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22대 대한민국 국회 국회정보길라잡이 국회의원검색
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Title page 1

Contents 3

Highlights 2

Letter 5

Background 8

The Military Health System, DHA, and Military Departments 8

Clinical Quality Management 9

DHA and DOD Guidance 11

The Military Departments Are in Varying Stages of Updating Clinical Quality Management Policies for Operational Settings to Align with DHA Procedures 12

Military Departments Generally Follow the Same Process to Report and Manage Patient Safety Events 15

Military Departments Generally Follow the DHA Procedures Manual to Report and Manage Patient Safety Events in Operational Settings... 15

An Updated Patient Safety Reporting System Is Intended to Facilitate Reporting of Patient Safety Events in Operational Settings 19

Military Departments Generally Use DHA's Procedures for Health Care Risk Management Investigations for Operational Settings 21

Military Departments Generally Follow DHA's Procedures Manual for Health Care Risk Management Investigations in Operational Settings 21

Military Departments Are Responsible for Provider Investigations in Operational Settings and Have Taken Steps to Clarify Responsibilities... 24

Concluding Observations 25

Agency Comments 25

Appendix I: Implementation Status of Selected Clinical Quality Management Programs 26

Appendix II: Reported Patient Safety Event Data for Operational Settings, Fiscal Years 2022 Through 2024 28

Appendix III: Additional Health Care Risk Management Activities in Operational Settings 30

Appendix IV: GAO Contact and Staff Acknowledgments 31

Tables 3

Table 1. Military Departments' Efforts to Implement Selected Programs in the Military Health System's Clinical Quality Management Framework, as of March 2026 26

Figures 3

Figure 1. Overview of Defense Health Agency Procedures Manual Process for Reviewing Patient Safety Events Reported in Operational Settings 16

Figure 2. Military Health System Quality Assurance Investigation Process 23

Figure 3. Selected Health Care Risk Management Activities for Operational Settings by Military Department 30

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