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Department of Defense Briefing by Secretary Hagel and Deputy Secretary Work on the Military Health System Review in the Pentagon Press Briefing Room

SECRETARY OF DEFENSE CHUCK HAGEL: Four months ago, I ordered a review of DOD's Military Health System. It focused on access to care, quality of care, and patient safety. This review was led by our Deputy Secretary of Defense, Bob Work, who's to my left.

And I want to thank Bob and I want to thank his team and all those here today and their teams for their leadership, for their efforts, and for the work that they've put in to this review.

We all feel very strongly that there is nothing more important for our people than the health and well-being of our people and their families. Our military health system is a large, global system with more than 50 hospitals and 600 clinics in America and around the world. It offers services ranging from battlefield MEDEVAC to pediatrics and dentistry.

Through direct and purchase care, it serves 9.6 million people, including service members, retirees, and their families. Combat care is and must always be a central focus for the military health care system. It's helped save and rehabilitate the lives of thousands and thousands of Americans who have worn our nation's uniform.

But our military health system has responsibilities beyond the battlefield, and our review focused on noncombat care. The review found pockets of excellence -- significant excellence, which we're very proud of -- and extraordinary doctors, nurses and staff who are deeply dedicated to the patients they serve. They are reflected by our three Surgeons General, who you will hear from in a few minutes.

It also found gaps, however, and facilities it must improve. The bottom-line finding is that the military health care system provides health care that is comparable in access, quality, and safety to average private-sector health care.

But we cannot accept average. We cannot accept average when it comes to caring for our men and women in uniform and their families. We can do better. We all agree we can do better.

The Surgeons General, and their staffs, and men and women who care for our people know that more than any of us and are dedicated to doing better. Even small lapses in care can lead to devastating and heartbreaking losses or injuries. We must hold the entire military health system to the same exacting standards that we demand of our combat missions.

So today, I'm directing the Department of Defense to take steps to ensure that the entire military health care system is not merely an average system, but a leading system, because that's what America's troops and their families deserve.

These are first steps, but they will help our hospitals and clinics foster a stronger culture of safety, quality, and accountability, a culture that must become second nature to all who execute DOD's critical health care system and our mission.

Today I'm directing all health care facilities identified as outliers in the categories of access, quality and safety to provide action plans for improvement to Deputy Secretary Work within 45 days. I'm directing the head of the Defense Health Agency, Dr. Woodson, who is here with us today, and all our Surgeons General, to ensure that we have unified standards for purchased, as well as direct care, and to establish a mechanism for patients and concerned stakeholders to provide ongoing input.

I'm also directing the department's health care leadership to establish a system wide performance management system that will help scrutinize lapses and monitor progress. And to enhance transparency, I'm requiring that all currently available data on our health care system be made publicly available.

By the end of the year, DOD will have a detailed implementation plan to ensure that the military health care system becomes the top performing system we all expect it to be and want it to be. These steps are the beginning, not the end, of an effort to improve our military health care system. And I will receive regular progress updates from DOD's health care leaders.

We have the finest military in the world. Our men and women in uniform and their families deserve the finest healthcare in the world. We all agree on that. I know our military health care providers agree with this and every part of it. And I thank them for what they do, what they continue to do every day, because they, more than anyone else, are committed to offering the best care for our people.

I know that Admiral Kirby was out here a couple minutes ago and laid out the format that we'd like to proceed with and that is to have our three surgeons general and the head of our health care system, Dr. Woodson, along with Dr. Junor and our Deputy Secretary of Defense, Bob Work, take questions as to how we're going to implement the recommendations that came out of the review, what are the next steps, and some of the other questions that you may have in regard to this review.

Thank you all very much. Thank you. Thank you.

DEPUTY SECRETARY OF DEFENSE BOB WORK: Well, good afternoon, everybody. It's great to be here with you this afternoon.

I just want to echo what our secretary has said, that the Department of Defense really does not have any higher priority than our men and women. They are the true secret weapon that the United States has. They're just unbelievable. They deserve the finest health care that we can possibly provide.

Now, it's a critical part of the sacred compact that we have made, all of the leaders, the service chiefs who aren't here today, but their Surgeons General, and when the secretary asked me to do this, I was actually quite excited. I was born into a Marine family. I was at the end of the military health care system, both in the continental United States and overseas.

As a Marine, and through the NROTC, I saw it from the side of someone who was going through an accession program. I was a single Marine. Once I was married, I was taking care of -- my wife was taken care of, and once we had a child, she was taken care of. And it just so happens that my wife was a former Army nurse.

So I feel that I have a lot of experience first-hand on what this system provides. I know it pretty well. And I share the secretary's commitment on getting it right.

Now, I believe this was an extremely honest assessment. We were very happy to hear that our health care system is comparable on average with all of the national civilian health care systems.

But as the secretary said, he does not expect us to be average. He wants us to be a leading organization, a learning organization. And he has tasked us to do so.

So there are areas where our system, we believe, performs as well as any in America. And there are other areas where performance falls short of the national benchmarks. And all of those we're going to take care of.

Our leaders throughout the department and the American public have an appropriate high standard for us, and we're going to try to achieve that standard. We don't want a good health care system. We want a leading health care system, among the best in the United States.

Now, the good news is, because of this assessment, which was extremely detailed. When you see the 700 pages on all of the data that we have, we have a pretty good idea on what are the best practices and what are the areas we need to improve upon.

And the recommendations contained in the report and the steps that Secretary Hagel has directed today is for us really to take those steps that will make us better. So this report, I just want to emphasize, is not the end. This will be the start of a process in which we all commit ourselves to becoming a leading, learning organization.

We feel very strongly that this should be a transparent process. We've met with the veterans’ service organizations and the military service organizations. We've requested their feedback, and they have been very forthcoming in giving us that feedback and helping us understand data, which they can help us interpret.

We had six outside experts completely divorced from the military health care system that we had actually come in. Three of them looked that, how we set up the process. And they all agreed that the way we were going about it was fair and very, very detailed.

And then we had three who looked at our conclusions and, by and large, they agreed with all of the findings and recommendations, with some specific caveats. So we remain committed to this transparency. I have told the veteran service organizations and the military service organizations that I will seek their feedback routinely. And I want to compliment all of them, because they've been absolutely critical to this effort, and I think they will remain critical as we go forward.

I want to commend the hard work of the teams, not only all of those in the health agency. This is the first-year anniversary of the health agency. And what this review told us is, we need to be better at having performance metrics across, but otherwise, the performance, you know, is comparable, as I said, to the national health care system right now.

Over 100 people worked on the report. I'd like to compliment the surgeons general. As the secretary said, there's nobody in this room that wants to improve this system better than the three individuals that are here and Dr. Woodson, who leads our health care -- health agency.

So they're only the beginning. We have a lot of work to do. This was a very, I think, fair report. There are things we have to do to get better, and we're committed to doing so.

I'm going to remain personally on top of this for the secretary. I'll be working very closely with Dr. Woodson and Dr. Junor and the surgeons general to provide routine reports to the secretary and also receive input from the veterans service organizations, the military service organizations, and our beneficiaries, all of the men and women and their dependents who serve in the greatest armed forces in the world.

I'd like to turn this over to Laura, and then we'll get right into questions.

DR. JUNOR: We took a very candid look at our military health system. And in fact, the review that we published today was unprecedented, both in terms of its scope and its approach. We looked at metrics, 37 metrics sets in all, that covered the entire enterprise of our military health system.

We also did several site visits. Those site visits not only serve as a check of our centrally collected data, but it also ensured that we have the opportunity to talk to the people that work in our military health system and with our beneficiaries.

We also collected data on three top-performing civilian health care medical centers, and we did this to provide a benchmark for what great performance looks like. So that's what provided us context.

And I do want to reiterate a point made by both the secretary and the deputy secretary, and that's that we know -- we found that no hospital systematically underperformed in any of the three dimensions of access, quality or safety. We continue to provide safe and reliable health care. But we can do better.

We were not -- we found the observations at the median and lower, and the fact that we had trouble getting information across the board unacceptable. We can do better. We have to do better. We hold ourselves at the highest level of performance that we can possibly achieve.

And toward that end, the secretary did as he described, he did set our paths for us on how we were going to do better. Beginning with the category of access, we know that for our beneficiaries, getting appointments when they need them is a very important thing. And our data are telling us that we're meeting the standards that we set for ourselves.

But throughout surveys and when we spoke to our beneficiaries, they were telling us a slightly different story, that there were access challenges.

So we don't understand the discrepancy in those two information streams, but we're going to. We're going to take a look and find out what's driving those differences, and we're going to especially take a look at access as it pertains to the civilian health care providers in our TRICARE system.

When it comes to safety and quality, we found that while our general performance was comparable to the civilian sector, again, we saw more average and low observations than we're comfortable with. We hold ourselves to a higher standard. We will do better.

Going forward, we're going to adopt the principles of a highly reliable organization. This is like aviation, and in those type of organizations, every member of the organization understands intuitively that it's their responsibility to report safety problems.

So in that respect, reporting safety problems isn't a burden on the system, it's the gift of a crisis averted. This is a cultural change and one that's important to make as we go forward.

We're also going to investigate the outliers, those observations that were below what we consider satisfactory. We're going to find out why they were below and develop mitigation plans to get them up higher.

Finally, we're going to implement a performance management system. What that means is we're going to identify a core set of metrics and DOD-wide standards, and we're going to monitor performance as they pertain to those standards.

We're also going to set up a central analytic capability to make sure that we understand the secret of high performers and how to bring up low performers.

I do want to echo the deputy secretary's emphasis on transparency and patient engagement. We are going to make our data more easily available to our beneficiaries and the public, and we're going to continue to publish data and solicit both patient and beneficiary feedback going forward.

Finally, I want to talk a little bit about the men and women that constitute our military health care system. They are extraordinary, and I am humbled and honored to work with the three surgeon generals who showcase this extraordinary workforce.

We send these people to the ends of the earth quite literally, to remote and austere locations, where they treat illnesses and injuries on any given day that's greater than what a civilian provider would likely encounter in their entire career.

They work on our frontlines under combat fire with little regard for their own safety. And the reason why I wanted to bring that up to you is even though this report found that there were things that we can do better, we're starting this journey with the most important ingredient, and that is a very capable, component, dedicated workforce.

And I am honored to work with them. We're going to figure out the path ahead together. Thank you.

REAR ADMIRAL JOHN KIRBY: I'll moderate the Q&A until we get about 15 or 20 minutes. Please identify who you are and who you're with.

Q: David Alexander from Reuters. I wonder if you could just address a little bit, were the issues that you uncovered here in any way comparable to what was being seen at the V.A. back when it was started three, four months ago?

DEP. SEC. WORK: I don't want to compare our department with their department because they have two fundamentally different missions. The Department of V.A. has a coherent body of beneficiaries, veterans who have left active service, whereas this enterprise has to have a medically ready force. We have to train the doctors to be able to go forward on our crises. And we have to have a ready medical force, which means they're ready to go, and a medically ready force, which means, do they have the right dental care? Are they ready to go forward?

So we really have two different missions. Where our missions overlap is on the -- essentially our families and all of our servicemen and women who are back here in the United States. We have a much higher turnover rate than the Department of Veterans Affairs. They have pretty stable people, like -- I think one of their clinics, only 2 percent turnover.

We have up to 30 percent turnover. So they're two different systems, and I wouldn't want to compare us with V.A. We were satisfied with the finding that we are comparable with the health care system and we have no crisis. But as everyone has said, we want to do better, we have to do better, and we can do better.

Q: Can you talk a little bit about this -- this thing that you found, the difference in opinion about -- I think it was like health care, access to health care seemed to be OK, but yet there were some reports that there was concern about...

DR. WOODSON: Yes, thanks for that question. And I think it gets to the issue of how you ask questions. One of the things we learned through, I think, this very important study that Secretary Hagel ordered, and sometimes your own perceptions don't match that of your beneficiaries. And this is why we're going to invite the stakeholders to ensure that we're framing the questions in our analytics appropriately to get at their perceptions of access and quality.

Q: Were you thinking that that was -- the issue was that they weren't getting seen as quickly as they should have been in -- in the waiting rooms or...

DR. WOODSON: Well, let me see if I can answer this with an example. So if you take our special operations communities -- and they're deploying all the time -- and our access standard for routine care is seven days, but because of their deployment, very aggressive schedules, they may want to get care in a day or two days. And so this is what I mean about difference in perception.

The seven-day rule may not really matter to someone who's constantly deploying and needs to take care of routine matters. And we need to tap into those stakeholders to adjust our perceptions and our rules so that they get the care that they want when they need it.

DR. JUNOR: I can help if it would help. I can give you our average relative standards. For appointments for specialty care appointments, our standard is four weeks. Our average, in terms of our data, we're showing that you get an appointment in just under 13 days. For routine care, it's about a week. Our average is showing six days, so slightly better than the standard. And emergency care, 24 hours, and we're about nailing that, and our data are saying about 24 hours.

DEP. SEC. WORK: I would like to say, though, that access is one of the issues that we have heard back that our data is not actually reflecting what our beneficiaries perceive. And the VSOs and the MSOs, the veteran service organizations and the military service organizations, are going to work with us as we work over this next 45 days, we're going to dive into this. We're saying, why is the data a little bit different?

So even though we are meeting our own standards, there is some variation, and we have to dig down deep into this. There's also a difference between purchase care, where people go off from a military treatment facility, and the care we provide. We're going to dive into that, and we're going to make sure we have it.

So on the access side, we're a little cautious right now, because we want to see, are we really -- is the data telling us what is really happening? And we're going to ask for a wide variety of different sources to help our feedback.

Q: (off mic) with Voice of America. I was interested -- Laura, you said several site visits. Can you tell us which places were visited?

DR. JUNOR: I don't have a list, but we can get that list for you. But I can tell you the schema that we chose. We chose seven -- we chose hospitals large and small. We chose hospitals across our enterprise to include one international hospital. So there's representatives from the VHA component and one from each of the three military departments.

Q: Did you check on any in combat zones? Because that's been a big criticism since 2012. You know, there have been reports that said up to 25 percent of Americans in in combat could have been -- you know, could have been saved had preventable measures been taken, bleeding out and such. Was there an extra step gone for these combat areas?

DR. JUNOR: This review focused on our military health facilities. So it did not touch the combat care. But we'd be happy to follow up with you on that issue.

LT. GEN. HOROHO: I'll take that question. When they looked at the data in the article that looked at the data from 2012 and earlier, one of the things that wasn't put in there is they looked at it through a clinical lens, so it was a sterile battlefield. They didn't into account firefighting. They didn't in account air evacuation and whether or not aircraft could land. They didn't take into account the response to the injuries at that time.

And so it was very much looked through a clinical lens on just the data retrospectively, but it's done that way because that allows researchers to really look and say, where can we make advancements and where should we focus for the future?

So I think that's why we've got to make sure that we're looking at it in total and not drawing the wrong conclusions. Thank you.

LT. GEN. TRAVIS: I'm glad you brought that up, because we've been providing outstanding care on the battlefield, all three services together. Part of the issue, I think, that that data came from was the fact that, can we advance or put more advanced care further forward to provide direct care at point of injury?

And, as a matter of fact, the Brits have been doing this. The British colleagues have been doing it. And now, as a matter of fact, in the Air Force, we're putting tactical critical care evacuation teams, which includes a little more advanced care, further forward. And these are severely wounded troops who, you know, probably in many places in the country may not be survivable if they were that injured in this country.

So we're always trying to get better. And, frankly, that was the gist of this report, is to be a learning organization. We learn from data. You saw part of that data. We'll advance care further forward on the battlefield, too, even though that wasn't the focus of this report.

Q: One last question. When you mentioned unified standards, Secretary Hagel mentioned unified standards, are we going to get to see those standards just like you were able to release the access standard? Can we get a list of all of the standards that have been agreed upon that's expected in this facility?

DR. WOODSON: I think as we go forward, certainly, and as we mature the Defense Health Agency, which has the responsibility of producing sort of the common business processes and common standards, we will be rolling those out, it will be transparent and unequivocal about -- some of them have been established already. But the issue is that it will be published.

REAR ADM. KIRBY: (off mic) go ahead.

Q: Yes, hi. I'm Dan Lamothe with the Washington Post. I wanted to drill down a little bit into the outliers. We didn't have that much time to read the report ahead, but I didn't see them identified. Can you speak at all to who they were, what kind of things you saw, and what's being done to address that?

DR. WOODSON: So when you have an opportunity to see the report, each of the facilities will be identified. You'll have an opportunity to examine all of the metrics that were used to identify high outliers, low outliers, the average. It'll all be apparent.

DR. JUNOR: There are literally 700 pages of glorious detail, lots of data. So every metric. And it's important to understand here, we're talking about 37 metric sets. Every set has a whole list of metrics within it, so we give you values for each one of those metric sets. That's why it's 700 pages.

VICE ADM. NATHAN: Let me add that the review is going to show some of the outliers that we've known of for a while and have already been addressing, as well as looking at areas of data that we're trying to make sure it has fidelity. So we've already charged these facilities with looking at any area where they're in an outlier and telling us expediently, A, is the data correct? Are you measuring it correctly and are you as good or as out of standards, as they say? And if you are, what is your action plan, working together as a region and as an enterprise to address these?

DEP. SEC. WORK: When you go through the data, you'll never find -- I don't think you'll find a hospital that is uniformly below standards in every single one. What you'll find is hospitals are very good in one area and not so good in another area and average in kind of the others.

And within 45 days, the three surgeon generals have to go in on all of the different ones that are below and say, what can we do to bring them up? And also identify the best practices across the enterprise so that we raise the average of the entire enterprise.

What Dr. Junor said is very important. There was no hospital that was found to be unsafe. Sometimes a hospital might be low in infection control, but they might be very high in prenatal care. So when you take a look at the enormous amount of data we were able to take care of, this gives us a very, very good kind of fingertip feel of where the surgeon generals have to put their approach, because it's all about prioritization, obviously.

REAR ADM. KIRBY: Go ahead (off mic)

Q: I'm Jared Serbu with Federal News Radio. On the blind spots that the report talks about in the purchased care system, what's kind of the plan to get after that? Because that's a broad, diverse population of providers, and I think you're locked into long-term contracts in all three TRICARE regions.

DR. WOODSON: Well, that's a very good question, and, of course, it poses a challenge to us. Everyone needs to understand that, essentially, we run a direct care system, all of the military treatment facilities that the surgeon generals oversee, and then we purchase care on the economy in the American health care system.

And so we have to move actually the American health care system along to produce the data that we need to define the quality of care that is delivered. And this is going to be a major focus of effort to produce contracts that require the delivery of information that allows us to give to our beneficiaries’ information on the quality of care that's delivered in the purchase care sector.

DR. JUNOR: Just to follow up, we've got one year to figure this out, and that's pretty aggressive. And we chose to be so aggressive to make sure that we made improvements, we didn't give ourselves any room to rest on our laurels. We are moving forward.

So the contract provided care from the civilian sector is our long pole in the tent, and it's going to be a challenge, but we're dedicated to figuring that out.

Q: And then on shortfalls, in being able to analyze data across the direct care system, how much does your new EHR solve that? Or do you need to do something separate?

DR. WOODSON: So that certainly will enhance our ability to track data, there's no doubt about it. And we're looking forward to the implementation of the new EHR. But having said that, it's also about building the system so that you can mine the data sets, derive the information you need that produce the actionable items that you need to work on.

REAR ADM. KIRBY: Barb [STARR]

Q: (off mic) shift slightly to a slightly different military health care issue right now. I think my question is for the surgeon -- all the surgeons general, starting with you, ma'am, perhaps. The military, the Army, all of you, you're deploying about 3,000 troops to West Africa into one of the largest public health crises the world has seen right now.

If I could start with you, ma'am, at the podium, can you talk to us a little bit about -- with the Army surgeon general, please, since you're deploying the largest number of troops -- could I talk to you about what the Army's public health concerns are in terms of -- not protecting the troops once they get there, but how -- how will you know that they are medically safe to return to their families, to return to their bases? And if you did get troops falling ill to Ebola over there, where are you going to get the evacuation capacity to bring them home? Or is the plan to treat them in theater in Africa? But especially, are troops going to be quarantined before they come back to the states? How will you know that they're healthy? If I could start with the Army surgeon general.

DR. JUNOR: I do want to jump in. Your question is very well-taken. There is nothing more important to us than taking care of our military forces before, during, and after any engagement. So this is first and foremost on our minds. We are working with experts right now on this. We don't have any news for you on this today, but we will keep you up to date.

What we wanted to focus on today was improvements that we're going to make in our military health care system.

Q: I do understand that. I asked ahead of time and was told that I could ask the question, which is why I'm proceeding with my question again. And I'm just wondering, if you don't have the answers, can any of those in uniform -- because military personnel and their families are concerned, and it's newsworthy -- can you tell us at least what the questions are that you're looking at? If you have no answers yet, what are the issues on the table that you've got to get some answers to?

DEP. SEC. WORK: Again, we really want to kind of focus on the military health care system, Barbara. I mean, there are several questions. And this has been -- I have actually been to a PC, a principals committee, on this. It's being worked across the government. We're getting input from the CDC, from USAID. We're taking a look at a lot of different things.

But I don't want to put the Surgeons Generals on the spot, because we don't have a unified plan today to talk to you about. But we will very soon, and we would -- I would expect John to have a separate kind of engagement which would look at that.

Q: Deputy Secretary Work, you talked yesterday about a variety of budgetary pressures looming over the Pentagon. Could you say a word about how this action plan and this issue is impacted by those or threatened by those?

DEP. SEC. WORK: Well, every single thing in the department right now is under enormous programmatic pressure. I don't want to really go into all of the things, but let say that there's probably two areas which are at the very top of the secretary's view. This is one of them, that we would not skimp in what we need to do to make this system as good as we can.

Luckily, we don't believe that that is going to require a lot of more resources. What this is going to require is us digging into the data and getting better, really instituting a culture, which we think is quite healthy right now, but to get to this whole idea of a culture where safety is paramount.

So this is very high. And there are certain other ones that are very high on the secretary's list, but this one, as he indicated today, he is not going to allow us to come in and say, let's cut the military health system by 20 percent.

Q: Is this a new effort that the C.R. prevents you from getting into until that's worked out? Or can you get started now on crunching the data and...

DEP. SEC. WORK: We're jumping in right now. The secretary's given us extremely aggressive timelines, 45 days to report back. You should all have a copy of the memo. If you don't, we'll provide you one.

But there are a lot of very important and aggressive timelines. The secretary does not want the grass growing under our feet. We are running right now. The Surgeons General have been part of this from the very beginning. The defense health agency has been part of it. They know where we have to go.

So we're not going to wait until the end of the fall review. You know, we're in the race right now.

REAR ADM. KIRBY: We're going to take just two more.

Q: Yes, thank you, Tom Philpott with Military Update. For the Surgeons General, we're used to the rhetoric of excellent health care for the military health care system. And now we have a report that says average health care. I wonder if I could get your reactions to that.

And, also, if it's not the medical personnel who are the problem, if they are still excellent, what basically are the problems, the challenges you have to get over to elevate yourselves to an excellent health care system?

VICE ADM. NATHAN: Well, thank you for the question. Number one is, in this review, we didn't just focus and comparing ourselves to any organization. We picked several that are already looked at as marquee and benchmark organizations. So in the review, where you see us falling short or pulling ahead of those, some of those are in respect to marquee organizations.

And when the secretary says that we're average, I think that's in the context of we consider ourselves to be above average, if not top shelf in combat casualty support and in the kind of care that you can expect if you're wounded in the battlefield.

Now you come to one of our home centers, and we want to be able to look you in the eye and say -- and I won't name any particular system, but if I asked all of you to think of a system in America by name, by brand-name, some would come to you that you think are where I'd like to be or where I'd love to get my care, because they're world-class. We want to strive to be that on the tip of your tongue.

We want to take efforts to take what we think is a good system now and make it great and make it greatest. And so I think -- and that's what our people want. That's all our people are asking for us. They're saying give us the materials and the effort and the training to do it. The good news is they've got the spirit, they've got the heart, and they've got the desire, so we've got the key ingredients.

REAR ADM. KIRBY: Richard?

Q: Colonel Work, please. You said earlier that performance -- performance in general has met national averages. You also said that there were areas where performance fell short. Can you describe those areas? Can you list those areas?

DEP. SEC. WORK: I wish I could. You have to actually go into the data, because as I said, we chose so many -- how many different measures did we look through?

(UNKNOWN): A hundred and seventy-eight.

DEP. SEC. WORK: We took about 78 measures -- 178. And we applied all 178 measures to every single one of our MTFs. So no particular, single hospital came out as saying, oh, my goodness, this hospital is really having a problem. What happened is some of them were good in some areas and some were not.

So I don't want to judge the data, because we want to be transparent and allow everyone to take a look at the data, come back to us, and say, hey, I don't -- you know, what are you thinking about that? There was no single area that I know of that stood out as saying, "Oh, my goodness, we have really got to get into this particular area."

I think one of the external reviewers said it best. When you take a look at the military health care system, it's broadly comparable to the civilian health care systems. There's pockets of excellence; there's pockets of below-average standards; and there's a wide variety of kind of average behavior.

And as everyone has said up to this point, we want everyone to take a look at us and say, "This is a leading-edge military health care system." So there's no particular area -- unless Dr. Woodson or any -- there's no particular area that stood out to us and said, oh, my goodness, we need to really jump on that.

DR. WOODSON: Let me just add to that comment, which I think is right on the mark. As you'll see in the report, there will be a number of metrics that were used -- that are used in civilian systems, these national -- let's say -- surgical quality insurance program metrics or the National Perinatal Information Center metrics.

Again, most -- if you look at who involves themselves in reporting these, you'll find that they're top-tier institutions. So in the national surgical information, only about 400 out of the 5,000 hospitals in the country participate. For the National Perinatal Information Center, only 84 or 85 hospitals out of the country participate. And we have chosen to participate with that cohort to measure ourselves against...

(CROSSTALK)

Q: When you had to relieve Colonel Brewster at Womack, General Cho at Lewis-McChord. What brought that about?

DR. WOODSON: I'll let the Army surgeon general address that.

LT. GEN. HOROHO: I'll be glad to take that question. Specifically, neither of those individuals -- and let me make a correction -- General Cho has not been relieved. He has been suspended pending the results of an IG investigation. So that is ongoing, and that was for complaints of toxic leadership.

Colonel Brewster was relieved from command, and his was from failure of leadership. It had nothing to do with clinical care; it had to do with failed leadership. So two very, very different cases. And those were also -- his was after an investigation was done, and there were substantiated findings that led to his relief.

REAR ADM. KIRBY: (off mic)

LT. GEN. TRAVIS: Just because I think it's relevant -- it was a great question -- I think, if anything, we owe our staffs at all of our facilities across the MHS probably more clarity in policy, probably a clearer set of expectations, a unified set of standards, which everybody should be held accountable to, and then a system which provides really good feedback to them all the time.

Each of us have been doing this for some years, and we do that now, and it's always constant improvement. That's what we do in health care, as with other health care systems.

But I think what we owe to everybody who serves in this military is a system, which means, despite the fact that we provide different support to our various services for very important reasons, as a health care system with beneficiaries flowing between services, even staff flowing between services, I think we need a more standardized approach to act like a system and I think the report helps us do that.

REAR ADM. KIRBY: Thanks, everybody. Appreciate your time.