" is brought together — which could, for example, involve physicians, physical therapists, or behavioral health — to discuss why the case was returned, and come up with a plan for preventing such returns in the future. "We communicated up and down line — PEBLOs, contact representatives, the affected clinic, and if necessary, the deputy commander of clinical services, to address the specific changes needed," says Rivera.

Often, he continues, the facility would get a return because supporting documentation such as MRIs, surgical reports, or lab work would be missing in a packet. "We developed a process where the PEBLOs themselves had access to these reports and then developed a shared drive to assure the relevant clinical consultants had put it in the packet and in the record," says Rivera. "We started including all relevant medical documentation directly in the MEB packet so it was at the fingertips of the adjudicator; this eliminated many returns." The team, he adds, developed and refined a PEBLO checklist to make sure everything that was required was in the actual case file before it was mailed.

Another improvement that was instituted was the quality check. "The PEBLO does a quality review throughout the process, and before we mailed the packet they would do one last quality check and then give it to one of the contact representatives' support clerks to make sure all the administrative data were correct as well, and to one other PEBLO to review the case," says Rivera.

This had educational value as well, he notes. "PEBLOs who review the packets see how the other PEBLOs do cases, so they learn from each other," he explains. "Visitors are surprised by how much across-the-board knowledge we have; it's one of the major reasons why we've been successful."

The quality check, adds Wolnik, is like an audit. "You go back into the individual's medical record and make sure all the results available on that individual were incorporated, that all consults required to be done with specialists were completed and included as part of the board," she explains.

Teamwork is critical

"I think the No. 1 key to our success was that this is an absolutely excellent example of teamwork throughout the facility," adds Wolnik. "It is not thought of as just one office issue or problem; we get all the players involved. There was also excellent support from command for our efforts. If we did not have buy-in from the top down, these improvement activities would have been that much more challenging to make successful and sustain."

Wolnik says she reports to process improvement every six months to show that the return rate has either been sustained or that there are issues that need to be addressed. For example, there were a couple of years where the rates rose again, due to the return of the First Infantry, resulting in a large influx of soldiers, and an increased workload due to staffing issues. These issues ultimately were addressed, however, and "We were advised recently that the return rates are still holding at what may be the lowest percent that has been returned throughout the army," says Wolnik.

The MEB process has evolved over the last five years, says Rivera, and "We react quickly to change. We report monthly and have several quality review checks of the entire process. When we see something trending wrong, we look at developing procedures to prevent it from continuing."

One such response involved the MEB dictation. "The PEBLO will take the dictation and type up a proceedings form, which has to be signed by the dictating physician — and, in some cases, more than one, such as physical and behavioral," Rivera explains. "A senior doctor in charge then has to review the case, as well as the deputy commander of clinical services. Then, it is presented to the soldier."

There was a time, he says, when the process took more than 21 days. "We developed a procedure that reduced the time to three days," says Rivera. "We set up an office in the MEB section, so instead of going from clinic to clinic for signatures, the doctors come up here at least twice a week to review all cases. The contract representative sends them e-mails daily on what needs to be signed."