This paper discusses the emerging concept of Continuous Improvement in Healthcare Support to Operations (CIHSO) recently introduced within NATO. It starts by summarising the developments in NATO policy regarding clinical governance and how this has evolved into CIHSO before examining the operational aspects of CIHSO within the Plan-Refine-Execute (PRE) process of operational planning process. It then looks at the components of a CIHSO system as it might apply to the deployed military healthcare system covering the functions of medical and tactical evacuation, deployed hospital care and executing medical operations. The last stage of PRE should include assessment through the tracking of key performance indicators of the military medical system. The UK and American systems of assurance for the deployed trauma system are reviewed as part of the clinical aspect of CIHSO, as well as consideration some of the emerging issues in the management of CIHSO in a multinational environment.

This paper considers the strategic aspects of medical support to military operations as delivered through multi-national collaboration. The military medical services are in essence a people organisation; the purpose of the organisation is primarily to support the people engaged in military operations, and also the people providing healthcare to them. Increasingly, supporting the latter also includes preparation for the ethical dilemmas that they will face. Providing health advice and healthcare on operations is now usually undertaken on a multinational basis, in order to generate sufficient medical capacity to meet the requirement with assets of the appropriate (and NATO mandated) capability. This will be an enduring feature, particularly in light of increasing costs of providing high quality healthcare and the operational and logistic challenges of delivering this capability in adverse environments, and in the context of medical personnel being a limited resource. The key to overcoming the challenges, often the result of the "people issues" such as cultural differences, is to recognise the value that the inherent diversity of multinational healthcare provision brings. The benefit is realised through sharing best practice, and the lessons from challenges met, as well as through burden sharing, and to understand that challenges are most commonly the result of misunderstandings, such as those inherent in language differences. The advice for those bringing a multinational team together includes considering the implications of culture (noting differences in national and military perspectives, and in medical processes such as clinical governance), to ensure effective communication, and to utilise feedback to confirm understanding. It is important not to prejudge or denigrate others. Share information and knowledge, provide positive reinforcement when things go well, and recognise that there will inevitably be challenges and use these as an opportunity to learn. Above all, the personal touch builds a culture within the multinational team that transcends national culture; celebrating success breeds success and thus optimal outcome for patients.

The humanitarian aid experience of a unit in Bosnia is described. Data are presented for primary care clinics undertaken, showing the range of conditions and age of patients seen. The role of the civilian aid agencies involved is described, together with recommendations for future training requirements for similar operations.

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