Military Personnel
Enhanced Collaboration and Process Improvements Needed for Determining Military Treatment Facility Medical Personnel Requirements Gao ID: GAO-10-696 July 29, 2010Military medical personnel, who are essential to maintaining one of the largest and most complex health systems in the nation, are in great demand due to the need to treat injured or ill servicemembers, and advances in technology that require specialized personnel. To determine how well the Department of Defense (DOD) and the services are developing their medical and dental personnel requirements, GAO evaluated (1) the extent to which the services have incorporated cross-service collaboration in their medical personnel requirement processes, and (2) the service-specific processes for determining their requirements for military and civilian medical personnel. To conduct this review, GAO evaluated manpower policies, analyzed the services' requirements data and determination processes, and interviewed officials from the Office of the Secretary of Defense (OSD) and each of the services.
While DOD's 2007 Military Health System Human Capital Strategic Plan emphasizes developing human capital solutions across the services to enable departmentwide decision making and analyses, the services' collaborative planning efforts regarding requirements determination for medical personnel working in fixed military treatment facilities have been limited. In one effort to integrate operations, DOD is consolidating medical facilities in the Washington, D.C., area under a joint task force that calls for joint staffing of the military treatment facilities in the region. However, officials have faced challenges in developing the manpower requirements for the joint facilities due to the use of outdated planning assumptions. Separately, the Office of the Secretary of Defense (OSD) sponsored another joint medical effort to develop a cross-service medical manpower standard for mental health personnel. This standard is being used to determine the amount of personnel needed to meet common, day-to-day psychological health needs of eligible beneficiaries across the services. However, to date, this standard is the only one of its kind, and OSD officials said that no other similar efforts currently exist. The services' continued focus on separate medical personnel requirements processes may not be consistent with the DOD strategic plan's vision of a more integrated approach, and the services may have missed opportunities to collaborate and develop cross-service manpower standards for common medical capabilities that are shared across military treatment facilities. Sustained and committed leadership emphasis on developing more effective ways of doing business, such as the use of cross-service medical manpower standards, is key to successful, collaborative human capital strategic planning. To the extent that the services need to maintain separate processes, GAO also found that their requirements processes are not, in all cases, validated and verifiable, as DOD policy requires. Selected specialty modules in the Army's model contain some outdated assumptions, such as the level of care currently being provided, and only a portion of the modules have been completely validated. While the Navy has employed an approach that uses current manning as a baseline and adjusts its requirements based on emerging needs or major changes to missions, the approach is not validated or verified as required by DOD guidance. The Air Force said it may not know its true medical requirements as the model it has relied on also is not currently validated or verified. Each of the services has recognized the need to have processes that can be validated and verified, and has taken steps to address these issues in recent years. However, without processes that are validated and verifiable, the services cannot be certain they are determining their medical personnel requirements in the most effective and efficient manner. Also, the services do not centrally manage their processes for their civilian medical personnel requirements. While local commanders determine these requirements, the services may be missing the opportunity to make a strategic determination of how many civilian medical professionals are needed to carry out their expected workloads. GAO recommends that OSD and the services emphasize a long-term joint approach to medical personnel requirements determination by identifying the common medical capabilities shared across the services and developing cross-service medical manpower standards, where applicable; and that the services take actions to improve their respective medical requirements determination processes. In written comments to a draft of this report, DOD generally concurred with these recommendations.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Brenda S. Farrell Team: Government Accountability Office: Defense Capabilities and Management Phone: (202) 512-3604GAO-10-696, Military Personnel: Enhanced Collaboration and Process Improvements Needed for Determining Military Treatment Facility Medical Personnel Requirements
This is the accessible text file for GAO report number GAO-10-696
entitled 'Military Personnel: Enhanced Collaboration and Process
Improvements Needed for Determining Military Treatment Facility
Medical Personnel Requirements' which was released on July 29, 2010.
This text file was formatted by the U.S. Government Accountability
Office (GAO) to be accessible to users with visual impairments, as
part of a longer term project to improve GAO products' accessibility.
Every attempt has been made to maintain the structural and data
integrity of the original printed product. Accessibility features,
such as text descriptions of tables, consecutively numbered footnotes
placed at the end of the file, and the text of agency comment letters,
are provided but may not exactly duplicate the presentation or format
of the printed version. The portable document format (PDF) file is an
exact electronic replica of the printed version. We welcome your
feedback. Please E-mail your comments regarding the contents or
accessibility features of this document to Webmaster@gao.gov.
This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed
in its entirety without further permission from GAO. Because this work
may contain copyrighted images or other material, permission from the
copyright holder may be necessary if you wish to reproduce this
material separately.
Report to Congressional Committees:
United States Government Accountability Office:
GAO:
July 2010:
Military Personnel:
Enhanced Collaboration and Process Improvements Needed for Determining
Military Treatment Facility Medical Personnel Requirements:
GAO-10-696:
GAO Highlights:
Highlights of GAO-10-696, a report to congressional committees.
Why GAO Did This Study:
Military medical personnel, who are essential to maintaining one of
the largest and most complex health systems in the nation, are in
great demand due to the need to treat injured or ill servicemembers,
and advances in technology that require specialized personnel. To
determine how well the Department of Defense (DOD) and the services
are developing their medical and dental personnel requirements, GAO
evaluated (1) the extent to which the services have incorporated cross-
service collaboration in their medical personnel requirement
processes, and (2) the service-specific processes for determining
their requirements for military and civilian medical personnel. To
conduct this review, GAO evaluated manpower policies, analyzed the
services‘ requirements data and determination processes, and
interviewed officials from the Office of the Secretary of Defense
(OSD) and each of the services.
What GAO Found:
While DOD‘s 2007 Military Health System Human Capital Strategic Plan
emphasizes developing human capital solutions across the services to
enable departmentwide decision making and analyses, the services‘
collaborative planning efforts regarding requirements determination
for medical personnel working in fixed military treatment facilities
have been limited. In one effort to integrate operations, DOD is
consolidating medical facilities in the Washington, D.C., area under a
joint task force that calls for joint staffing of the military
treatment facilities in the region. However, officials have faced
challenges in developing the manpower requirements for the joint
facilities due to the use of outdated planning assumptions.
Separately, the Office of the Secretary of Defense (OSD) sponsored
another joint medical effort to develop a cross-service medical
manpower standard for mental health personnel. This standard is being
used to determine the amount of personnel needed to meet common, day-
to-day psychological health needs of eligible beneficiaries across the
services. However, to date, this standard is the only one of its kind,
and OSD officials said that no other similar efforts currently exist.
The services‘ continued focus on separate medical personnel
requirements processes may not be consistent with the DOD strategic plan
‘s vision of a more integrated approach, and the services may have
missed opportunities to collaborate and develop cross-service manpower
standards for common medical capabilities that are shared across
military treatment facilities. Sustained and committed leadership
emphasis on developing more effective ways of doing business, such as
the use of cross-service medical manpower standards, is key to
successful, collaborative human capital strategic planning.
To the extent that the services need to maintain separate processes,
GAO also found that their requirements processes are not, in all
cases, validated and verifiable, as DOD policy requires. Selected
specialty modules in the Army‘s model contain some outdated
assumptions, such as the level of care currently being provided, and
only a portion of the modules have been completely validated. While
the Navy has employed an approach that uses current manning as a
baseline and adjusts its requirements based on emerging needs or major
changes to missions, the approach is not validated or verified as
required by DOD guidance. The Air Force said it may not know its true
medical requirements as the model it has relied on also is not
currently validated or verified. Each of the services has recognized
the need to have processes that can be validated and verified, and has
taken steps to address these issues in recent years. However, without
processes that are validated and verifiable, the services cannot be
certain they are determining their medical personnel requirements in
the most effective and efficient manner. Also, the services do not
centrally manage their processes for their civilian medical personnel
requirements. While local commanders determine these requirements, the
services may be missing the opportunity to make a strategic
determination of how many civilian medical professionals are needed to
carry out their expected workloads.
What GAO Recommends:
GAO recommends that OSD and the services emphasize a long-term joint
approach to medical personnel requirements determination by
identifying the common medical capabilities shared across the services
and developing cross-service medical manpower standards, where
applicable; and that the services take actions to improve their
respective medical requirements determination processes. In written
comments to a draft of this report, DOD generally concurred with these
recommendations.
View [hyperlink, http://www.gao.gov/products/GAO-10-696] or key
components. For more information, contact Brenda S. Farrell at (202)
512-3604 or farrellb@gao.gov.
[End of section]
Contents:
Letter:
Background:
DOD's Policy Emphasizes Jointness, although the Services'
Collaborative Efforts in Determining Medical Personnel Requirements
Have Been Limited:
The Services' Respective Processes for Developing Requirements Are Not
in All Cases, Validated and Verifiable, and Do Not Centrally Account
for Civilian Personnel Requirements:
Conclusions:
Recommendations for Executive Action:
Agency Comments and our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: Summary of Fiscal Year 2009 Active Duty Medical Personnel
Levels:
Appendix III: Comments from the Department of Defense:
Appendix IV: GAO Contacts and Staff Acknowledgments:
Table:
Table 1: Fiscal Year 2009 Requirements, Authorized Positions, and End
Strengths by Service and Specialty:
Figures:
Figure 1: Distribution of Active Duty, Reserve, and Civilian Workforce
in Total and Specifically for Medical Workforce, by Service:
Figure 2: Distribution of Active Duty Medical Personnel by Specialty:
Abbreviations:
BRAC: Base Realignment and Closure:
DOD: Department of Defense:
GAO: Government Accountability Office:
OSD: Office of the Secretary of Defense:
PHRAMS: Psychological Health Risk-Adjusted Model for Staffing:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
July 29, 2010:
Congressional Committees:
The physicians, dentists, nurses, and other health care personnel who
work for the Department of Defense (DOD) are in great demand due to
projected nationwide medical personnel shortages over the next decade
and are essential to maintaining DOD's substantial health care
delivery capability, which provides a full range of medical care to
active duty military personnel and all other eligible beneficiaries
sometimes at no cost.[Footnote 1] With more than 9.6 million eligible
beneficiaries receiving care from DOD's 59 inpatient medical
facilities, 364 health clinics, and, at times, private-sector
providers, the cost of DOD's medical system has risen from $17.4
billion in fiscal year 2000[Footnote 2] to approximately $50 billion
in fiscal year 2010, and it currently represents more than 9 percent
of the DOD budget. Moreover, health care costs are expected to
continue to escalate in the future. Because this amount does not
include the cost of health care that is needed overseas to support two
concurrent wars, or the costs to recruit and retain military
personnel, the total amount DOD is spending on military health care is
even higher. U.S. forces are expected to continue operations in Iraq
and Afghanistan and, as a result, add to the workload of military
treatment facilities for servicemembers who become injured or ill.
Although tremendous advances in military medicine have led to reduced
mortality rates among U.S. servicemembers, these patients may require
lengthy hospital stays and extensive rehabilitation with highly
trained staff to meet their medical care needs. A higher demand for
health care personnel is also anticipated due to the increased numbers
of overall personnel in both the Army and the Marine Corps from an
effort known as Grow the Force. Key in its efforts to address the
challenge of managing the medical forces across the services and
determining the right number and mix of medical personnel to meet the
various needs of the Military Health System is DOD's plan to promote
collaboration and integration in human capital management, while
simultaneously respecting service-specific doctrine. Further, DOD's
implementation of several strategic initiatives, such as Base
Realignment and Closure decisions and the development of several joint
ventures under its evolving framework for a Joint/Unified Medical
Command, have forced the department to undertake steps designed to re-
examine, among other things, its medical personnel requirements.
Our previous work has highlighted a range of long-standing issues
surrounding DOD's Military Health System. For example, we reported in
March 1995 that interservice rivalries and conflicting
responsibilities hindered Military Health System improvement efforts.
[Footnote 3] We noted in that report that the services have
historically resisted efforts to change, preferring to maintain their
own health care systems, primarily on the grounds that each service
has unique medical activities and requirements. In our February 2005
report on challenges facing the U.S. government in the 21st century,
we identified DOD's health care system as an area in which DOD could
achieve economies of scale and improve delivery by combining,
realigning, or otherwise changing selected support functions.[Footnote
4] That report noted that although DOD's civilian and military leaders
appear committed to reform, DOD must overcome cultural resistance in
the individual services, as well as the inertia of various
organizations, policies, and practices (such as "stovepiping" or
compartmentalizing of information or functions) that became well
rooted in the Cold War era. In October 2007, we reported that DOD had
taken incremental steps toward improving efficiencies within its
Military Health System by establishing a joint medical effort in the
National Capital Region, as well as the Joint Medical Education and
Training Center in San Antonio, Texas.[Footnote 5] While we recognized
that incremental improvements are sometimes appropriate, we
recommended that DOD take steps to measure whether its efforts were
meeting the goal of eliminating unnecessary duplication. DOD concurred
with this recommendation and has identified the steps that the
department has taken to address it. Further, DOD's April 2006
Quadrennial Defense Review Roadmap for Medical Transformation
recognized the department's need to transform its Military Health
System, and the 2010 Quadrennial Defense Review acknowledged that DOD
needs to reform the way in which it does business and to eliminate
challenges that hinder its success.
The Senate Armed Services Committee, in its report accompanying the
National Defense Authorization Act for Fiscal Year 2009, directed GAO
to report to congressional defense committees on medical and dental
personnel requirements of the Departments of the Army, Navy, and Air
Force, including their reserve components, in order to, among other
things, meet their medical missions in support of contingency
operations and deliver high quality health care to eligible
beneficiaries.[Footnote 6] In April 2009, we responded to that mandate
in a published briefing to the defense committees on personnel
authorizations and end strengths, by medical specialty.[Footnote 7]
Subsequently, we agreed with congressional defense committees to
undertake additional related work and initiated two reviews on issues
related to military medical and dental personnel requirements in
support of (1) fixed military treatment facilities and (2) contingency
operations in Iraq and Afghanistan.[Footnote 8] For this report, we
focused on medical and dental personnel requirements in support of
DOD's fixed military treatment facilities. We evaluated (1) the extent
to which the services have incorporated cross-service collaboration in
their planning efforts for determining their medical personnel
requirements, and (2) the service-specific processes for determining
their requirements for military and civilian medical personnel.
For our first objective, we analyzed DOD and Army, Navy, and Air Force
policies, directives, and other relevant strategic planning documents.
We also obtained and analyzed memoranda and other documents related to
DOD and the services' ongoing collaborative efforts. Further, we
interviewed various officials from the Office of the Assistant
Secretary of Defense for Health Affairs and each of the services to
obtain a more detailed understanding of the history, objectives,
status, and challenges of their ongoing cross-service medical efforts.
For our second objective, we analyzed instructions concerning
personnel management procedures from each of the services. We also
obtained and examined personnel requirements and authorized positions
data for selected medical specialties for fiscal year 2009 and
evaluated the reliability of the data we obtained and analyzed. We
found it sufficiently reliable for the purposes of this audit.
Additionally, we obtained and analyzed existing service requirements
models in use and interviewed officials from each of the services in
order to understand the processes they implement to determine their
specific service's medical personnel requirements. For more detailed
information on our scope and methodology, see appendix I.
We conducted this performance audit from August 2009 through July 2010
in accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe
that the evidence obtained provides a reasonable basis for our
findings and conclusions based on our audit objectives.
Background:
DOD's medical mission is twofold in that it maintains a readiness
mission and a benefits mission. The readiness mission requires DOD to
maintain the needed availability of its uniformed medical personnel in
order to support the armed forces during military operations. The
benefits mission provides servicemembers, retirees, and their
dependents with access to health care at its military hospitals and
clinics throughout the United States and overseas. Military medical
personnel are essential to maintaining DOD's large and complex health
system and are in great demand because of the need to treat injured or
ill servicemembers and due to advances in medical technologies that
require specialized personnel. They simultaneously support contingency
operations, military operations that are more routine in nature,
medical research efforts, and the delivery of beneficiary health care
to patients across the globe.
The management organization of DOD's Military Health System comprises
many levels. The Assistant Secretary of Defense for Health Affairs
[Footnote 9] is the principal advisor for all DOD health policies,
programs, and force health protection activities, and this official
reports to the Under Secretary of Defense for Personnel and Readiness,
who in turn reports to the Secretary of Defense. Health Affairs issues
policies, procedures, and standards that govern DOD medical programs
and has the authority to issue DOD instructions, publications, and
directive-type memoranda that implement policy approved by the
Secretary of Defense. It integrates the services' submissions and
prepares, presents, and justifies a unified medical budget that
provides resources for the Military Health System. Health Affairs is
also authorized to communicate directly with the heads of DOD
components regarding these issues.[Footnote 10] Additionally, Health
Affairs develops policies and standards to ensure effective and
efficient results through the approved joint process for joint medical
capabilities integration, clinical standardization, and operational
validation of all medical material.
The Secretaries of the Departments of the Army, Navy, and Air Force
are responsible (subject to the authority, direction, and control of
the Secretary of Defense) for the operation and efficiency of their
departments. In addition, the service secretaries issue implementation
instructions to their departments based on policies that Health
Affairs develops. By law, the service secretaries are also responsible
(again, subject to the authority, direction, and control of the
Secretary of Defense) for promoting cooperation and coordination among
the military departments and defense agencies to provide effective,
efficient, and economical administration, and to eliminate
duplication.[Footnote 11]
The Army, Navy, and Air Force have their own Surgeons General who have
overall responsibility for medical operations within their respective
departments.[Footnote 12] Within the Army, the Army Surgeon General
simultaneously heads the Army Medical Department and the Army Medical
Command. In leading the Army Medical Department, the Surgeon General
serves as the primary advisor to the Secretary of the Army on all
health and medical issues. In addition, the Army Surgeon General has
overall responsibility for the Armywide health services system to
include development, policy direction, organization, and management of
the system through such activities as recruiting, organizing,
equipping, supplying, and training, as assigned by the Secretary of
the Army. As the Commanding General of the Army Medical Command, the
Surgeon General leads five regional medical commands and their fixed
military treatment facilities, and other Army Medical Department
agencies. The Navy Surgeon General serves as the Director of Naval
Medicine and is the Chief of the Navy Bureau of Medicine and Surgery.
As the director of Naval Medicine, the Surgeon General is the
principal advisor to the Chief of Naval Operations on health care
service programs for the Department of the Navy, and develops and
issues health care policies and directions. As the chief of the Navy
Bureau of Medicine and Surgery, the Surgeon General oversees the
delivery of health care in the Navy and Marine Corps and commands the
Navy shore medical facilities. The Air Force Surgeon General is that
service's most senior medical officer and head of the Air Force
Medical Service. The Air Force Surgeon General is responsible for
guidance, direction, and oversight for all matters pertaining to the
formulation, review, and execution of plans, policies, programs, and
budgets related to carrying out the mission of the Air Force Medical
System to provide for the health care of Air Force personnel and their
families.
The service medical components contribute to the Military Health
System missions by operating military treatment facilities throughout
the United States and the world. These facilities consist of 59
hospitals capable of providing diagnostic, therapeutic, and inpatient
care, as well as hundreds of clinics that primarily handle health
screenings and ambulatory care. The Army, Navy, and Air Force staff
their military treatment facilities with active duty, reserve, and
civilian personnel. Contractors also play a role in the execution of
the Military Health System mission by providing medical, clinical, and
administrative staff and support services within both the military
treatment facilities and the network of private hospitals and
providers in the community. Reliance on contractors in the medical
community varies by location and need. DOD is not required by law to
include the number of medical contractors it employs in its annual
Defense Manpower Requirements Report; therefore, the number of medical
contractors onboard at any point in time is not readily available.
DOD's medical force is comprised of approximately 228,000 personnel,
including about 116,000 active duty personnel, 67,000 reserve
component personnel, and 45,000 civilians. As seen in figure 1, the
distribution of the medical workforce is fairly proportional to the
distribution of the total workforce for each of the three services.
Figure 1: Distribution of Active Duty, Reserve, and Civilian Workforce
in Total and Specifically for Medical Workforce, by Service:
[Refer to PDF for image: 2 pie-charts]
Distribution of total workforce:
Air Force: 679,100: 24%;
Navy: 819,900: 29%;
Army: 1,310,100: 47%.
Distribution of medical workforce:
Air Force: 54,098: 24%;
Navy: 52,576: 23%;
Army: 121,432: 53%.
Source: Fiscal Year 2009 Defense Manpower Requirements Report.
[End of figure]
Although the personnel distribution varies by service, collectively
the active duty and reserve workforces make up approximately 80
percent of the medical force, with the active duty comprising about 51
percent and the reserves 29 percent. Civilians comprise 20 percent of
the medical workforce. In providing technical comments to a draft of
this report, DOD noted that among the military services, the Army has
the highest percentage of civilians. For example, within the Army
Medical Command, 58 percent of its fiscal year 2011 medical workforce
is projected to be comprised of Army civilians.
According to the 2007 Military Health System Human Capital Strategic
Plan, the medical workforce is comprised of several specialty medical
corps, including Medical, Dental, Nurse, Medical Service, Medical
Specialist, Biomedical Sciences, Veterinary, Warrant Officers, Medical
Enlisted, and Dental Enlisted. This plan also states that the largest
corps is the active duty Medical Enlisted Corps, which consists of
about 75,000 individuals and makes up about 65 percent of DOD's active
duty medical force. Figure 2 represents the distribution of active
duty medical personnel by specialty.
Figure 2: Distribution of Active Duty Medical Personnel by Specialty:
[Refer to PDF for image: pie-chart]
Medical enlisted: 75,084: 65%;
Medical: 11,432: 10%;
Nurse: 9,332: 8%;
Medical services: 7,676: 7%;
Dental enlisted: 5,725: 5%;
Dental: 2,843: 2%;
Other: Biomedical sciences: 2,134; Medical specialist: 1,175;
Veterinary: 430; Warrant officers: 140: 3%.
Source: Fiscal Year 2009 Defense Manpower Requirements Report.
[End of figure]
A more detailed breakout of each of the services' medical specialty
personnel levels is presented in appendix II. That appendix shows, for
fiscal year 2009, how each of the services allocated its positions
within each of its medical specialties based on identified needs,
financial resources, and personnel availability.
DOD's Policy Emphasizes Jointness, although the Services'
Collaborative Efforts in Determining Medical Personnel Requirements
Have Been Limited:
While DOD has emphasized jointness and undertaken joint initiatives
across the department, the extent to which the services have
incorporated cross-service collaboration in their planning efforts for
determining their medical personnel requirements has been limited. The
2007 Military Health System Human Capital Strategic Plan 2008-2013
emphasizes the importance of planning, coordinating, collaborating,
and developing human capital solutions across the services to enable
departmentwide decision making.[Footnote 13] Additionally, a DOD
directive requires developing plans and procedures and pursuing common
and cross-cutting modeling tools and data.[Footnote 14] Furthermore,
DOD is moving toward having joint medical regions in which DOD-
operated medical treatment facilities are staffed using personnel from
across the service such as the consolidation of the military treatment
facilities in the Washington, D.C., area. Also, DOD established a
cross-service, baseline medical manpower standard for mental health
providers, which was released in January 2010. While these efforts
represent progress by the services in working collaboratively, the
services have encountered challenges in their implementation.
DOD Emphasizes Jointness in Its Strategic Plan and Quadrennial Defense
Review:
Issued in November 2007, DOD's medical personnel strategic plan--the
Military Health System Human Capital Strategic Plan 2008-2013--
emphasizes coordination and collaboration across the services. This
plan sets forth a vision, guiding principles, goals, and objectives
for the management of the Military Health System's medical personnel.
The strategic plan articulates a vision of an interoperable and agile
total medical force that meets the missions defined by National
Security Strategy requirements. Emphasized throughout this strategic
plan is the premise that the mission of the Military Health System can
be better met by increasing emphasis on planning, coordinating,
collaborating, and developing human capital solutions across the
services. More specifically, this strategic plan states that the
Military Health System cannot continue to recruit, develop, train,
reward, and retain its workforce solely through each service
independently, as mission requirements demand that they work together
to achieve interoperability and agility.
The 2007 Military Health System Human Capital Strategic Plan also
aligns with critical areas on medical transformation initially
presented in the April 2006 Quadrennial Defense Review Roadmap for
Medical Transformation, which encouraged the Military Health System to
create standardized processes, tools, and resources to improve
efficiency and eliminate redundancies across the services. This goal
is reiterated by a specific DOD directive requiring the services to
maximize commonality, reuse, interoperability, efficiencies, and
effectiveness of component-specific modeling data and tools. The
Military Health System Strategic Plan is also cited in the 2010
Quadrennial Defense Review, which generally observes that DOD needs to
reform the way in which it does business to address challenges--such
as parochial interests and sometimes adversarial relationships within
the Pentagon and with other parts of government--that are hindering
its success.
Joint Medical Effort in the Washington, D.C., Area Represents Cross-
Service Collaboration but Has Encountered Challenges in Developing Its
Military Medical Personnel Requirements:
To eliminate redundancies in medical operations, integrate services,
and achieve better economies of scale, DOD is implementing a joint
medical effort in the National Capital Region of Washington, D.C.,
known as Joint Task Force National Capital Region Medical. This effort
stems from a 2005 Base Realignment and Closure (BRAC) Commission
recommendation to relocate patient care activities from the Walter
Reed Army Medical Center Washington, D.C., to the National Naval
Medical Center, Bethesda, Maryland, and to a new community hospital at
Fort Belvoir, Virginia. The BRAC Commission presented its list of
final recommendations to the President of the United States, which
included a cost/savings estimate for this joint medical effort. The
President approved the recommendations in their entirety and
subsequently forwarded them to Congress, and they became effective in
November 2005. Our analysis of DOD fiscal year 2010 BRAC budget showed
that the cost to implement this realignment is estimated to be $2.4
billion, consisting primarily of $1.7 billion in construction costs.
That analysis also showed that DOD projects its net annual recurring
savings of this effort to be $172 million.[Footnote 15]
In September 2007, the Deputy Secretary of Defense issued a memorandum
that formally established Joint Task Force National Capital Region
Medical. One of its two facilities, the new Walter Reed National
Military Medical Center, will be located on the Bethesda campus, and
according to the Deputy Secretary of Defense, is expected to deliver
effective and efficient, world-class military health care, as well as
consolidate and realign military health care in the region. Its
medical services will include primary care, secondary care (that is,
care provided by a consulting physician at the request of a primary
physician), and tertiary care (that is, very specialized care
performed by physicians with facilities and skills for special
investigation and medical treatment). DOD plans to close the current
Walter Reed Army Medical Center facility by September 2011. The second
facility at Fort Belvoir, Virginia, is being expanded to provide
comprehensive primary and secondary patient care services. Joint Task
Force National Capital Region Medical's vision, mission, and
principles include as a key priority the establishment of common
standards and processes, and calls for interoperability. According to
a statement in the 2010 Comprehensive Master Plan for the Nation
Capital Region Medical, this medical realignment represents a merger
of nearly 10,000 healthcare and support staff. The document also
states that the department has currently determined an active duty
personnel distribution between the new Walter Reed National Military
Medical Center in Bethesda and the Fort Belvoir Community Hospital,
and that the services have identified the resources to meet the
manning requirements. Joint Task Force National Capital Region
Medical, which reached fully operational capability status on
September 30, 2008, represents an important initiative within the
Military Health System because, if successful, Joint Task Force
officials believe it will be a model for the future of military
medicine. Officials also noted to us that this joint medical effort in
Washington, D.C., is a new process and, Joint Task Force officials are
working with the services to work through details to achieve joint
medical commands in the National Capital Region.
Officials, however, have faced challenges in consolidating and
realigning the medical manpower portion of this newly formed joint
medical effort within the National Capital Region. Additionally,
according to officials we spoke with, several assumptions used
throughout the development of the joint manning document--that (1) the
population served would remain static from 2004, (2) the clinical
workload to be met would be based on that of 2004, and (3) the 2004
medical missions would remain constant--have become outdated.
According to officials, the military treatment facilities in the
National Capital Region have seen a significant increase in their
clinical workload over 2004 levels as a result of injuries sustained
by servicemembers following the acceleration in overseas operations in
Iraq that was announced in 2007. Further, they said these injuries
entail additional medical missions that the Joint Task Force officials
have not been able to fully incorporate into the clinical workload or
the personnel requirements determination. Such additional missions
include an increased need for advanced limb and wound care, and
traumatic brain injury care. Also, in order to develop the joint
manning document for the newly formed and jointly staffed facilities,
officials had to fuse the results of the services' dissimilar medical
personnel requirements determination processes. In doing so, they
found that the services' official manning documents contained
inaccuracies. Several civilian and military Joint Task Force
officials, who analyzed manpower documents to determine the levels of
medical personnel currently on board for each service, told us that
the services had employed civilian and contract personnel at their
facilities but not recorded them on the manpower documents upon which
these officials based the development of the joint manning document.
For these various reasons, the joint task force officials have
encountered significant challenges in developing an accurate,
complete, and realistic joint manning document that lays out the
medical requirements by specialty for the newly formed joint
facilities.
DOD officials attribute the problems to formative, early stage
development issues, and acknowledged that, if service manpower
determination processes had used similar language, nomenclatures, and
approaches, the creation of the joint manning document would have been
a more straightforward process. Officials also told us, however, that
while the collaboration encountered to date has been challenging, it
has been beneficial in building the relationship among the medical
components and operational components of the services. These officials
stated that with continued collaboration among the services and future
operational experience, the Joint Task Force's leadership intends to
identify data-driven refinements to projected manpower requirements
that would better capture efficiencies, enhance service quality, and
build on selected strategic interests.
DOD and the Services Collaborated to Develop a Recently Released Cross-
Service Medical Manpower Standard for Mental Health Providers:
A second joint medical personnel effort, quite different from that of
the realignment previously described, is DOD and the services' ongoing
development and implementation of a cross-service medical manpower
standard known as the Psychological Health Risk-Adjusted Model for
Staffing (PHRAMS). PHRAMS represents the culmination of a
collaborative manpower requirements effort to develop a standardized,
more consistent approach across the services for determining mental
health personnel requirements. Health Affairs sponsored the
development of the cross-service PHRAMS manpower standard to address
the growth in demand for mental health services, as well as to give
the services a standard by which to develop mental health requirements
needed to meet the common, day-to-day psychological health needs of
eligible beneficiaries across the services. The model projects mental
health medical requirements over a 5-year planning horizon and
provides a gap analysis for the first year, in order to assist the
services in addressing near-term personnel shortages. It also provides
a consistent staffing standard containing several fixed parameters,
such as the size of the beneficiary population and utilization rates,
which Health Affairs will re-evaluate annually when the model is
updated. Finally, the model contains variables that can change at the
services' discretion, such as the number of patients seen annually by
a provider and an adjustment rate to reflect increased deployments for
servicemembers in the hospital's area of responsibility. Health
Affairs released the final model to the services in January 2010.
Currently, the Army, Navy, and Air Force are using PHRAMS to generate
mental health staffing requirements at their military treatment
facilities that are to be incorporated into the fiscal year 2012
budget submission later this year and because the model was only
recently released to the services, the effect of its implementation on
cost savings or requirement numbers is still unknown. Additionally,
Health Affairs officials said that the services will continue to
assess potential applications of PHRAMS. While the services are not
specifically required to use PHRAMS or to develop more models, Health
Affairs officials told us that the publishing of the Military Health
System Human Capital Strategic Plan has encouraged dialogue among the
services on collaboration, and such dialogue may facilitate the
identification of further opportunities for development of manpower
requirements models.
Service-Specific Medical Requirements Determination Processes Are Not
Consistent with Collaborative Planning:
To the extent that PHRAMS represents a positive collaborative
initiative, to date it is the only model of its kind. The services are
responsible for organizing, equipping, and training their respective
forces, and service officials assert that their respective needs are
sufficiently different to warrant maintaining service-unique processes
for requirement determination. While each of the services has unique
operational medical capabilities, such as Army veterinary medicine,
Navy undersea medicine, and Air Force aerospace medicine, the day-to-
day operations at military medical treatment facilities are very
similar across the services, and they could advantageously be more
collaboratively managed. A DOD directive requires the respective heads
of the services to maximize the commonality, reuse, interoperability,
efficiencies, and effectiveness of component-specific modeling data
and tools,[Footnote 16] but Health Affairs officials said that no
other current collaboration efforts for determining medical personnel
requirements or developing medical manpower standards, other than
PHRAMS, are currently under way. Committed and effective leadership is
a critical aspect of enhancing collaboration. Committed leadership by
those involved in collaborative efforts from all levels of the
organization is needed to overcome the many barriers to working across
boundaries. Key organizational issues, like strategic workforce
planning, are most likely to succeed if, at their outset, top program
and human capital leaders set the direction, pace, and tone and
provide a clear, consistent rationale for the transformation. With
leadership emphasis and expectations that the services will continue
to explore opportunities to develop cross-service medical manpower
standards, such as PHRAMS, and consistent management focus on
collaboration within DOD's Military Health System, the services will
have more opportunities to develop collaborative work force planning
efforts for common medical capabilities that they share throughout
their military treatment facilities--an approach that is consistent
with the Military Health System Human Capital Strategic Plan's vision
of a more integrated approach across service lines.[Footnote 17]
The Services' Respective Processes for Developing Requirements Are Not
Validated and Verifiable in All Cases and Do Not Centrally Account for
Civilian Personnel Requirements:
While a need exists for the services to work more collaboratively to
determine their medical personnel requirements, the services' also
maintain processes to address service-specific needs. In accordance
with a DOD directive,[Footnote 18] personnel requirements are to be
established according to workload at the minimum levels necessary to
accomplish mission and performance objectives. Additionally, a DOD
instruction[Footnote 19] calls for the models and associated data used
to support DOD processes and decisions to be validated and verified
throughout their life cycles, and accredited for the model's intended
purpose. While all of the services currently are taking steps to
update and refine their medical personnel requirement processes, these
processes, however, are not yet fully validated or verifiable.
Further, the services do not centrally manage their civilian medical
personnel requirements.
Army's Model Contains Some Outdated Information and Is in the Process
of Being Updated and Validated:
The Army uses its Automated Staffing Assessment Model to determine
manpower requirements for Army fixed military treatment facility and
other Army Medical Command organizations. This model is based
primarily on approved population and workload data, but it also
incorporates industry performance data to determine manpower
requirements for the various medical specialties. The Automated
Staffing Assessment Model consists of over 240 modules for determining
essential medical requirements for many medical specialties such as
physicians, nurses, dentists, medical service corps, and
veterinarians, to name a few, at the work center level across Army
fixed military treatment facilities. The model uses the current
population of the various military treatment facilities as the major
determinant of the number of medical personnel needed at each
facility. In addition, a number of key, workload-based assumptions
inform the model, including patient care hours, population
projections, provider-to-patient ratio, and provider-to-support
technician ratio. However, in certain cases, our analyses of selected
modules revealed areas that need improvement. For example, our
analyses of the inpatient nursing and dental modules revealed the use
of some obsolete assumptions. Specifically, we found that the Army's
nursing requirements module had not been updated or used since 2005 to
determine nursing requirements. Further, according to dental command
officials, the dental module in use is an Army legacy model that is
over 40 years old and does not reflect the more advanced level of
dental care currently being provided, such as the increased need for
complex dental repair work rather than simple extractions. DOD noted
in technical comments on a draft of this report that the nursing and
dental modules were recently updated and submitted for validation.
According to Army officials, updates to Army medical manpower models
are subject to a review process by the U.S. Army Manpower Analysis
Agency, and to final approval by the Office of the Assistant Secretary
of the Army for Manpower and Reserve Affairs. A module can be approved
for 3 years if it is determined to be logical, analytical, verifiable,
and based on accurate data sources. However, if a module is based
solely on data provided by subject matter experts and functional
estimates of the primary tasks associated with the specialty, the
model will be approved for 1 year--as is the case for the recently
validated veterinary specialty module. According to Army officials,
prior to 2008, the Army required a random sample of 2 percent of the
requirements models to be validated for reasonableness; however,
currently, it uses a more stringent approach that requires all models
to be validated. Army documents show that the Army's manpower analysis
agency completed validation of 4 of the 240 modules in 2009 and 2 more
so far in 2010. In addition, 12 more modules have either been
submitted for review and approval or are nearing submission. In
technical comments to a draft of this report, DOD noted that the Army
believes the number of requirements covered by its staffing assessment
model is more important than the number of modules as we have
discussed. As such, the Army noted that nearly 20 percent of its
medical personnel requirements have been updated and about another 20
percent of its requirements have been submitted for validation however
are pending approvals. Moreover, Army Medical Command officials have
been working with representatives from the Army Manpower Analysis
Agency to develop a specific time line and priorities for validation
of the remaining modules, but currently no definitive schedule has
been set yet for completing the validation.
Army officials recognized that the approach to model validation that
they had been using, including its previous reliance on sampling
methods, was not providing the Army with complete and sufficient
information. With committed and sustained leadership emphasis to
complete and maintain the validation of all the modules, the Army will
be in a better position to be certain it is determining its medical
personnel requirements in an effective and efficient manner.
Navy Does Not Have a Validated and Verifiable Process but Is Moving
toward a Validated Model:
The Navy has not used a model to determine the medical personnel
requirements for its fixed military treatment facilities. Instead,
Navy officials explained that, the Navy's process is to use current
manning as a baseline and adjust the figure based on emerging needs or
major changes in its medical mission. Additionally, Navy officials
explained that local military treatment facility commanders prepare
annual business plans for their medical facilities and include
proposed changes to the facilities' personnel requirements based on
such information as enrolled population, utilization rates, and on
expert functional knowledge at the military treatment facility. These
business case analyses are then submitted and reviewed through the
chain of command and approved by the Navy Surgeon General as medical
resources allow. While the Navy routinely employs this approach to
determine its medical personnel requirements, it is not a validated or
verified methodology as required by DOD guidance.
To better assess its medical personnel requirement needs at the
medical specialty level, the Navy is beginning to develop medical
manpower standards which officials indicate will be used as the basis
for future requirements determination. According to Navy officials,
they plan to use the Navy Medicine Benchmark Model for its 93 medical
functional areas. As this model will determine the benchmark for the
number of personnel needed in a medical specialty at a military
treatment facility, the model will be used to identify surpluses or
shortages in personnel at each facility and identifying the optimal
military, civilian, and contractor mix. DOD noted in technical
comments responding to a draft of this report that the Navy Bureau of
Medicine and Surgery Headquarters is the approval authority for
determining whether a medical personnel requirements model or process
is valid and verifiable. Navy medical officials explained that they
are still in the process of determining the model's validity for each
of its medical specialty areas, and they did not provide a time
schedule as to when this would be completed. Although the Navy is
implementing this model to help determine its medical personnel
requirements, Navy officials asserted to us that the Navy does not
have any unmet requirements, as it uses private-sector medical care
when military treatment facilities are unable to provide the care.
Navy officials recognized the business case analysis process did not
provide the validated and verifiable approach needed to determine
their medical manpower requirements. With committed and sustained
leadership emphasis to implement and maintain a fully validated
benchmark model, the Navy similarly will be in a better position to be
certain it is determining its medical personnel requirements in an
effective and efficient manner.
Air Force Currently Uses a Nonvalidated, Nonverifiable Model and Other
Information to Determine Its Medical Requirements but Has Begun
Developing a Newer Model:
In 2002, the Air Force Surgeon General collaborated with the private
sector to design the Product Line Analysis and Transformation Tool
that produced medical manpower staffing models utilizing industry
standards and research and the experiences of Air Force medical
personnel. While the models were presented in 2003 for validation and
approval, the Air Force leadership did not approve this model for
determining manpower standards for its medical specialties because the
models were not based on objectively quantifiable data sources.
Although the Air Force considered any medical requirements developed
using the model as unverifiable, it allowed Air Force medical
officials to continue to use the models as a part of its requirements
determination process. Currently, Air Force medical officials use, in
addition to the model, historical workload, historical and like-size
facility manning, industry models, functional models, and statistical
analysis of variance by facility to generate their medical personnel
requirements. The current requirements development process can be
performed using either a top-down or a bottom-up approach. The top-
down approach begins with Air Force leadership, usually at the rank of
general, determining that a military treatment facility has a need for
new requirements. The bottom-up approach occurs when officials at a
military treatment facility identify a need for a new requirement and
then work through the major commands to change or alter its current
requirements. The major commands then work with the Air Force Medical
Operations Agency to bring a request for new or changed requirements
to the Air Force Surgeon General. The new or changed requirements
undergo a vetting process that ranges from the military treatment
facility to the Chief of Staff before they are approved. Any changes
to requirements are based on identified need as experts in functional
areas obtain new data or refined standards.
To establish the feasibility of providing a verifiable means of
medical manpower standards development support to the Air Force
medical community, the Air Force Medical Service and the Air Force
Manpower Agency signed a Memorandum of Agreement whereby the Air Force
Manpower Agency will develop new manpower standards for all Air Force
medical specialties, based on data that have been collected for each.
According to officials, this effort began in January 2010, and they
hope to have completed developing all of the manpower standards by
2015. In order to do so, the Air Force Manpower Agency is planning to
hire 15 officials--10 civilians and 5 military--to research, develop,
and validate the new manpower standards. This effort will include such
tasks as developing the data collection approach, performing the
analysis on all of the data, developing the manpower models, and
identifying process improvement opportunities.
Air Force officials recognized that their recent efforts to develop
medical manpower standards stem from the Air Force's need for a
validated and verifiable manpower requirements determination process.
With committed and sustained leadership emphasis on maintaining
validated medical manpower models, the Air Force is in a similar
position as the other services in that it would be in a better
position to know its true medical needs by medical specialty and to be
certain it is determining its medical personnel requirements in a more
effective and efficient manner.
The Services Do Not Centrally Account for Civilian Personnel
Requirements:
DOD's efforts to determine its medical personnel requirements at
military treatment facilities are further limited by the fact that the
services have not fully incorporated into their requirements processes
the use of civilians who deliver health care at the same stage in the
process where they determine their military medical personnel
requirements. A DOD directive requires that, for areas employing both
military and civilian personnel, manpower requirements shall be
determined in total and designated as either military or civilian, but
not both, as an active, reserve, or civilian determination must be
made for each requirement.[Footnote 20] The Military Health System
Human Capital Strategic Plan also asserts that more efforts should be
made to have the optimal mix of medical personnel. However, while
civilian personnel constitute about 20 percent of the services'
medical workforce, the services' current requirements processes are
generic in nature and do not differentiate positions as military or
civilian.[Footnote 21] We found that all three services first
determine their collective requirements. Then, at the local level,
after all of the positions at a military treatment facility are
staffed with the available military personnel, the commander of the
local military treatment facility determines whether a position will
be designated as civilian or contractor. In making determinations to
use civilian personnel, local commanders use several factors, such as
whether the position is military essential--to support readiness or
operational missions--or inherently governmental--which would require
the position be filled with a government employee. Additionally,
commanders consider financial resources and the availability of
civilian or contractor personnel in the local area. In technical
comments provided in response to a draft of this report, DOD officials
disagreed with our statement that the services do not centrally
account for civilian personnel requirements. DOD noted that workload
generated by civilians is captured and depicted in a centralized
information management system. However, based on the explanation of
this system given by DOD, we note that this system captures the number
of civilian personnel already on board and the areas in which they are
employed. It does not identify the number of civilian personnel needed
and required by each service to meet the missions of fixed military
treatment facilities, nor does it centrally account for civilian
personnel requirements. In addition, several military treatment
facility personnel told us that more direction or centralized guidance
would aid them, in many cases, in their management of their civilian
personnel. DOD's 2009 update to its Civilian Human Capital Strategic
Plan[Footnote 22] lists global civilian end strength numbers for five
mission critical medical occupational series--medical officers,
nurses, pharmacists, clinical psychologists, and licensed clinical
social workers. This update also gives projected accession and
recruiting goals needed to reach those global end strength numbers.
However, the update does not project any civilian end strength numbers
at the medical specialty levels within these occupational series nor
does it indicate the military treatment facilities at which these
civilians are needed. If the services do not identify civilian
personnel requirements for military treatment facilities in the
overall requirements planning process, the services may be missing the
opportunity to make a strategic determination of how many medical
professionals--military or civilian--are needed in total to carry out
their expected missions and workloads. The services assume added risk
if their medical requirements are not completely met, and if the
requirements are unknown, the extent of that risk cannot be estimated.
If risk is unknown, the services cannot develop appropriate risk-
mitigation strategies for their unmet medical personnel requirements.
Conclusions:
To achieve a military health system that can respond to our country's
changing national security needs by using both the right numbers and
the right mix of forces, DOD has emphasized the need for collaboration
of efforts in the medical arena, and committed and sustained
leadership emphasis is key to successful collaboration. The efforts
taken to date by OSD and the services to develop and implement
specific cross-service manpower related programs have been a step in
the right direction for building a collaborative approach to
determining military medical personnel requirements. As such, it is
important that the services continue to focus on developing programs,
solutions, and measures for managing medical personnel requirements
across the services and focus on the long-term, broader picture. By
doing so, OSD and the services will have more opportunities to create
departmentwide benefits and would more fully support the Military
Health System's strategic planning goal of collaboration. Also, as the
services work toward a joint approach, it is important for them to
have sound medical personnel requirement determination processes in
place, to enable them to identify the personnel numbers and mix they
need to fully perform their medical missions. If the services are to
effectively and efficiently provide daily care to active duty and
retired servicemembers and their dependents in their fixed medical
facilities, it is important that each of their medical personnel
requirement processes reflects currency, validation, and verification.
Areas of improvement exist within the services' medical requirements
processes, and until these processes are up-to-date, fully validated,
and verifiable, it is not clear whether the services can be certain
they are determining their medical personnel requirements in an
effective and efficient manner.
Recommendations for Executive Action:
Consistent with DOD emphasis on developing human capital solutions
across the services to enable departmentwide decision making and
analyses within its Military Health System, we recommend that the
Secretary of Defense direct the Assistant Secretary of Defense for
Health Affairs and the Service Secretaries to take the following two
actions.
* Identify the common medical capabilities that are shared across the
services in their military treatment facilities that would benefit
from the development of cross-service medical manpower standards; and:
* Where applicable, develop and implement cross-service medical
manpower standards for those common medical capabilities.
To improve the Army's current medical personnel requirements
determination process, we recommend that the Secretary of the Army
direct the Army Surgeon General to take the following three actions.
* Update assumptions and other key data elements contained within
specialty modules of the Automated Staffing Assessment Model;
* Develop and implement a definitive revalidation schedule for the
specialty modules of the Automated Staffing Assessment Model; and:
* Include its reliance on civilian medical personnel in its
assumptions as it updates and validates their medical personnel
requirements determination modules.
To improve the Navy's current medical personnel requirements
determination process, we recommend that the Secretary of the Navy
direct the Navy Surgeon General to take the following two actions.
* Develop a validated and verifiable process to determine its medical
manpower requirements; and:
* Include its reliance on civilian medical personnel in its
assumptions as it develops, and then validates, its medical personnel
requirements determination model.
To improve the Air Force's current medical personnel requirements
determination process, we recommend that the Secretary of the Air
Force direct the Air Force Surgeon General to take the following two
actions.
* Develop a validated and verifiable process to determine its medical
manpower requirements; and:
* Include its reliance on civilian medical personnel in its
assumptions as it develops, and then validates, its medical personnel
requirements determination model.
Agency Comments and our Evaluation:
In written comments provided in response to a draft of this report,
DOD concurred or partially concurred with all of our recommendations.
DOD's written comments are reprinted in appendix III of this report.
Additionally, DOD provided technical comments that we have
incorporated where appropriate.
In concurring with our recommendations regarding identifying,
developing, and implementing cross-service medical manpower standards
for medical capabilities that are shared across the services, DOD
noted that a cost-benefit analysis must precede a review of shared
capabilities to ensure that there is a significant, measurable benefit
in cost, quality, or access to medical care before department medical
funds are expended. We agree that this course of action would
constitute a reasonable part of a process to identify which
specialties would benefit from such efforts.
In concurring with our recommendations to improve the Army's current
medical personnel requirements determination process by updating
assumptions, developing and implementing a revalidation schedule, and
including its reliance on civilian medical personnel in its
assumptions, DOD stated that the Army will continue to update
assumptions and other key data elements within the Army Automated
Staffing Assessment Model as our recommendation suggested and will
closely coordinate efforts between Army Medical Command and the U.S.
Army Manpower Analysis Agency to implement a revalidation schedule for
the medical personnel requirements determination models. DOD further
noted in its response to a draft of this report that the Army will
continue to capture civilian contribution to the generation of medical
workload in its Automated Staffing Assessment Model, and that 58
percent of Army Medical Command's workforce is civilian. Although we
believe Army's efforts to capture civilian contribution is important
to understanding its workforce, the intent of our recommendation is
for the Army to better delineate military versus civilian personnel
requirements during the requirements determination process as called
for in DOD Directive 1100.4.
In its partial concurrence with our recommendations for the Navy to
develop a validated and verifiable process to determine its medical
manpower requirements and to include its reliance upon civilian
medical personnel in its assumptions, DOD noted that the Navy
initiated a comprehensive effort to redefine how medical manpower
requirements are determined, the results of which are expected by fall
2010. We note this effort in our report, and it is in line with the
intent of our recommendation, but we continue to assert the need for
this effort to be completed. Further, DOD noted that the Navy Surgeon
General has always taken and will continue to emphasize a total force
approach in future planning and programming for medical personnel. We
note, however, that while we recognize the value of such an approach,
our recommendation concerns, as with the Army, the need for the Navy
to delineate military versus civilian personnel requirements during
the requirements determination process as called for in DOD Directive
1100.4.
In concurring with our recommendations that the Air Force Surgeon
General develop a validated and verifiable process to determine
medical manpower requirements and include its reliance on civilian
medical personnel in its assumptions, DOD noted that the Air Force is
in the process of developing new manpower standards for its medical
specialties, having finalized a Memorandum of Agreement between the
Air Force Medical Service and Air Force Manpower Agency in May 2010.
We note the potential of this effort as a strong step toward
fulfilling this recommendation. Further, DOD noted that the new Air
Force manpower standards will include the identification of civilian
equivalents for those positions not deemed military essential, and
that civilian requirements are also reviewed and determined through
the Inherently Governmental/Commercial Activity process. We agree that
Air Force's new medical requirements determination standards, to
include civilians, will have the potential to address the intent of
our recommendation. The Inherently Governmental/Commercial Activity
process, however, does not completely address the need to delineate
military versus civilian personnel requirements during the
requirements determination process as our recommendation suggests and
as called for in DOD Directive 1100.4.
Additionally, one of DOD's technical comments concerns our
recommendations regarding the services' need to include their reliance
on civilian medical personnel in their assumptions when developing and
validating their medical personnel requirements determination models.
In this technical comment, DOD suggested that we delete the section of
our report headed by the statement "The Services Do Not Centrally
Account for Civilian Personnel Requirements." DOD noted that all three
services use a reporting system that captures and depicts workload
generated by civilians in a centralized information management system.
However, we note that the workload generated by civilians constitutes
an after-the-fact status of assignments rather than a consideration in
generating the requirements before these civilians are assigned to
fill a requirement. Thus, we continue to believe the validity of our
aforementioned heading reflecting our findings in this area has merit.
Finally, DOD provided in its technical comments to a draft of this
report a table that they believe illustrates recent collaborative
efforts. Two of the six examples--Psychological Health Risk-Adjusted
Model for Staffing and Joint Task Force National Capital Region
Medical--are discussed extensively in this report. DOD noted four more
examples to illustrate recent collaborative efforts, such as proposed
legislation for financial assistance to provide scholarships to
civilian medical providers, that we did not include in our report
because we believe that these examples are not directly related to the
development of cross-service manpower standards or medical personnel
requirements, which is the focus of this report. We have, however,
reprinted DOD's table in appendix III.
We are sending copies of this report to the Secretary of Defense and
the Secretaries of the Army, Navy, and Air Force. In addition, the
report will be available at no charge on the GAO Web site at
[hyperlink, http://www.gao.gov]. If you or your staff have any
questions on the information discussed in this report, please contact
me at (202) 512-3604 or farrellb@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this report. GAO staff who made key contributions to
this report are listed in appendix VI.
Signed by:
Brenda S. Farrell:
Director:
Defense Capabilities and Management:
List of Committees:
The Honorable Carl Levin:
Chairman:
The Honorable John McCain:
Ranking Member:
Committee on Armed Services:
United States Senate:
The Honorable Daniel K. Inouye:
Chairman:
The Honorable Thad Cochran:
Ranking Member:
Subcommittee on Defense:
Committee on Appropriations:
United States Senate:
The Honorable Ike Skelton:
Chairman:
The Honorable Howard P. McKeon:
Ranking Member:
Committee on Armed Services:
House of Representatives:
The Honorable Norman D. Dicks:
Chairman:
The Honorable C.W. Bill Young:
Ranking Member:
Subcommittee on Defense:
Committee on Appropriations:
House of Representatives:
[End of section]
Appendix I: Scope and Methodology:
This engagement examines the processes used by the military services
to determine their medical personnel requirements for staffing, to
include the number and specialty mix of military and civilian
employees, at fixed medical treatment facilities. We interviewed
officials and, where appropriate, obtained documentation at the
following locations:
* Office of the Assistant Secretary of Defense for Health Affairs,
Washington, D.C.;
* Army Medical Command, San Antonio, Texas;
* United States Army Manpower Analysis Agency, Fort Belvoir, Virginia;
* Brooke Army Medical Center, San Antonio, Texas;
* Navy Bureau of Medicine and Surgery, Washington, D.C.;
* Navy Medical Support Group, Jacksonville, Florida;
* Naval Medical Center Portsmouth, Portsmouth, Virginia;
* Air Force Medical Service, Washington, D.C.;
* Air Force Manpower Agency, San Antonio, Texas; and,
* 12th Medical Group--Randolph Air Force Base Clinic, San Antonio,
Texas.
To evaluate the extent to which the services have collaborated in
their strategic planning efforts for the determination of their
medical personnel requirements, we reviewed manpower, personnel, and
Military Health System policies and plans for the Department of
Defense and the services. Especially pertinent were Department of
Defense Directive 5000.59, on Modeling and Simulation management, and
the Military Health System Human Capital Strategic Plan for Fiscal
Years 2008-2013. We compared the guidance, goals, and strategies in
those documents with the ongoing medical personnel requirements
determination processes used by the services, which we determined by
analyzing documentation and interviewing officials from each of the
locations listed. We also analyzed documentation and interviewed
officials from Joint Task Force National Capital Region Medical and
the San Antonio Military Medical Center to learn about joint medical
operations that are being developed and implemented. Further, we met
with officials from the Center for Naval Analyses who are currently
working under a contract with the Office of the Assistant Secretary of
Defense for Health Affairs to develop a cross-service medical manpower
standard for behavioral health specialties known as the Psychological
Health Risk-Adjusted Model for Staffing.
To evaluate the service-specific processes for determining their
requirements for military and civilian medical personnel, we reviewed
documentation provided to us by officials, whom we then interviewed,
from each of the offices previously cited. We obtained and reviewed
the Army's Automated Staffing Assessment Model for four medical
specialties: physicians, dentists, nurses, and mental health care. We
interviewed agency officials who operate the models for each of these
specialties to understand how these models are used, how accurate the
data are, and whether the models had been validated by the Army's
Manpower Analysis Agency. We additionally interviewed officials from
the Navy Bureau of Medicine and Surgery and the Air Force Medical
Service regarding the processes they use to determine their medical
manpower requirements. We also collected data on medical personnel
requirements, authorized positions, and end strengths for fiscal year
2009 from each of the services' medical departments and from the
Defense Manpower Data Center's Health Manpower Statistics Report. The
Army is the only service that provided service-specific data, while
the Air Force and Navy deferred to the Defense Manpower Data Center's
Health Manpower Statistics Report. We coordinated our analysis and our
results with a methodologist from GAO's Applied Research and Methods
team. Additionally, with guidance from the methodologist, we also
evaluated the reliability of the data we obtained and found it
sufficiently reliable for the purposes of this audit.
We conducted this performance audit from August 2009 through July 2010
in accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe
that the evidence obtained provides a reasonable basis for our
findings and conclusions based on our audit objectives.
[End of section]
Appendix II: Summary of Fiscal Year 2009 Active Duty Medical Personnel
Levels:
The following data show the results of service-specific medical
personnel requirement processes (where available) in comparison with
funded and filled positions.
Table 1: Fiscal Year 2009 Requirements, Authorized Positions, and End
Strengths by Service and Specialty:
Specialty: Allergy/Immunology;
Army: Requirement: 32;
Army: Authorized: 29;
Army: Strength: 39;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 5;
Navy: Strength: 3;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 13;
Air Force: Strength: 20.
Specialty: Anesthesiology;
Army: Requirement: 158;
Army: Authorized: 137;
Army: Strength: 162;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 123;
Navy: Strength: 142;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 80;
Air Force: Strength: 91.
Specialty: Aviation/Aerospace Medicine;
Army: Requirement: 76;
Army: Authorized: 56;
Army: Strength: 29;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 0;
Navy: Strength: 0;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 213;
Air Force: Strength: 182.
Specialty: Aviation/Aerospace Medicine Non-Residency Trained;
Army: Requirement: [Empty];
Army: Authorized: [Empty];
Army: Strength: [Empty];
Navy: Requirement[A]: [Empty];
Navy: Authorized: 215;
Navy: Strength: 219;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 151;
Air Force: Strength: 189.
Specialty: Aviation/Aerospace Medicine Residency Trained;
Army: Requirement: [Empty];
Army: Authorized: [Empty];
Army: Strength: [Empty];
Navy: Requirement[A]: [Empty];
Navy: Authorized: 64;
Navy: Strength: 47;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 264;
Air Force: Strength: 47.
Specialty: Cardiac/Thoracic Surgery;
Army: Requirement: 20;
Army: Authorized: 19;
Army: Strength: 19;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 15;
Navy: Strength: 8;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 7;
Air Force: Strength: 8.
Specialty: Cardiology;
Army: Requirement: 69;
Army: Authorized: 65;
Army: Strength: 80;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 30;
Navy: Strength: 34;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 26;
Air Force: Strength: 30.
Specialty: Colon/Rectal Surgery;
Army: Requirement: [Empty];
Army: Authorized: [Empty];
Army: Strength: [Empty];
Navy: Requirement[A]: [Empty];
Navy: Authorized: 9;
Navy: Strength: 13;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 7;
Air Force: Strength: 7.
Specialty: Critical Care/Trauma Medicine;
Army: Requirement: 12;
Army: Authorized: 12;
Army: Strength: 9;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 28;
Navy: Strength: 1;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 0;
Air Force: Strength: 1.
Specialty: Critical Care/Trauma Surgery;
Army: Requirement: [Empty];
Army: Authorized: [Empty];
Army: Strength: [Empty];
Navy: Requirement[A]: [Empty];
Navy: Authorized: 19;
Navy: Strength: 17;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 17;
Air Force: Strength: 17.
Specialty: Dermatology;
Army: Requirement: 71;
Army: Authorized: 67;
Army: Strength: 91;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 31;
Navy: Strength: 33;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 25;
Air Force: Strength: 25.
Specialty: Emergency Medicine;
Army: Requirement: 189;
Army: Authorized: 162;
Army: Strength: 218;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 117;
Navy: Strength: 140;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 94;
Air Force: Strength: 139.
Specialty: Endocrinology;
Army: Requirement: 17;
Army: Authorized: 16;
Army: Strength: 20;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 8;
Navy: Strength: 10;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 6;
Air Force: Strength: 8.
Specialty: Executive Medicine[C];
Army: Requirement: 105;
Army: Authorized: 96;
Army: Strength: 0;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 58;
Navy: Strength: 0;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 123;
Air Force: Strength: 0.
Specialty: Family Practice;
Army: Requirement: 575;
Army: Authorized: 458;
Army: Strength: 432;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 359;
Navy: Strength: 362;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 435;
Air Force: Strength: 473.
Specialty: Gastroenterology;
Army: Requirement: 54;
Army: Authorized: 52;
Army: Strength: 57;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 18;
Navy: Strength: 21;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 20;
Air Force: Strength: 16.
Specialty: General Medicine;
Army: Requirement: 0[D];
Army: Authorized: 0[D];
Army: Strength: 160[D];
Navy: Requirement[A]: [Empty];
Navy: Authorized: 461;
Navy: Strength: 263;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 3;
Air Force: Strength: 56.
Specialty: General Surgery;
Army: Requirement: 246;
Army: Authorized: 229;
Army: Strength: 274;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 109;
Navy: Strength: 108;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 83;
Air Force: Strength: 87.
Specialty: Graduate Medical Education (Post Graduate All Years);
Army: Requirement: [Empty];
Army: Authorized: [Empty];
Army: Strength: [Empty];
Navy: Requirement[A]: [Empty];
Navy: Authorized: 1053;
Navy: Strength: 1072;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 896;
Air Force: Strength: 903.
Specialty: Hematology/Oncology;
Army: Requirement: 41;
Army: Authorized: 40;
Army: Strength: 43;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 12;
Navy: Strength: 17;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 18;
Air Force: Strength: 14.
Specialty: Infectious Disease;
Army: Requirement: 63;
Army: Authorized: 59;
Army: Strength: 62;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 29;
Navy: Strength: 34;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 16;
Air Force: Strength: 17.
Specialty: Internal Medicine;
Army: Requirement: 315 [E];
Army: Authorized: 254 [E];
Army: Strength: 277 [E];
Navy: Requirement[A]: [Empty];
Navy: Authorized: 69;
Navy: Strength: 117;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 110;
Air Force: Strength: 142.
Specialty: Nephrology;
Army: Requirement: 20;
Army: Authorized: 18;
Army: Strength: 20;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 9;
Navy: Strength: 8;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 10;
Air Force: Strength: 13.
Specialty: Neurological Surgery;
Army: Requirement: 25;
Army: Authorized: 22;
Army: Strength: 17;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 14;
Navy: Strength: 21;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 9;
Air Force: Strength: 9.
Specialty: Neurology;
Army: Requirement: 64[F];
Army: Authorized: 61[F];
Army: Strength: 63[F];
Navy: Requirement[A]: [Empty];
Navy: Authorized: 22;
Navy: Strength: 27;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 20;
Air Force: Strength: 29.
Specialty: Nuclear Medicine;
Army: Requirement: 29;
Army: Authorized: 24;
Army: Strength: 21;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 1;
Navy: Strength: 0;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 1;
Air Force: Strength: 1.
Specialty: Obstetrics/Gynecology;
Army: Requirement: 209;
Army: Authorized: 190;
Army: Strength: 219;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 98;
Navy: Strength: 120;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 81;
Air Force: Strength: 106.
Specialty: Occupational Medicine;
Army: Requirement: 26;
Army: Authorized: 24;
Army: Strength: 24;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 34;
Navy: Strength: 33;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 7;
Air Force: Strength: 13.
Specialty: Oncology Surgery;
Army: Requirement: [Empty];
Army: Authorized: [Empty];
Army: Strength: [Empty];
Navy: Requirement[A]: [Empty];
Navy: Authorized: 5;
Navy: Strength: 10;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 4;
Air Force: Strength: 3.
Specialty: Ophthalmology;
Army: Requirement: 90;
Army: Authorized: 82;
Army: Strength: 100;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 40;
Navy: Strength: 48;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 26;
Air Force: Strength: 38.
Specialty: Orthopedic Surgery;
Army: Requirement: 225;
Army: Authorized: 213;
Army: Strength: 243;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 117;
Navy: Strength: 117;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 83;
Air Force: Strength: 104.
Specialty: Otorhinolaryngology;
Army: Requirement: 78;
Army: Authorized: 75;
Army: Strength: 87;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 42;
Navy: Strength: 56;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 21;
Air Force: Strength: 41.
Specialty: Pathology;
Army: Requirement: 134;
Army: Authorized: 108;
Army: Strength: 118;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 57;
Navy: Strength: 65;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 53;
Air Force: Strength: 58.
Specialty: Pediatric Surgery;
Army: Requirement: [Empty];
Army: Authorized: [Empty];
Army: Strength: [Empty];
Navy: Requirement[A]: [Empty];
Navy: Authorized: 6;
Navy: Strength: 4;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 1;
Air Force: Strength: 1.
Specialty: Pediatrics, General;
Army: Requirement: 189;
Army: Authorized: 175;
Army: Strength: 165;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 56;
Navy: Strength: 67;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 146;
Air Force: Strength: 171.
Specialty: Pediatrics, Subspecialties;
Army: Requirement: 82;
Army: Authorized: 80;
Army: Strength: 129;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 58;
Navy: Strength: 65;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 36;
Air Force: Strength: 66.
Specialty: Peripheral Vascular Surgery;
Army: Requirement: 17;
Army: Authorized: 15;
Army: Strength: 20;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 10;
Navy: Strength: 10;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 6;
Air Force: Strength: 7.
Specialty: Physical Rehabilitation Medicine;
Army: Requirement: 40;
Army: Authorized: 40;
Army: Strength: 52;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 3;
Navy: Strength: 3;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 0;
Air Force: Strength: 1.
Specialty: Plastic Surgery;
Army: Requirement: 16;
Army: Authorized: 15;
Army: Strength: 18;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 9;
Navy: Strength: 10;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 11;
Air Force: Strength: 9.
Specialty: Preventive Medicine;
Army: Requirement: 105;
Army: Authorized: 92;
Army: Strength: 84;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 47;
Navy: Strength: 38;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 20;
Air Force: Strength: 25.
Specialty: Psychiatry;
Army: Requirement: 205[G];
Army: Authorized: 188[G];
Army: Strength: 180[G];
Navy: Requirement[A]: [Empty];
Navy: Authorized: 90;
Navy: Strength: 94;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 91;
Air Force: Strength: 102.
Specialty: Pulmonary Disease;
Army: Requirement: 48;
Army: Authorized: 45;
Army: Strength: 44;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 18;
Navy: Strength: 34;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 23;
Air Force: Strength: 26.
Specialty: Radiology, Diagnostic;
Army: Requirement: 223;
Army: Authorized: 184;
Army: Strength: 222;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 86;
Navy: Strength: 99;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 89;
Air Force: Strength: 135.
Specialty: Radiology, Therapeutic;
Army: Requirement: 10;
Army: Authorized: 10;
Army: Strength: 18;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 8;
Navy: Strength: 11;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 8;
Air Force: Strength: 12.
Specialty: Rheumatology;
Army: Requirement: 13;
Army: Authorized: 12;
Army: Strength: 15;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 5;
Navy: Strength: 7;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 8;
Air Force: Strength: 9.
Specialty: Undersea Medicine;
Army: Requirement: [Empty];
Army: Authorized: [Empty];
Army: Strength: [Empty];
Navy: Requirement[A]: [Empty];
Navy: Authorized: 88;
Navy: Strength: 94;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 0;
Air Force: Strength: 0.
Specialty: Urology;
Army: Requirement: 75;
Army: Authorized: 65;
Army: Strength: 71;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 28;
Navy: Strength: 27;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 18;
Air Force: Strength: 24.
Specialty: Comprehensive Dentistry;
Army: Requirement: 204;
Army: Authorized: 200;
Army: Strength: 204;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 124;
Navy: Strength: 139;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 233;
Air Force: Strength: 230.
Specialty: Endodontics;
Army: Requirement: 48;
Army: Authorized: 48;
Army: Strength: 61;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 41;
Navy: Strength: 43;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 24;
Air Force: Strength: 28.
Specialty: Executive Dentistry [C];
Army: Requirement: 68;
Army: Authorized: 60;
Army: Strength: 0;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 13;
Navy: Strength: 0;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 31;
Air Force: Strength: 0.
Specialty: General Dentistry;
Army: Requirement: 282;
Army: Authorized: 272;
Army: Strength: 247;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 578;
Navy: Strength: 496;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 296;
Air Force: Strength: 335.
Specialty: Graduate Dental Education;
Army: Requirement: [Empty];
Army: Authorized: [Empty];
Army: Strength: [Empty];
Navy: Requirement[A]: [Empty];
Navy: Authorized: 131;
Navy: Strength: 110;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 163;
Air Force: Strength: 166.
Specialty: Oral Maxillofacial Surgery;
Army: Requirement: 78;
Army: Authorized: 77;
Army: Strength: 99;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 77;
Navy: Strength: 74;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 39;
Air Force: Strength: 45.
Specialty: Oral Pathology;
Army: Requirement: 11;
Army: Authorized: 11;
Army: Strength: 11;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 17;
Navy: Strength: 16;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 5;
Air Force: Strength: 5.
Specialty: Orthodontics;
Army: Requirement: 30;
Army: Authorized: 30;
Army: Strength: 35;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 15;
Navy: Strength: 16;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 31;
Air Force: Strength: 34.
Specialty: Pedodontics;
Army: Requirement: 24;
Army: Authorized: 24;
Army: Strength: 22;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 11;
Navy: Strength: 16;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 15;
Air Force: Strength: 20.
Specialty: Periodontics;
Army: Requirement: 47;
Army: Authorized: 46;
Army: Strength: 54;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 41;
Navy: Strength: 47;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 50;
Air Force: Strength: 51.
Specialty: Prosthodontics;
Army: Requirement: 55;
Army: Authorized: 54;
Army: Strength: 72;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 64;
Navy: Strength: 56;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 49;
Air Force: Strength: 48.
Specialty: Public Health Dentistry;
Army: Requirement: 5;
Army: Authorized: 4;
Army: Strength: 5;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 3;
Navy: Strength: 6;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 2;
Air Force: Strength: 3.
Specialty: Community Health Nurse;
Army: Requirement: 89;
Army: Authorized: 87;
Army: Strength: 119;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 0;
Navy: Strength: 21;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 0;
Air Force: Strength: 0.
Specialty: Critical Care Nurse;
Army: Requirement: 426;
Army: Authorized: 419;
Army: Strength: 442;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 311;
Navy: Strength: 297;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 345;
Air Force: Strength: 416.
Specialty: Emergency/Trauma Nurse;
Army: Requirement: 111;
Army: Authorized: 107;
Army: Strength: 142;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 161;
Navy: Strength: 201;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 189;
Air Force: Strength: 227.
Specialty: Family Nurse Practitioner;
Army: Requirement: 156;
Army: Authorized: 145;
Army: Strength: 143;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 78;
Navy: Strength: 87;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 64;
Air Force: Strength: 63.
Specialty: Flight Nurse;
Army: Requirement: [Empty];
Army: Authorized: [Empty];
Army: Strength: [Empty];
Navy: Requirement[A]: [Empty];
Navy: Authorized: 4;
Navy: Strength: 2;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 190;
Air Force: Strength: 100.
Specialty: General Nursing;
Army: Requirement: 143;
Army: Authorized: 131;
Army: Strength: 0;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 1240;
Navy: Strength: 479;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 0;
Air Force: Strength: 0.
Specialty: Medical/Surgical Nurse;
Army: Requirement: 1141;
Army: Authorized: 1047;
Army: Strength: 1654;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 437;
Navy: Strength: 619;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 1516;
Air Force: Strength: 1560.
Specialty: Mental Health Nurse;
Army: Requirement: 55;
Army: Authorized: 47;
Army: Strength: 61;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 43;
Navy: Strength: 63;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 30;
Air Force: Strength: 32.
Specialty: Mental Health Nurse Practitioner;
Army: Requirement: 22;
Army: Authorized: 21;
Army: Strength: 27;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 9;
Navy: Strength: 17;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 15;
Air Force: Strength: 16.
Specialty: Neonatal Intensive Care Unit Nurse;
Army: Requirement: [Empty];
Army: Authorized: [Empty];
Army: Strength: [Empty];
Navy: Requirement[A]: [Empty];
Navy: Authorized: 29;
Navy: Strength: 23;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 66;
Air Force: Strength: 52.
Specialty: Nurse Anesthetist;
Army: Requirement: 249;
Army: Authorized: 225;
Army: Strength: 140;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 205;
Navy: Strength: 203;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 130;
Air Force: Strength: 135.
Specialty: Nurse Education;
Army: Requirement: [Empty];
Army: Authorized: [Empty];
Army: Strength: [Empty];
Navy: Requirement[A]: [Empty];
Navy: Authorized: 64;
Navy: Strength: 46;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 71;
Air Force: Strength: 53.
Specialty: Nurse Midwife;
Army: Requirement: 41;
Army: Authorized: 38;
Army: Strength: 36;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 26;
Navy: Strength: 29;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 20;
Air Force: Strength: 20.
Specialty: Nurse Service Administration;
Army: Requirement: [Empty];
Army: Authorized: [Empty];
Army: Strength: [Empty];
Navy: Requirement[A]: [Empty];
Navy: Authorized: 59;
Navy: Strength: 212;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 225;
Air Force: Strength: 0.
Specialty: Obstetrics Nurse;
Army: Requirement: 176;
Army: Authorized: 152;
Army: Strength: 173;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 133;
Navy: Strength: 239;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 250;
Air Force: Strength: 277.
Specialty: Operating Room Nurse;
Army: Requirement: 266;
Army: Authorized: 259;
Army: Strength: 249;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 274;
Navy: Strength: 237;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 237;
Air Force: Strength: 219.
Specialty: Pediatric Nurse Practitioner;
Army: Requirement: [Empty];
Army: Authorized: [Empty];
Army: Strength: [Empty];
Navy: Requirement[A]: [Empty];
Navy: Authorized: 28;
Navy: Strength: 28;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 34;
Air Force: Strength: 25.
Specialty: Women's Health Nurse Practitioner;
Army: Requirement: [Empty];
Army: Authorized: [Empty];
Army: Strength: [Empty];
Navy: Requirement[A]: [Empty];
Navy: Authorized: 13;
Navy: Strength: 11;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 69;
Air Force: Strength: 81.
Specialty: Veterinary;
Army: Requirement: 327;
Army: Authorized: 304;
Army: Strength: 361;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 0;
Navy: Strength: 0;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 0;
Air Force: Strength: 0.
Specialty: Audiology and Speech;
Army: Requirement: 36;
Army: Authorized: 32;
Army: Strength: 31;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 18;
Navy: Strength: 18;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 40;
Air Force: Strength: 41.
Specialty: Biochemistry;
Army: Requirement: 85;
Army: Authorized: 58;
Army: Strength: 84;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 33;
Navy: Strength: 36;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 7;
Air Force: Strength: 2.
Specialty: Bioenvironmental Engineering;
Army: Requirement: [Empty];
Army: Authorized: [Empty];
Army: Strength: [Empty];
Navy: Requirement[A]: [Empty];
Navy: Authorized: 0;
Navy: Strength: 0;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 352;
Air Force: Strength: 362.
Specialty: Clinical Laboratory;
Army: Requirement: 79;
Army: Authorized: 73;
Army: Strength: 111;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 67;
Navy: Strength: 78;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 153;
Air Force: Strength: 177.
Specialty: Dietician;
Army: Requirement: 105;
Army: Authorized: 90;
Army: Strength: 133;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 22;
Navy: Strength: 30;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 41;
Air Force: Strength: 58.
Specialty: Entomology;
Army: Requirement: 46;
Army: Authorized: 40;
Army: Strength: 44;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 33;
Navy: Strength: 38;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 14;
Air Force: Strength: 16.
Specialty: Environmental Health;
Army: Requirement: 88;
Army: Authorized: 84;
Army: Strength: 142;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 80;
Navy: Strength: 78;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 189;
Air Force: Strength: 182.
Specialty: Health Services Administration;
Army: Requirement: 1033;
Army: Authorized: 827;
Army: Strength: 700;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 1263;
Navy: Strength: 988;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 1027;
Air Force: Strength: 1030.
Specialty: Industrial Hygiene;
Army: Requirement: [Empty];
Army: Authorized: [Empty];
Army: Strength: [Empty];
Navy: Requirement[A]: [Empty];
Navy: Authorized: 102;
Navy: Strength: 116;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 14;
Air Force: Strength: 7.
Specialty: Microbiology;
Army: Requirement: 62;
Army: Authorized: 46;
Army: Strength: 75;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 43;
Navy: Strength: 50;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 10;
Air Force: Strength: 9.
Specialty: Nuclear Medical Science;
Army: Requirement: 46;
Army: Authorized: 43;
Army: Strength: 43;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 64;
Navy: Strength: 71;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 10;
Air Force: Strength: 1.
Specialty: Occupational Therapy;
Army: Requirement: 59;
Army: Authorized: 50;
Army: Strength: 83;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 19;
Navy: Strength: 21;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 19;
Air Force: Strength: 16.
Specialty: Optometry;
Army: Requirement: 86;
Army: Authorized: 83;
Army: Strength: 107;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 106;
Navy: Strength: 115;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 133;
Air Force: Strength: 132.
Specialty: Other Biomedical Officer;
Army: Requirement: 61;
Army: Authorized: 53;
Army: Strength: [Empty];
Navy: Requirement[A]: [Empty];
Navy: Authorized: 0;
Navy: Strength: 0;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 100;
Air Force: Strength: 0.
Specialty: Pharmacy;
Army: Requirement: 139;
Army: Authorized: 123;
Army: Strength: 130;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 116;
Navy: Strength: 115;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 253;
Air Force: Strength: 233.
Specialty: Physical Therapy;
Army: Requirement: 157;
Army: Authorized: 142;
Army: Strength: 214;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 67;
Navy: Strength: 78;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 133;
Air Force: Strength: 145.
Specialty: Physician Assistant;
Army: Requirement: 184;
Army: Authorized: 151;
Army: Strength: 278;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 212;
Navy: Strength: 166;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 277;
Air Force: Strength: 292.
Specialty: Physiology;
Army: Requirement: [Empty];
Army: Authorized: [Empty];
Army: Strength: [Empty];
Navy: Requirement[A]: [Empty];
Navy: Authorized: 91;
Navy: Strength: 108;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 115;
Air Force: Strength: 120.
Specialty: Podiatry;
Army: Requirement: 24;
Army: Authorized: 20;
Army: Strength: 24;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 20;
Navy: Strength: 15;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 17;
Air Force: Strength: 15.
Specialty: Psychology, Clinical;
Army: Requirement: 76;
Army: Authorized: 66;
Army: Strength: 131;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 133;
Navy: Strength: 129;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 255;
Air Force: Strength: 215.
Specialty: Psychology, Non-Clinical;
Army: Requirement: 23;
Army: Authorized: 17;
Army: Strength: 19;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 45;
Navy: Strength: 47;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 0;
Air Force: Strength: 0.
Specialty: Social Work;
Army: Requirement: 109;
Army: Authorized: 97;
Army: Strength: 131;
Navy: Requirement[A]: [Empty];
Navy: Authorized: 27;
Navy: Strength: 22;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 191;
Air Force: Strength: 213.
Source: DOD data.
[A] Navy does not have a validated process for developing medical
personnel requirements, so GAO is not reporting requirements for Navy.
[B] Air Force does not currently have medical personnel requirements
by specialty but is developing manpower standards for future use.
[C] Executive positions are administrative and are filled by personnel
from the other specialties listed.
[D] Army's general medical personnel are no longer tracked on manning
documents. End strength represents interns filling the specialty.
[E] Navy and Air Force calculated Internal Medicine by adding
Internist and Clinical Pharmacologist; we have done the same with
Army's data.
[F] Navy and Air Force calculated Neurology by adding Neurologist and
Child Neurologist; we have done the same with Army's data.
[G] Navy and Air Force calculated Psychiatry by adding Psychiatrist
and Child Psychiatrist; we have done the same with Army's data.
[End of table]
[End of section]
Appendix III: Comments from the Department of Defense:
Department of Defense:
Office Of The Assistant Secretary Of Defense:
Health Affairs:
Washington, DC 20301-1200:
July 19, 2010:
Ms. Brenda S. Farrell:
Director, Defense Capabilities and Management:
U.S. Government Accountability Office:
441 G. Street, N.W.
Washington, DC 20548:
Dear Ms. Farrell:
This is the Department of Defense response to GAO #351382 Draft Report
"Military Personnel: Enhanced Collaboration and Process Improvements
Needed for Determining Military Treatment Facility Medical Personnel
Requirement," (GAO-10696, GAO Code #351382) dated June 18, 2010.
We agree with the GAO findings and recommendations discussed in the
report. We have provided suggested technical corrections which we feel
should be included in the final version. The present personnel
requirements system, while not perfect and not uniform across all
three Military Departments, does allow new requirements to be
developed and adequately reflects each Military Department's needs.
Thank you for the opportunity to review and comment on the Draft
Report and for meeting with Mr. Middleton and senior representatives
on June 29, 2010. Our comments on the recommendations and some
technical corrections are addressed in the attached.
My points of contact on this issue are Mr. Michael Hopper (Functional)
at (703) 681-1698 and Mr. Gunther Zimmerman (Audit Liaison) at (703)
681-4360.
Sincerely,
Signed by:
Charles L. Rice, M.D.
President, Uniformed Services University of the Health Sciences:
Performing the Duties of the Assistant Secretary of Defense (Health
Affairs):
Enclosures: As stated:
[End of letter]
GAO Draft Report ” Dated 18 June 2010:
(GAO Code-351382/GA0-10-696):
"Military Personnel: Enhanced Collaboration And Process Improvements
Need For Determining Military Treatment Facility Medical Personnel
Requirements"
Department Of Defense Response To The Recommendations:
Consistent with DoD emphasis on developing human capital solutions
across the services to enable department wide decision making and
analyses within its Military Health System, we recommend that the
Secretary of Defense direct the Assistant Secretary of Defense for
Health Affairs and the Service Secretaries to:
Recommendation 1: Identify the common medical capabilities that are
shared across the services in their military treatment facilities that
would benefit from the development of cross-service medical manpower
standards.
DoD Response: Partially Concur. This review can be accomplished
however must include a cost-benefit analysis before making any
determination to develop cross-Service medical manpower standards. If
there is not a significant, measurable benefit in cost, quality or
access to medical care, then it would not be prudent to expend
Department medical funds on such activities.
Recommendation 2: Where applicable, develop and implement cross-
service medical manpower standards for those common medical
capabilities.
DoD Response: Concur. Developing cross-Service manpower standards in
specific medical functional areas, where there is measurable benefit
to the Department and/or the patient, makes good sense. This is what
has been done in Mental Health, for instance.
Recommendation 3: The GAO recommends that the Secretary of the Army
direct the Army Surgeon General to update assumptions and other key
data elements contained within specialty modules of the Army Staffing
Assessment model. (See page 21 /GAO Draft Report.)
DoD Response: Concur. Army will continue to update the Automated
Staffing Assessment Model (ASAM).
Recommendation 4: The GAO recommends that the Secretary of the Army
direct the Army Surgeon General to develop and implement a definitive
re-validation schedule for the specialty modules of the Army Staffing
Assessment model. (Sec page 21/GAO Draft Report.)
DoD Response: Concur. This will be closely coordinated between MEDCOM
and the US Army Manpower Analysis Agency.
Recommendation 5: The GAO recommends that the Secretary of the Army
direct the Army Surgeon General to include its reliance on civilian
medical personnel in its assumptions as it updates and validates their
medical personnel requirements determination modules. (See page 21/GAO
Draft Report.)
DoD Response: Partially Concur. 58% of MEDCOM's workforce is civilian.
Civilian contribution to the generation of medical workload will
continue to be captured by the ASAM to ensure accurate medical
manpower requirements determination in Army military treatment
facilities.
Recommendation 6: The GAO recommends that the Secretary of the Navy
direct the Navy Surgeon General to develop a validated and verifiable
process to determine its medical manpower requirements. (See page
21/GAO Draft Report.)
DoD Response: Partially concur. Approximately two years ago Navy
Medicine initiated a comprehensive effort to address and redefine how
medical manpower requirements were determined to meet the operational
and MTF requirements. In conjunction with this effort the
Navy Surgeon General directed the development and validation of a
requirements model. Initial delivery of the prototype model for
testing and validation is expected by Fall 2010 and validation
&verification efforts will commence at that time.
Recommendation 7: The GAO recommends that the Secretary of the Navy
direct the Navy Surgeon General to include its reliance on civilian
medical personnel in its assumptions as it develops, and then
validates, its medical personnel requirements determination model.
(See page 21 /GAO Draft Report)
DoD Response: Partially concur. The Navy Surgeon General, in
evaluating medical personnel requirements, has always taken a Total
Force approach to include not just Active Duty, but also Reserve,
Civilian and Contract Personnel. The Navy Surgeon General will
continue with this emphasis in all future planning and programming for
medical personnel.
Recommendation 8: The GAO recommends that the Secretary of the Air
Force direct the Air Force Surgeon General to develop a validated and
verifiable process to determine its medical manpower requirements,
(See page 21/GAO Draft Report)
DoD Response: Concur. On [0 May 2010, a Memorandum of Agreement
between the Air Force Medical Service (AFMS) and the Air Force
Manpower Agency (AFMA) was finalized whereby AFMA will develop new
manpower standards for all AFMS product lines, The AFMA Flight that
will develop these standards activates on I July 2010 and will
initiate the first manpower studies on or about 1 August 2010. This
flight will be collocated with the Air Force Medical Operations Agency
(AFMOA) ensuring that manpower engineers obtain the most current
information from those subject matter experts in the specific area of
study.
Recommendation 9: The GAO recommends that the Secretary of the Air
Force direct the Air Force Surgeon General to include its reliance on
civilian medical personnel in its assumptions as it develops, and then
validates, its medical personnel requirements determination model.
(See page 21/GAO Draft Report)
DoD Response: Partially Concur. AFMS manpower standards being
developed by AFMA include the identification of civilian equivalents
for those positions that are not deemed military essential. This
allows the AFMS to substitute civilians based on requirements and is
based on Critical Operational Readiness Requirement (CORR). Civilian
requirements arc also reviewed and determined through the Inherently
Governmental/Commercial Activity process. The AFMS recently modified
the Family Practice manpower model where civilian medical personnel
are an integral part of the mission which is the case for each work
center throughout the AFMS.
Table 1: Strategic Collaboration On Medical Personnel Requirements:
The Military Health System (MHS) strategic intention in workforce
planning is to improve integration and interoperability between the
human capital functions of the Services and HA/TMA by providing
collaborative human capital direction. The 2007 MHS Human Capital
Strategic Plan states "we maintain and respect our Service specific
doctrines, we support joint missions and need to continue to develop
our workplace capabilities to succeed in those environments." The
Human Capital Strategic Plan remains a key document; a refresh will be
released July 2010. The following examples illustrate recent
collaborative efforts.
* Patient-Centered Medical Home (PCMH). PCMH is a collaboratively
developed model of Primary Care to improve continuity of care and
enhance access through patient-centered care. There have been
transparent discussions on staffing ratios, enrollment ratios and
other planning factors.
* Psychological Health Risk-Adjusted Model for Staffing (PITRAMS). The
culmination of a collaborative manpower requirements effort from Army,
Air Force, and Navy and ASD/HA and TMA, PHRAMS is a standardized
evidence-based staffing model to ensure consistency in mental health
staffing. The PHRAMS application will be used by the Services for
program and workforce planning for the FY 2012-2017 Program Objective
Memorandum.
* Joint Task Force Capital Medicine (JTF CAPMED). The JTF CAPMED is a
collaborative effort to transform, realign, and significantly enhance
military healthcare in the National Capital Region (NCR) today and in
the future by establishing jointly manned medical facilities. There is
a unique opportunity to integrate processes to achieve economies of
scale, eliminate redundancies, enhance clinical care and improve other
functions and capabilities.
* Strategic Analysis Working Group (SAWG). The SAWG is a collaborative
forum for planning and programming medical requirements for
operational missions. The SAWG, with each Service and Combatant
Command Representative as members, supports both the planning and
programming processes. The SAWG encourages the use of similar tools,
data, software and models to determine operational medical
requirements.
* Proposed legislation for Financial Assistance for Health Professions-
Civilian. This proposed legislation was developed collaboratively with
the Services to provide scholarships to civilian medical providers,
similar to the highly successful scholarship program in-place for
military providers. The goal is to improve recruiting and retention of
civilian medical providers in the military healthcare system.
* Title 38 Task Force. With the repeal of the National Security
Personnel System (NSPS), DoD needs pay flexibility and ability to
offer competitive salaries to adequately recruit and compensate
civilian employees in critical healthcare occupations. Collaborative
efforts across the Services and HA/TMA resulted in commitment to use
Title 38 authorities to facilitate the transition of 30 healthcare
occupations out of NSPS by 31 December, 2011.
[End of table]
[End of section]
Appendix IV: GAO Contacts and Staff Acknowledgments:
GAO Contact:
Brenda S. Farrell, (202) 512-3604 or farrellb@gao.gov:
Acknowledgments:
In addition to the individual named above, David Moser (Assistant
Director), Rebecca Beale, Chaneé Gaskin, Randy Neice, Cheryl Weissman,
Michael Willems, and Elizabeth Wood made key contributions to this
report.
[End of section]
Footnotes:
[1] DOD provides medical care for its active duty servicemembers,
retirees, and their eligible dependents through its TRICARE program.
TRICARE brings together the health care resources of the Army, Navy,
and Air Force and supplements them with networks of civilian health
care providers. TRICARE offers three options--Prime, Extra, and
Standard. Depending on which option is chosen, active duty
servicemembers and their families may pay no enrollment fees and may
have little or no deductibles or cost shares. Retirees (under 65),
their families, and all other beneficiaries may have to pay annual
enrollment fees and/or cost shares based on where they receive care.
[2] Amount in fiscal year 2000 dollars. Using medical cost conversion
factors, this amount would equal $30.8 billion in fiscal year 2010
dollars.
[3] GAO, Defense Health Care: Issues and Challenges Confronting
Military Medicine, [hyperlink,
http://www.gao.gov/products/GAO/HEHS-95-104] (Washington, D.C.: March
22, 1995).
[4] GAO, 21st Century Challenges: Reexamining the Base of the Federal
Government, [hyperlink, http://www.gao.gov/products/GAO-05-325SP]
(Washington, D.C.: February 2005).
[5] GAO, Defense Health Care: DOD Needs to Address the Expected
Benefits, Costs, and Risks for Its Newly Approved Medical Command
Structure, [hyperlink, http://www.gao.gov/products/GAO-08-122]
(Washington, D.C.: Oct. 12, 2007).
[6] S. Rep. No 110-335, at 353 (2008).
[7] GAO, Military Personnel: Status of Accession, Retention, and End
Strength for Military Medical Officers and Preliminary Observations
Regarding Accession and Retention Challenges, [hyperlink,
http://www.gao.gov/products/GAO-09-469R] (Washington, D.C.: April 16,
2009).
[8] We anticipate issuing a report on medical personnel requirements
in support of contingency operations in Iraq and Afghanistan later
this year.
[9] For purposes of this report, the Assistant Secretary of Defense
for Health Affairs will be referred to as Health Affairs.
[10] Department of Defense Directive 5136.01, Assistant Secretary of
Defense for Health Affairs (Jun. 4, 2008).
[11] 10 U.S.C. § 3013(c)(5), 10 U.S.C. § 5013(c)(5), and 10 U.S.C. §
8013(c)(5).
[12] The U.S. Navy provides all of the medical care for the U.S.
Marine Corps.
[13] Military Health System Human Capital Strategic Plan for 2008-2013
(Nov. 2007).
[14] Department of Defense Directive 5000.59, DOD Modeling and
Simulation Management, § 5.7.3 (Aug. 8, 2007).
[15] Military Base Realignments and Closures: Estimated Costs Have
Increased While Savings Estimates Have Decreased Since Fiscal Year
2009, [hyperlink, http://www.gao.gov/products/GAO-10-98R] (Washington,
D.C.: November 13, 2009).
[16] Department of Defense Directive 5000.59, § 5.7.3 (Aug. 8, 2007).
[17] In providing technical comments to a draft of this report, DOD
noted it has made progress in the past few years towards joint
unitization of personnel, such as tri-service staffed hospitals in
Kuwait and Iraq; the establishment of a human capital office at the
Health Affairs level for providing coordination and assistance to the
services in establishing a joint human capital strategy for civilian
personnel; tri-service team to develop special pay structures for
medical professionals; and the development of two information
management systems used by all three military departments to establish
more standardized data and data sharing among the services. While we
recognize these efforts as examples of cross-service collaboration,
they are not directly related to the medical personnel requirements
determination process for fixed military treatment facilities, which
is the focus of this report.
[18] Department of Defense Directive 1100.4, Guidance for Manpower
Management, § 3.2 (Feb. 12, 2005).
[19] Department of Defense Instruction 5000.61, DOD Modeling and
Simulation Verification, Validation, and Accreditation (Dec. 9, 2009).
[20] Department of Defense Directive 1100.4, § 3.2.3 (Feb. 12, 2005).
[21] Section 721 of the National Defense Authorization Act for Fiscal
Year 2008, Pub. L. No. 110-181 (2008) (as amended by section 701 of
the National Defense Authorization Act for Fiscal Year 2010, Pub. L.
No. 111-84 (2009)) prohibits the secretaries of the military
departments from converting any military medical positions to civilian
medical positions during the period beginning on or after October 1,
2007.
[22] The Department of Defense's Fiscal Year 2009 Status Report on the
Implementation of the Department's Strategic Civilian Human Capital
Plan 2006-2010, March 31, 2010.
[End of section]
GAO's Mission:
The Government Accountability Office, the audit, evaluation and
investigative arm of Congress, exists to support Congress in meeting
its constitutional responsibilities and to help improve the performance
and accountability of the federal government for the American people.
GAO examines the use of public funds; evaluates federal programs and
policies; and provides analyses, recommendations, and other assistance
to help Congress make informed oversight, policy, and funding
decisions. GAO's commitment to good government is reflected in its core
values of accountability, integrity, and reliability.
Obtaining Copies of GAO Reports and Testimony:
The fastest and easiest way to obtain copies of GAO documents at no
cost is through GAO's Web site [hyperlink, http://www.gao.gov]. Each
weekday, GAO posts newly released reports, testimony, and
correspondence on its Web site. To have GAO e-mail you a list of newly
posted products every afternoon, go to [hyperlink, http://www.gao.gov]
and select "E-mail Updates."
Order by Phone:
The price of each GAO publication reflects GAO‘s actual cost of
production and distribution and depends on the number of pages in the
publication and whether the publication is printed in color or black and
white. Pricing and ordering information is posted on GAO‘s Web site,
[hyperlink, http://www.gao.gov/ordering.htm].
Place orders by calling (202) 512-6000, toll free (866) 801-7077, or
TDD (202) 512-2537.
Orders may be paid for using American Express, Discover Card,
MasterCard, Visa, check, or money order. Call for additional
information.
To Report Fraud, Waste, and Abuse in Federal Programs:
Contact:
Web site: [hyperlink, http://www.gao.gov/fraudnet/fraudnet.htm]:
E-mail: fraudnet@gao.gov:
Automated answering system: (800) 424-5454 or (202) 512-7470:
Congressional Relations:
Ralph Dawn, Managing Director, dawnr@gao.gov:
(202) 512-4400:
U.S. Government Accountability Office:
441 G Street NW, Room 7125:
Washington, D.C. 20548:
Public Affairs:
Chuck Young, Managing Director, youngc1@gao.gov:
(202) 512-4800:
U.S. Government Accountability Office:
441 G Street NW, Room 7149:
Washington, D.C. 20548:
