Effort to Improve Navy Health Care Lags

Navy officials have demonstrated an “absence of commitment” to improving substandard care at naval medical facilities, particularly for those patients treated in emergency rooms, according to an internal review made public Thursday by Sen. Pete Wilson (R-Calif.).

The report by the Navy inspector general’s office found that the service had made “very little progress” toward correcting previously disclosed deficiences in treatment provided at three regional headquarters of the Naval Medical Command and at 10 medical facilities, including the naval hospitals at San Diego, Camp Pendleton and Oakland.

Among other things, the report concluded that emergency rooms at these facilities frequently are staffed with untrained personnel and that “these staffing practices led to many adverse occurrences and to many malpractice claims.”

Adverse Publicity

The report follows many months of adverse publicity about military medicine, including the court-martial of Navy Cmdr. Donal Billig on charges of involuntary manslaughter in the deaths of five heart patients at Bethesda Naval Hospital in Maryland. A survey of Navy hospitals in Southern California by The Times last year uncovered 25 cases of malpractice that left 13 people dead and 12 injured.

“Virtually without exception, the doctors, nurses, medical service corps and the enlisted personnel at the inspected activities are making a heroic effort to ensure that patients receive the highest quality of care possible,” the report said.

“The common denominator in all areas where progress has been slow or unsatisfactory is an absence of a commitment to such progress by top Navy medical management, i.e., a resistance to change and a business-as-usual approach.”

Wilson, who is chairman of the Armed Services subcommittee on manpower and personnel and who last year underwent an appendectomy at Bethesda Naval Hospital, said that the Navy should no longer be required to provide direct health care for civilians--including dependents, retirees and members of Congress.

Time for Change

“Business as usual is not acceptable in military medicine,” he said. “It may well be time to alter in some substantial way the manner in which health care is provided to the beneficiaries of the military health care system.”

Wilson also accused Vice Admiral L. H. Seaton, director of naval medicine and surgeon general of the Navy, of misleading his Senate subcommittee by testifying that the problems are being remedied. He demanded an explanation from Navy Secretary John F. Lehman Jr.

The Navy had no immediate comment on Wilson’s charges.

The report, which the Navy has not yet made public, concluded that the emergency rooms in naval medical hospitals lack adequately trained staff and up-to-date facilities.

Untrained Personnel

It noted that the emergency rooms are often manned after 11 p.m. by physicians with no training in emergency care such as dermatologists, psychiatrists, radiologists or pathologists. Even during the day, it said, the emergency rooms are staffed by untrained personnel or, “all too often, (by) persons who failed in other patient care areas.”

In addition, it said, emergency rooms are often “taxed to the limit” by patients because they are the easiest access route to the naval medical system for patients who have difficulty getting appointments in hospital outpatient clinics. For example, San Diego’s naval emergency medicine department treats 75,000 patients a year, or up to 300 a day.

“Young people with fractures, women with acute pain, retirees with heart problems and infants with fevers are all routinely seen in the EMD (emergency medical department) treatment areas,” the report said.

In criticizing emergency facilities, the report cited several specific examples, noting that the patient cubicles are too far from the main desk at the San Diego facility and that the cardiac-monitoring beds are a corridor away from the main desk at Camp Pendleton.

Management Systems Criticized

The report also was critical of the management systems designed to control the quality of care and the record-keeping at these facilities. An inspection of medical records uncovered what was described as “problems with chart organization, the legibility of entries and signatures, completeness of entries such as vital signs, height and weight on physical exam sheets and similar deficiencies.”

Two particular management systems--known as the credentialing program for health care personnel and the quality assurance process--came in for criticism by Wilson, who said that they had been misrepresented in testimony by the Navy surgeon general.

“While the surgeon general was testifying that the Navy’s health provider credentialing program was ‘one of the cornerstones’ of the quality assurance program, the inspector general was finding that the ‘timely implementation of the credentials program has been hampered by cumbersome administrative requirements, inadequate staff and suboptimal headquarters support,’ ” Wilson said.

Similarly, he added: “While the surgeon general was testifying that comprehensive quality assurance instructions markedly improved . . . the inspector general was finding that the quality assurance program has ‘insufficient personnel, insufficient dedication billets, excessive personnel turnover and weak training programs.’ ”

In response to criticism of the military medical system, the Pentagon last week took the unusual step of providing for civilian review of the performance of military doctors. It awarded a $4.63-million contract to the Commission on Professional and Hospital Activites, a private organization, to conduct monthly “peer reviews” of doctors working at the 168 U.S. military hospital worldwide.