FAYETTEVILLE, N.C. -- At any hospital, patient safety and quality of care depend on the willingness of medical workers to identify problems. The goal is for medical workers to be free to speak bluntly to -- and about -- higher-ups without being ignored or punished.
In interviews and email exchanges, many doctors, nurses and other medical workers said military hospitals fall short of that objective, describing how they were brushed off, transferred, investigated, passed over for promotions or fired after they pointed out problems with care.
During an examination of military hospitals this year, The New York Times asked readers to recount their experiences via a private electronic portal. Among more than 1,200 comments were dozens from medical workers about how the system thwarted efforts to deliver superior care.
At Fort Bragg, investigators last March had a special task beyond conducting their periodic evaluation of Womack Army Medical Center, one of the military's busiest hospitals. A medical technologist had complained of dangerous lapses in the prevention of infections. The inspectors planned to follow up.
But Teresa Gilbert, the technologist, said supervisors excluded her from meetings with the inspectors from the Joint Commission, an independent agency that accredits hospitals. "I was told my opinions were not necessary, nor were they warranted," said Gilbert, an infection-control specialist.
The review ended badly for Womack, one of 54 domestic and overseas military hospitals that serve more than 3 million active-duty service members, retirees and family members. The inspectors found fault with infection prevention and many other aspects of care, putting the hospital's accreditation under a cloud for months.
It was disastrous for Gilbert, too. She said she was reprimanded for being an obstructionist, reduced to part-time hours, investigated for what she called trumped-up charges and transferred to a clerk's job.
The message to hospital workers, she said, was clear: "You don't go against us. If you do, we will get you."
Senior military health officials said they were working aggressively to instill a culture in which complaints are welcomed and addressed.
"We want people to come forward," Lt. Gen. Patricia Horoho, the Army surgeon general, said in a statement to the Times. "We are committed to patient safety, we are committed to transparency, and there will be no compromise."
But hospital workers, both military and civilian, described compromise as routine. The nature of military medicine, they said, muddles the emphasis on patient safety and quality of care.
The command structure is so rigid that a nurse can oversee a doctor because the nurse holds a higher military rank. Promotions often reward administrative deeds over medical performance. Legal accountability is diminished: Active-duty service members cannot sue for malpractice, and other patients can sue only the government, not individual doctors or nurses.
An analysis of military hospital data by the Times this year found that preventable errors are chronic and rates of complications, when measured, are high in two cornerstones of treatment: maternity care and surgery. Hospitals also routinely failed to investigate after patients died unexpectedly or suffered permanent harm.
The Pentagon's review, ordered in May by Defense Secretary Chuck Hagel, resulted in orders for improvements at almost every hospital. Senior Pentagon health officials said they were especially concerned by suggestions of a systemwide shortcoming: medical workers' reluctance to identify problems.
More than a dozen physicians and nurses said in interviews that their own experiences illustrated why workers are reluctant. A former military surgeon at Womack said he was passed over for promotion after he said his supervisor had failed to properly examine a patient who later died of cancer. A psychiatrist who worked at Wright-Patterson Air Force Base in Ohio said her supervisor tried to oust her after she complained that residents were not properly supervised. A former anesthesiologist at San Antonio Military Medical Center said his supervisor initiated a review of his credentials after he questioned why she failed to insert a breathing tube in a patient who later died and why another doctor gave the wrong type of blood to a patient.
"Regardless of whether there is the reality of retribution, if there is a perception of one that is going to stifle open discussion," said Vice Adm. Matthew Nathan, the Navy's surgeon general.
One way to counter that is to publicly celebrate whistleblowers' courage, Nathan and other senior health officials said.
For Gilbert, complaining about dangerous lapses in the prevention of infections did not make her a heroine. Instead, she said, it made her a pariah -- shunned by co-workers and marked for dismissal.
Womack is one of the Army's busiest hospitals, serving about 55,000 active-duty service members at Fort Bragg and their families. Gilbert, 51, said she began to raise concerns after the hospital's infection-control chief retired in late 2012 and was replaced by a parade of successors lacking any special training.
Analysts with the Mihalik Group, a health care consulting firm hired to scrutinize the hospital before its accreditation review in March, also were concerned. In a confidential October 2013 report obtained by the Times, they faulted the hospital on nearly 60 performance measures.
Emergency-room patients were improperly screened and charts were incomplete, even for patients undergoing high-risk procedures, the report said. Medication was not labeled with patients' names. One patient was incorrectly categorized as a "do not resuscitate" case. Low-level nurses assessed patients and planned care without the required supervision.
The analysts zeroed in on infection control, warning that the Joint Commission could consider failures there an "immediate threat to life." They found that staff members left unsterilized instruments out for emergency use, failed to properly disinfect medical devices and could not document their competence in sterilization.
"The findings here are extremely serious and put patients at risk," the analysts wrote. "Immediate correction is needed."
Gilbert called the report "frightening." In January, after the hospital failed for three months to act on it, she alerted the Joint Commission.
Two months later, inspectors found the hospital was violating 19 standards, including infection control, management, staff competence and patient safety. The hospital remained accredited, but follow-up inspections were ordered.
In mid-May, a 29-year-old mother of three died after two residents performed a routine tubal ligation and emergency-room nurses failed to identify her case as a priority when she returned that same afternoon in pain.
Already under fire for the accreditation problems, the hospital commander was dismissed and his deputies were replaced. Separately, the Army ordered an investigation into why inspectors had found that the hospital violated infection-control standards. In July, Brig. Gen. Robert Tenhet, the medical commander for the region encompassing Womack, handed Gilbert a letter suggesting that she was to blame.
"While you were quite knowledgeable in your field, you were very difficult to work with," it cited other hospital workers as saying. "Specifically, you were characterized as an obstructionist and someone who withheld critical information." In a statement, Tenhet said he could not discuss individuals but must sometimes counsel staff members about performance issues unrelated to raising patient-safety concerns.
Gilbert was transferred to a clerk's desk, without a computer, telephone or duties. "People I have known for 20 years were afraid to talk to me," she said.
Gilbert said stress-related medical problems forced her to stop working. She received three notices that the hospital intended to fire her. Asked about the case this month, an Army spokesman cited "multiple substantiated disciplinary infractions." On Wednesday, after inquiries from the Times, the Army suspended any action for 60 days.
"I just can't believe the lengths that they are going to," Gilbert said. "Before this, I have never been written up for anything. I have never had a bad evaluation, ever.
"I never imagined it would be like this."
Information for this article was contributed by Andrew W. Lehren of The New York Times.
A Section on 12/21/2014