The NDAA required that the new JTS and  DOD’s implementation plan include the following four elements:  1.  serve as the reference body for all trauma care provided across the  2.  establish standards of care for trauma services provided at military  3.  coordinate the translation of research from DOD’s centers of  excellence into standards of clinical trauma care, and  4.  coordinate the incorporation of lessons learned from trauma education  and training partnerships pursuant to section 708 of the NDAA into  clinical practice. DOD’s Joint Trauma System Implementation Plan Includes the Four Elements Required by the NDAA, but Does Not Yet Fully Incorporate Leading Practices for Planning

The implementation plan submitted by DOD to Congress on August 7,  2017 includes a description of the four elements required by the NDAA. It  also provides an overview of the implementation activities, including  realigning the U.S. Army’s current Joint Trauma System Defense Center  of Excellence to become part of the new system within DHA. We found that  DOD’s planning documents, prepared to date, incorporate only some of  the leading practices. Strategies: In addition to defining goals, the documents also  include some strategies to achieve those goals, such as specific  actions that DOD plans to take and target dates for accomplishing  these actions. The documents also identify DHA as the  lead office within DOD that is responsible for executing and  achieving this action. Element Two—Establish Standards of Trauma Care for Military Services

DOD’s planning documents incorporate goals and plans to assess  progress, but do not yet fully incorporate leading practices related to  strategies and risks. Goals: According to the documents, DOD’s goal for this element  is twofold:  1) to develop, publish, and assess standards of care in  DOD’s CPGs. Strategies: DOD’s planning documents describe how the new  JTS will continue to produce, update, and monitor adherence to  CPGs and designates JTS as the office that is primarily  responsible for leading these efforts. According to DOD officials, this frequency exceeds standards  established by leading civilian organizations. Element Three— Coordinate the Translation of Research into Trauma Care Standards

One of the planning documents provides a general overview of how DOD  plans to coordinate the translation of research from its centers of  excellence—including the JTS DCOE and other trauma care centers of  excellence—into trauma care standards, but the planning documents  have yet to incorporate any of the four leading practices, including goals,  strategies, risks, or plans to assess progress. DOD officials also told us the  current JTS DCOE routinely interacts with the various DOD organizations  responsible for trauma-related research, such as by holding weekly  discussions on trauma care issues. Officials stated that they do not  expect these interactions to change as the JTS DCOE transitions to the  new JTS. Element Four— Incorporate Lessons Learned from Trauma Education and Training Partnerships

The planning documents for this element do not yet incorporate any of the  four leading practices, including goals, strategies to achieve goals, risks,  or plans to assess progress. Specifically, the department has submitted its  implementation plan to Congress as required and has developed other  supplemental planning documents that describe how it plans to address  the four required elements of the new system. Incorporating these  elements is a critical step for DOD as it works to improve trauma care  consistently across the military health system. Although the NDAA  requires that DOD begin implementation in 2018, DOD’s planning is  ongoing, and its planning documents do not fully incorporate leading  practices that can help ensure the success of its efforts. By not doing so,  DOD may be missing an opportunity to ensure that its efforts to  implement a new JTS are effective and to help reduce trauma-related  deaths and injuries across the military. Recommendation

To fully implement the four required elements of the new Joint Trauma  System, the Director of the Defense Health Agency should fully  incorporate leading practices—including establishing goals, planning  strategies to achieve goals, identifying and addressing risks, and  assessing progress—in its planning to guide implementation efforts.
Why GAO Did This Study

Traumatic injury is a major cause of death and disability in the military, but improved trauma care has the potential to improve these outcomes. DOD has worked to improve trauma care over time, such as by establishing a Joint Trauma System Defense Center of Excellence to examine trauma care and share best practices.
To improve trauma care across DOD, the NDAA for Fiscal Year 2017 directed DOD to establish a new JTS within DOD's Defense Health Agency. The NDAA requires that the new JTS include four specified elements, and also required DOD to submit to Congress an implementation plan that included the four elements. The NDAA also included a provision for GAO to review DOD's planning for the new JTS.
GAO assessed whether the implementation plan includes the four required elements and the extent to which DOD's planning efforts to date reflect leading practices from prior GAO work, such as identifying goals and strategies to achieve those goals. To conduct its work, GAO assessed DOD's implementation plan and other supplemental planning documents identified by DOD, and interviewed DOD officials.

What GAO Found

The Joint Trauma System (JTS) implementation plan submitted to Congress by the Department of Defense (DOD) in August 2017 includes a description of the four elements required by the National Defense Authorization Act (NDAA) and an overview of implementation activities. For example, it indicates how the Army's current JTS Defense Center of Excellence will become part of DOD's new JTS.
However, the plan and other supplemental planning documents prepared to date do not fully incorporate leading practices for planning as identified by prior GAO work. GAO has previously found that implementation plans incorporating these leading practices—goals, strategies to achieve goals, risks that can affect goals, and plans to assess progress toward goals—help ensure organizations achieve their objectives. For each of the four required elements, GAO found that these leading practices either were partially incorporated or had not been incorporated:
Element 1—Serve as the reference body for all trauma care provided across the military health system. DOD documents include specific goals, such as consolidating data from multiple trauma registries. They also include some strategies to achieve the goals, such as identifying lead offices and time frames to complete specific actions. However, the documents provide limited details on actions DOD plans to take, and do not indicate how DOD plans to address risks or assess its progress.
Element 2—Establish standards of care for trauma care services. DOD documents include a goal to develop, publish, and assess clinical practice guidelines that serve as standards of trauma care. These documents also describe how the new JTS will continue to produce, update, and monitor adherence to the guidelines. However, they do not fully indicate plans to address risks, such as ensuring effective dissemination.
Element 3—Coordinate the translation of research from DOD centers of excellence into standards of clinical trauma care. DOD planning documents do not incorporate any leading practices for this element. DOD officials told GAO that clinical standards incorporate relevant research and that officials responsible for trauma care standards routinely interact with officials responsible for research. Officials expect this practice to continue under the new JTS.
Element 4—Coordinate the incorporation of lessons learned from trauma education and training partnerships into clinical practice. DOD planning documents do not incorporate any leading practices for this element. According to officials, DOD must first establish a separate directorate responsible for partnerships with civilian trauma centers before determining how to incorporate lessons from partnerships into the new JTS.
According to DOD, the JTS implementation plan is a general overview of implementation activities, and planning efforts are ongoing. By not fully incorporating leading practices in its planning documents, DOD may be missing opportunities to ensure that the JTS is effectively implemented, to provide more effective trauma care across the military, and to help reduce trauma-related deaths and disabilities.

What GAO Recommends

GAO recommends that DOD incorporate leading practices in its planning to guide implementation efforts. DOD agreed with the recommendation.