Article Text

Download PDFPDF
Continuous improvement in healthcare support on NATO operations
  1. Jacopo Frassini
  1. Interoperability Branch, NATO Centre of Excellence for Military Medicine, Budapest, Hungary
  1. Correspondence to Capt Jacopo Frassini, Interoperability Branch, NATO Centre of Excellence for Military Medicine, Budapest, Hungary; interop.doctrine2{at}


An unprecedented characteristic of modern healthcare is the progressive increase in information that is available to provide optimal services to patients. Healthcare organisations need to effectively process information, by identifying proper sources and relevance of evidence in order to outline a credible management system. The North Atlantic Treaty Organization (NATO) Military Committee advocates the provision of evidence-based practices in medical support to deployed forces. Moreover, the changing and adapting requirements to deliver up-to-date medical solutions in NATO must also be balanced against the difficult marriage between warfare and healthcare that demands a strong coordination between medical and non-medical multinational players. Continuous Improvement in Healthcare Support to Operations (CIHSO), originally shaped as part of the plan-refine-execute operational planning process to bring best standards of care to troops in a well-defined combat scenario, represents a powerful transformational opportunity to translate evolving knowledge into best military medical practices. The aim of this paper is to discuss areas of possible intervention where CIHSO can enhance quality and safety in allied healthcare systems by progressing from an operational application of clinical governance into a strategic evidence-based decision-making medical tool of the Alliance.

  • clinical governance
  • quality in health care
  • health & safety
  • protocols & guidelines
  • international health services

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


Allied Nations are responsible for their fighting force and rely on their own systems of command and control in order to monitor and manage the quality of healthcare during combat operations.1 Clinical governance of deployed medical units is also specific for each operational environment and the health-related risk mitigation must be rapidly adaptive according to evolving situations. In the general policies for the provision of allied medical support, the North Atlantic Treaty Organization (NATO) Military Committee states that ‘medical care is based on internationally accepted best medical practice’ and that ‘a quality assurance system—is established—in order to achieve continuous improvement in healthcare support on operations’.2 NATO Doctrine further defines how ‘CIHSO assures, that the healthcare provided is meeting the standards expected, that challenges are acknowledged and reflected within a plan-refine-execute process and that experience is used to optimise healthcare support on operations’.1 CIHSO results from the integration of: ‘risk management, sharing best practice, sustaining a learning organisation and building capacity’,1 which are not confined functions of the operational level. Multinational medical initiatives grow constantly during the preparation of individual deployments and reach out to the process of transformation aiming at long-term objectives. This represents an advancing supranational level of clinical governance that requires unprecedented coordination in identifying best internationally accepted standards of care, joint efforts in the development of shared medical capabilities and agreed initiatives for new concepts. CIHSO in NATO can finally be achieved when clinical governance in individual operations results from a strong evidence-based allied medical doctrine that guides decisions of operational commands which bear the final burden of deciding on patient outcomes in already difficult combat conditions.


CIHSO represents an evolution of clinical governance in NATO policy as a process to ensure quality in deployed healthcare systems.3 4 Clinical governance is a framework through which healthcare organisations are accountable for continuously improving the quality of their services and safe-guarding high standards of care by creating an environment in which excellence in clinical care will flourish.5–7 In operations, clinical governance starts with all available input sources from the operational and medical performance of allied healthcare systems and ends with the appraisal of the same figures after implementing specific corrections supported by evidence (plan-refine-execute cycle in Figure 1). However, in NATO evidence is not synthesised by deployed commands but by Nations during the NATO Standardization Process which offers the environment where medical evidence periodically meets combat support requirements (standardization cycle in Figure 1). On these occasions, evidence is discussed in groups of national medical representatives in order to find the best agreement among individual allies to achieve military effectiveness with the adoption of best collectively agreed solutions. At this stage, Nations make informed decisions on whether to undertake specific interventions before ratification of the agreed standards. After promulgation, improvements go into the national chain of command and control and are executed in NATO campaigns, becoming the operational, mission-specific branch of CIHSO. Consequently, the quality of the decision-making process in allied strategic-level medical bodies drives the quality by which CIHSO engages the standardization process and ultimately supports the achievement of best possible patient outcomes in multinational healthcare systems. Outcomes are finally monitored, becoming inputs again and close the cycle (Figure 2).

Figure 1

Connections in the allied processes of transformation, standardization and plan-refine-execute in the medical domain and the area where CIHSO can be applied to deliver best evidence-based practices into operations. CIHSO, Continuous Improvement in Healthcare Support to Operations; CJHQ, combined joint headquarters.

Figure 2

Continuous Improvement in Healthcare Support to Operations in the standardization process and national area of influence.

Medical standardization in NATO is very similar to the development of medical guidelines which are the product of a systematic review of evidence with the final release of graded recommendations on the largest expert consensus.8 9 According to WHO, evidence-based recommendations for public health policies tell intended end-users what should be done in specific situations to achieve the best health outcomes possible, individually and collectively.10 Recommendations resulting from the work of NATO Medical Boards, Working Groups and Panels inevitably shape the body of guidelines intended to have an anticipated positive impact on health in operations, either as a direct action or as an indirect effect on the use of military resources for medical purposes. It requires a transparent methodological framework controlled by a learning environment where experience can be reliably processed into knowledge. In addition to medical standardization, the NATO Transformation Process is a continuous and proactive process of exploring, developing and integrating innovative concepts, doctrine and capabilities to improve the effectiveness and interoperability of military forces (transformation cycle in Figure 1).11 Transformation supports the medical learning environment by directing the efforts to the strategic objectives of the Alliance but does not influence current operations on the short term. In order to rapidly bring the benefits of evolving knowledge in all NATO operations, CIHSO is the medical tool that links transformation to patient outcomes by negotiating evidence-based solutions at the proper level of the allied decision-making processes. Clinical governance can be considered as the result of three main features of modern military healthcare organisations: accountability for safety and risk management, quality in the selection of the standards and improvement in performance (Figure 3).

Figure 3

The three pillars supporting clinical governance from evidence-based practices: accountability, standards and improvement.


CIHSO does not mandate any new structure in the NATO system, except that designated responsibility for clinical governance must exist. While accountability for strategic guidance originates from the decisions collectively taken by Nations, it is more difficult to outline the obligations of various medical players involved in the planning and execution of NATO operations as to who should translate the principle of clinical governance into locally appropriate structures, processes, roles and responsibilities. Along with the increase of difficulties to provide the full spectrum of medical services to their own troops, multinational initiatives have been rising to share the burden of medical support.12 Without the corresponding development of a quality management system, the growing number of multinational solutions may imply more fragmentation in accountability and lack in transparency in the organisation of services. For example, in the fragmented scenario of a typical allied aeromedical evacuation system (Figure 4), NATO operational commanders and their medical staff represent the only authorities in the Joint Operational Area to regulate patients through the continuum of care and to be aware of the current practical options to outreach the full spectrum of medical capabilities before returning patients to national responsibility. Reasonably, the operational branch of CIHSO should be considered part of the medical annex of the Operation Plan (OPLAN) and incorporated into the executive tasks of the medical staff at all levels of command providing clear roles, traceable decisions and unequivocal responsibilities for a continuous improvement of the healthcare performance.

Figure 4

Deployed aeromedical evacuation system and simplified separation of medical responsibility among allied contributors (picture design by LT Ákos Szénási, NATO Centre of Excellence for Military Medicine). NATO, North Atlantic Treaty Organization.

However, deployed NATO headquarters cannot be considered accountable for the care delivered in the most tactical and strategic zones of the medical support (green areas in Figure 4), where Troop Contributing Nations are still the main risk owners and develop military capabilities in accordance with their level of ambition. In order to include medical performance indicators generated in the battlefield or homeland hospitals, National authorities should be able to share sensitive information that is restricted at more levels in national regulations. For this reason, CIHSO in NATO is not a comprehensive tool of clinical governance, starting at the point of injury up to definite outcome, but a quality management system limited to the multinational domain of the healthcare support on allied operations (blue area in Figure 4).

The important role of the NATO standardization process is based on the opportunity of Nations to cover this gap and grow a common understanding of their medical capabilities, procedures, guidelines and best practice used in the deep area of national responsibility. The periodic meetings of Working Groups create an environment of mutual trust where national medical experience, protected by different regulations in its originating data, is presented as releasable evidence supporting the development of evidence-based standards that make CIHSO an effective learning system.


A NATO standard is defined as a document, established by consensus and approved by a recognised body within the NATO standardization process, that provides, for common and repeated use, rules, guidelines or characteristics for activities or their results, aimed at the achievement of the optimum degree of order in a given context.13 However, it remains a National decision to fully or partially comply with NATO standards when developing their own standards of care. The rapidly growing popularity of collective healthcare solutions might paradoxically increase the risk of losing track of what standard of care is currently applied in a specific operation or area. In order to prevent confusion, CIHSO offers a platform where standards of care are harmonised, deconflicted and prioritised so that Troop Contributing Nations do not need to be individually engaged in the direct provision of care to their troops, but only make sure that their troops are supported by a deployed healthcare system structured according to the agreed standards. Allied standards are meant to provide a minimum common background to enhance synergies among Nations and assist interoperability in collective defence.13–16

It is also important to understand that NATO posture results from a more comprehensive process where agreed solutions in the Alliance have a hierarchy according to the kind of publication in which they are stated.17 In the highest place of the pyramid (Figure 5), the top-level National representatives set principles and policies, then doctrine is developed accordingly by selected groups of experts and then down to the tactical documents required by military leaders in operations. Similarly, NATO medical standards correspond to the relevance that is assigned to the respective document and subordinated publications must comply with the originating documents in order to avoid misperception in precedence and role. Allied medical doctrine explains how things are done and has a direct effect on clinical outcomes of patients when considered as a community of individuals. NATO defines doctrine as ‘fundamental principles by which the military forces guide their actions in support of objectives’.18 While focusing on the operational-level, doctrine promotes a common perspective from which to plan, train and conduct operations and represents what is taught, believed and advocated as best practice.18 Medical guidelines resulting from the standardization process are non-mandatory best practices intended to facilitate understanding and implementation of allied standards in the clinical domain by single medical end-users.10

Figure 5

Pyramid representing the hierarchy in NATO Allied documents (credit: modified from NATO ADL Medical Standardization Course17) showing the area of influence of Continuous Improvement in Healthcare Support to Operations (CIHSO).

Allied publications cannot be typically considered only recommendations, but directions to a wide military audience resulting from international agreements on interoperability requirements,13 which might interfere with the medical flexibility in the individual decision-making process for providing care in specific circumstances. For this reason, allied publications should not be interpreted as clinical directions but planning references and do not represent an exclusive medical dictum. However, the standardization process is the phase where medical evidence meets the hierarchy of NATO documents, the standardization process is the phase where medical evidence meets the hierarchy of NATO documents and where medical decisions are most probable to affect patient outcomes on large numbers.

To help CIHSO achieve a modern methodology, military medical experts should assess proposed solutions entering the NATO standardization process according to their effect on patient outcomes. Medical evidence should be collected and qualified to separately develop planning tools or clinical recommendations (Figure 6). Planning references go into allied publications to be used by the whole military community (ie, the 10-1-2(+2) timeline). Standards of care, intended for medical practitioners, are collected in clinical guidelines representing a set of referenced and graded recommendations (ie, the use of blood products in prehospital settings). Medical practitioners at either tactical-level or operational-level will so have granted their flexibility to fit prioritised, evidence-based recommendations to the individual clinical circumstances and combat scenario to reach the best possible patient outcomes. Fortunately, medicine is an already standardized profession in the Western world and the selection of standards of care as clinical guidelines is expected to be much easier than the process of identifying medical planning references that are more subject to national variability.13 The NATO methodology in the development of standards 13 does not need to change to include CIHSO. CIHSO affects the production of medical guidelines and not of Allied Publications, which can be cleared of all clinical content and related implications. At the same time, allied nations are assisted by a modern evidence-based methodology to support with transparency the development of either medical planning solutions or recommendations to effectively address military operations under separated organisational and clinical perspectives.

Figure 6

Proposed diagram to separate doctrine development from clinical guidelines.


In a learning organisation, improvement refers to the optimisation of already existing solutions and considers future as a result of change, which necessarily adds uncertainty to consolidated praxes. When change can be controlled, best medical practice is still supported by scientifically validated experience and leads to predictable patient outcomes because applied processes have solid grounds connected with proven results. CIHSO is a quality management system focusing on practical solutions for the medical operational level by enhancing synergies in the Alliance and contributing to increasing transparency, simplicity and cohesion. Modern collective defence is constantly challenged by an array of rapidly changing situations and threats.19 20 Consequently, military healthcare systems are potentially exposed to uncontrolled change which contrasts with the idea of a measured optimisation of applied solutions and requires the development of new approaches that may have disrupting consequences on previous routines. In this dynamic environment, CIHSO alone may not have a definite answer but can support conceptualisation of change by reducing uncertainty with available knowledge and rapidly link transformational concepts to tactical requirements. In order to deliver quality in allied operations and achieve military medical advantage in novel scenarios, CIHSO needs to rely on a perspective, an environment and a body of rules.

The perspective

Medicine does not have evidence for everything but gaps in knowledge can be mitigated by applying established models to novel challenges. Analogies with available experience must be analysed, and corrections supported by logical decision makings. The convincing convergence of multiple independent assumptions and the impartial collection of relevant supportive references help to identify performance end points, select tolerance margins, outline mitigations, plan alternatives and choose adequate metrics in order to pursue credible targets through CIHSO as a result of flexible decision-making processes.

The environment

Healthcare support systems are not stand-alone services in the military. Differently from civilian organisations, they are part of wide operational community driven by military requirements and military objectives. Military medicine deeply differs from other domains of medicine where clinical evidence is assessed in clinical environments, meaning that recommendations are given on the healthcare needs where other financial, technical and logistic services are in a supportive position towards clinical requirements. CIHSO is deeply constrained by the context in which medical practices are meant to exist. Clinical evidence can support clinical solutions in clinical environments that are not deliverable in military campaigns. A comprehensive tactical awareness is a primary requisite to assess whether common medical practices have substantially different outcomes in combat operations compared with other settings and if specific medical solutions provided through military systems achieve results that are not applicable elsewhere. The consequences of injecting new medical solutions in a multidisciplinary environment where medicine is mainly a supporting service should not be underestimated. A realistic and holistic assessment focused on the military objectives is needed to balance the risk of competition for resources among combat support services and to deconflict ethical obligations within the combat environment in order to provide sustainable mission success.

The rules

A characteristic of modern medicine is the progressive increase in information that is available to deliver optimal practice and protect the fighting force. Fragmentation of medical doctrine in different allied publications increases the risk of losing that wanted core collective understanding to sustain operational efforts with durable interoperable solutions.14 The body of allied medical publications resulting from the NATO standardization process should be clear, simple, transparent, widely applicable, acceptable and accessible.15 Where possible, ‘new’ NATO standards should not be new at all, but chosen among established standards from the national or international level.13 Such mechanisms lead to the reduction of redundant concepts, repeated definitions and conflicting notions that make medical doctrine vulnerable to unsynchronised changes and interoperability gaps. CIHSO represents an opportunity to maintain coherence and effectiveness in medical standardization by providing a single quality checkpoint in support to the development of medical doctrine.


CIHSO is an evolution of clinical governance in NATO policy as a process to ensure quality and safety in deployed healthcare systems. Clinical governance can succeed in delivering best medical practice deep into NATO campaigns if accountability is acknowledged at all levels of leadership. In multinational allied environments, quality of care starts with the identification of agreed medical standards related to operational and medical requirements with implications on patient outcomes. Consequently, it is important to differentiate those standards intended to be used as planning references by the whole military community from those intended as clinical recommendations for best medical practice. In highly dynamic military systems exposed to mutable threats, allied healthcare support must be able to adapt quickly and improve by setting measurable targets of performance, reduce vulnerability in applied methods and keep an acceptable balance between feasibility of medical solutions and their sustainability in an operational environment.

Ethics statements

Patient consent for publication



  • Disclaimer No direct funds have been used to produce this manuscript, the author wrote this contribute by his own initiative within the approved activities of his duties.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.