Women represent a large share of the population eligible for MHS  services. For example, as of the end of fiscal year 2014, 49 percent of all  eligible MHS health care beneficiaries aged 18 or older were female, and  among active-duty servicemembers and their dependents served by the  MHS, females represented 43 percent. Health care services for women represent a significant percentage of the  care provided by domestic military hospitals. Each health system and hospital may select from  a variety of measures for women’s health care services to assess the  quality of care they provide, and to initiate efforts to improve the delivery  of care. Almost All Domestic Military Hospitals Offered General Women’s Health Care Services, with Fewer Offering Specialty Care Services

As of July 2015, almost all of the 41 domestic military hospitals offered a  basic or higher level of maternity and neonatal care services, although  fewer offered more specialized levels of these services, according to  military-service and NCR officials. All 41 hospitals offered general  gynecological care, including contraceptive services and cervical cancer  screenings, while fewer hospitals offered more specialized gynecological  care, such as treatment for gynecological cancers. The MHS Draws on Expertise of Internal Advisory Groups and National Clinical Organizations to Select Quality Measures

According to MHS officials, the MHS selects quality measures for  women’s health care services based on assessments and input from  advisory groups at multiple levels of the MHS, including at the  department, military-service, and hospital levels. Specifically, members of these advisory groups participate in the activities  of national clinical organizations and educate their colleagues within the  MHS about new developments in health-care quality assessment,  including new quality measures. According to MHS and military service and NCR officials,  coordination of the selection of quality measures for women’s health care  services across the military services has increased in the past several  years. For example, the PAG, which  coordinates the MHS’s efforts to improve the quality of maternity and  neonatal care, annually reviews quality measures. The dashboard is intended to provide more timely quality  information to providers during a patient’s hospital stay. The MHS Selected 90 Quality Measures for Women’s Health Care Services in 2015 and Used Them in a Variety of Quality Improvement Activities

In 2015, the MHS selected 90 quality measures for women’s health care  services, which were collected across all three services and NCR. In 2015, the MHS Collected Data on 90 Quality Measures for Women’s Health Care Services in Military Hospitals

In 2015, the MHS collected data for 90 quality measures related to  maternity, neonatal, and gynecological care. Seventy-three of the 90  women’s health care services quality measures that the MHS collected  data on in 2015 were related to maternity or neonatal care, and included  measures related to areas that had been identified nationally as being  problematic, such as high rates of maternal morbidity and elective  cesarean sections and low rates of breastfeeding. Seventeen of the 90 women’s  health care services quality measures that the MHS collected data on in  2015 were related to gynecological care, including surgery and preventive  screening. Gynecological surgery measures included 14 measures from  the National Surgical Quality Improvement Program (NSQIP), which  identified the rate of different types of adverse outcomes within 30 days  following surgery. The MHS, the Military Services and NCR, and Individual Military Hospitals Used Quality Measures to Identify and Implement Quality Improvement Activities

In 2015, the MHS, the military services and NCR, and individual military  hospitals used information from the data they collected through quality  measurement efforts to identify and implement quality improvement  activities. For example, according to  MHS officials, the MHS 2015 Perinatal Quality Initiative was implemented  across all military hospitals in response to a finding that postpartum  hemorrhage rates were higher in military hospitals compared to certain  civilian hospitals. This initiative addressed various processes of care,  including training for military hospital staff, conducting postpartum  hemorrhage simulation drills, and implementing quality tools. Agency Comments

We are not making recommendations in this report. We provided DOD  with a draft copy of this report for review and comment. DOD provided  technical comments, which we incorporated as appropriate. Appendix II: Location and Number of Beds of Domestic Military Hospitals by Military Service

In 2015, the Military Health System’s direct care system included 41  domestic military hospitals across the three military services (Army, Navy,  and Air Force), and the National Capital Region (NCR).
Why GAO Did This Study

DOD provides health care services to active-duty servicemembers, their dependents, and others, in part through direct care provided at military hospitals and clinics located on military bases. Women represent a significant percentage of the population eligible for MHS services, comprising nearly half of the 7 million adults eligible for coverage at the end of fiscal year 2014.
In recent years, DOD’s study of the quality of care in the MHS raised questions about the quality of health care at military hospitals, including the quality of women’s health care services. The Carl Levin and Howard P. “Buck” McKeon National Defense Authorization Act for Fiscal Year 2015 included a provision for GAO to describe the availability of women’s health care services at military hospitals, particularly maternity care, and the measurement and monitoring of the quality of these services.
This report describes: (1) the extent to which women’s health care services are available to servicemembers and other beneficiaries at domestic military hospitals; (2) how the MHS selects quality measures for women’s health care services provided at military hospitals; and (3) the quality measures that the MHS has selected for women’s health care services and how they are used to improve the quality of care. GAO reviewed documentation, information, and data provided by DOD and the military services, on women’s health care services available as of July 2015, and interviewed officials from DOD, the military services and NCR, and six hospitals (selected based on military service, geographic diversity, and volume of deliveries).

What GAO Found

Almost all of the domestic military hospitals in the Department of Defense’s (DOD) Military Health System (MHS) offered general women’s health care services, including general maternity, neonatal, and gynecological care, with fewer offering specialty care services. Specifically, according to officials from the three military services and the National Capital Region (NCR) (which includes two military hospitals in the Washington, D.C. area), 37 of the 41 domestic military hospitals offered a basic or specialized level of maternity and neonatal care services, although fewer offered more specialized levels of these services. All of the 41 hospitals offered general gynecological care, including contraceptive services and cervical cancer screenings, while fewer offered more specialized care, such as treatment for gynecological cancers, according to officials.
According to MHS officials, the MHS selects quality measures for women’s health care services based on assessments and input from advisory groups at multiple levels of the MHS, including at the department, military service, and hospital levels. Members of these advisory groups participate in the activities of national clinical organizations and educate their colleagues within the MHS about new developments in health-care quality assessment, including new quality measures. According to officials from the MHS and all three services and NCR, coordination of the selection of quality measures for women’s health care services across the military services and NCR has increased in the past several years, including for the selection of measures to include in a perinatal quality measures “dashboard,” which is being developed to provide more timely quality information to providers during the patient’s stay in the hospital.
In 2015, the MHS collected data for 90 quality measures related to maternity, neonatal, and gynecological care, a number of which related to areas that had been identified nationally as being problematic and associated with high rates of maternal morbidity. In maternity and neonatal care, for example, data was collected on elective deliveries (where the birth is facilitated, such as with medication or surgical cesarean section, without a medical indication). For gynecological care, the MHS collected data for quality measures related to prevention, such as screenings for breast and cervical cancer, and gynecological surgery, such as morbidity rates within 30 days following surgery. The MHS, the military services and NCR, and individual military hospitals used the data collected to identify areas for quality improvement and implement related improvement activities. For example, MHS officials told GAO that the MHS’s 2015 Perinatal Quality Initiative was implemented across all military hospitals in response to a finding that postpartum hemorrhage rates were higher in military hospitals compared to certain civilian hospitals. This initiative included training for hospital staff, clinical simulation drills, and using quality tools to help providers prepare for and carry out steps to minimize the risk and negative outcomes of the condition. Officials reported that after implementation of the initiative, postpartum hemorrhage rates decreased, on average, across the MHS.


What GAO Recommends

GAO is not making recommendations in this report. DOD reviewed a draft of this report and provided technical comments, which GAO incorporated as appropriate.