Military Personnel
DOD Addressing Challenges in Iraq and Afghanistan but Opportunities Exist to Enhance the Planning Process for Army Medical Personnel Requirements Gao ID: GAO-11-163 February 10, 2011In Process
Medical officials in theater continually assess the number and the types of military medical personnel they need to support contingency operations in Iraq and Afghanistan and analyze the risks if gaps occur. Given congressional interest about deployed civilians, DOD reported to Congress in April 2010 that with each new mission, the need for new civilian skills has resulted in an increase in deployed civilians and that these civilians are not immune to the dangers associated with contingency operations. Although GAO did not learn of any DOD deployed civilians turned away for care in theater during this review, it is unclear the extent they can expect routine medical care in theater given that a DOD directive and theater guidance differ with regard to their eligibility for routine care. By clarifying these documents, DOD could reduce uncertainty about the level of routine care deployed DOD civilians can expect in theater and provide more informed insights into the military medical personnel requirements planning process. Army theater commanders have been reconfiguring or splitting medical units to cover more geographical areas in theater to better provide advanced emergency life-saving care quicker, but Army doctrine and the organizational design of these units, including needed staff, have not been fully updated to reflect these changes. Studies show that for those severely injured or wounded, 90 percent do not survive if advanced medical care is not provided within 60 minutes of injury. Officials in theater told GAO they are using specialized personnel documents to staff these medical units with more up-to- date personnel requirements to address gaps caused by splitting medical units, and that current doctrine and organizational design were not sufficient to address the capability needed for splitting medical units. According to an Army regulation, it maintains its lessons learned program to systematically update Army doctrine and enhance the Army's preparedness to conduct current and future operations. By updating Army doctrine and organizational documents for the design of medical units that could be used in other theaters, the Army could benefit from incorporating its lessons learned, where appropriate, and be better assured the current practice of splitting medical units to quickly provide advanced life-saving emergency medical care to those severely injured or wounded does not lead to unnecessary staffing challenges. Army commanders have used two approaches--cross-leveling and backfilling--to fill medical personnel gaps that arise in theater due to reasons such as illnesses, emergency leave, and resignations of medical personnel. When these gaps in needed medical personnel occur, the Army's 90-day rotation policy--while intended to ease the financial burden of deploying reserve medical personnel and help retain them--has presented some challenges in quickly filling these gaps in theater with reserve medical personnel when a medical provider is not able to deploy. However, Army data show the magnitude of these unfilled gaps or late arrivals for the reserve component medical providers ranged from about 3 percent to 7 percent from January 2008 to July 2010. GAO recommends that (1) DOD clarify the level of routine medical care that deployed DOD civilian employees can expect in theater and (2) the Army update its doctrine and the organizational design of split medical units. In response to a draft of this report, DOD generally concurred with the 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-11-163, Military Personnel: DOD Addressing Challenges in Iraq and Afghanistan but Opportunities Exist to Enhance the Planning Process for Army Medical Personnel Requirements
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United States Government Accountability Office:
GAO:
Report to Congressional Committees:
February 2011:
Military Personnel:
DOD Addressing Challenges in Iraq and Afghanistan but Opportunities
Exist to Enhance the Planning Process for Army Medical Personnel
Requirements:
GAO-11-163:
GAO Highlights:
Highlights of GAO-11-163, a report to congressional committees.
Why GAO Did This Study:
For ongoing operations in Afghanistan and Iraq, military medical
personnel are among the first to arrive and the last to leave.
Sustained U.S. involvement in these operations has placed stresses on
the Department of Defense‘s (DOD) medical personnel. As the U.S.
military role in Iraq and Afghanistan changes, the Army must adapt the
number and mix of medical personnel it deploys. In response to Congress‘
continued interest in the services‘ medical personnel requirements in
Iraq and Afghanistan, GAO evaluated the extent to which (1) DOD has
assessed its need for medical personnel in theater to support ongoing
operations, (2) the Army has adapted the composition and use of
medical units to provide advanced medical care, and (3) the Army fills
medical personnel gaps that arise in theater. To do so, GAO analyzed
DOD policies and procedures on identifying personnel requirements,
deploying medical personnel, and filling medical personnel gaps in
Iraq and Afghanistan, and interviewed officials.
What GAO Found:
Medical officials in theater continually assess the number and the
types of military medical personnel they need to support contingency
operations in Iraq and Afghanistan and analyze the risks if gaps
occur. Given congressional interest about deployed civilians, DOD
reported to Congress in April 2010 that with each new mission, the
need for new civilian skills has resulted in an increase in deployed
civilians and that these civilians are not immune to the dangers
associated with contingency operations. Although GAO did not learn of
any DOD deployed civilians turned away for care in theater during this
review, it is unclear the extent they can expect routine medical care
in theater given that a DOD directive and theater guidance differ with
regard to their eligibility for routine care. By clarifying these
documents, DOD could reduce uncertainty about the level of routine
care deployed DOD civilians can expect in theater and provide more
informed insights into the military medical personnel requirements
planning process.
Army theater commanders have been reconfiguring or splitting medical
units to cover more geographical areas in theater to better provide
advanced emergency life-saving care quicker, but Army doctrine and the
organizational design of these units, including needed staff, have not
been fully updated to reflect these changes. Studies show that for
those severely injured or wounded, 90 percent do not survive if
advanced medical care is not provided within 60 minutes of injury.
Officials in theater told GAO they are using specialized personnel
documents to staff these medical units with more up-to-date personnel
requirements to address gaps caused by splitting medical units, and
that current doctrine and organizational design were not sufficient to
address the capability needed for splitting medical units. According
to an Army regulation, it maintains its lessons learned program to
systematically update Army doctrine and enhance the Army‘s
preparedness to conduct current and future operations. By updating
Army doctrine and organizational documents for the design of medical
units that could be used in other theaters, the Army could benefit
from incorporating its lessons learned, where appropriate, and be
better assured the current practice of splitting medical units to
quickly provide advanced life-saving emergency medical care to those
severely injured or wounded does not lead to unnecessary staffing
challenges.
Army commanders have used two approaches-”cross-leveling and
backfilling-”to fill medical personnel gaps that arise in theater due
to reasons such as illnesses, emergency leave, and resignations of
medical personnel. When these gaps in needed medical personnel occur,
the Army‘s 90-day rotation policy-”while intended to ease the
financial burden of deploying reserve medical personnel and help
retain them”-has presented some challenges in quickly filling these
gaps in theater with reserve medical personnel when a medical provider
is not able to deploy. However, Army data show the magnitude of these
unfilled gaps or late arrivals for the reserve component medical
providers ranged from about 3 percent to 7 percent from January 2008
to July 2010.
What GAO Recommends:
GAO recommends that (1) DOD clarify the level of routine medical care
that deployed DOD civilian employees can expect in theater and (2) the
Army update its doctrine and the organizational design of split
medical units. In response to a draft of this report, DOD generally
concurred with the recommendations.
View [hyperlink, http://www.gao.gov/products/GAO-11-163] or key
components. For more information, contact Brenda S. Farrell at (202)
512-3604 or farrellb@gao.gov.
[End of section]
Contents:
Letter:
Background:
Theater Commanders Continually Assess Medical Personnel Requirements,
but DOD's Directive on Routine Medical Care for DOD Deployed Civilians
Is Not Consistent with In-theater Guidance:
Medical Units Are Being Reconfigured to Provide Advanced Emergency
Care More Quickly and Over Broader Geographical Areas, but Army
Doctrine Does Not Fully Reflect These Reconfigurations:
Theater Commanders Have Used Two Approaches for Filling Medical
Personnel Gaps:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: The Global Force Management Process and Service Processes
to Identify and Select Medical Personnel to Fill Requirements for
Deployment to Iraq and Afghanistan:
Appendix III: Comments from the Department of Defense:
Appendix IV: GAO Contacts and Staff Acknowledgments:
Table:
Table 1: Organizations and Offices Contacted During Engagement:
Figures:
Figure 1: Breakdown of Military Medical Personnel in Iraq and
Afghanistan by Service as of July 2010:
Figure 2: Levels of Military Medical Care That May Be Provided to U.S.
Military Personnel:
Figure 3: DOD's Process to Meet Personnel Requirements in Support of
Operations in Iraq and Afghanistan:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
February 10, 2011:
Congressional Committees:
When contingencies such as Operation Enduring Freedom in Afghanistan
and Operation Iraqi Freedom arise, military medical personnel[Footnote
1] are among the first to arrive and the last to leave. Sustained U.S.
involvement in Iraq, Afghanistan, and elsewhere has placed stresses on
the Department of Defense's (DOD) medical personnel, particularly for
certain high-demand specialists such as psychiatrists and physician
assistants. DOD medical personnel have dual responsibilities to
provide medical care at health care facilities in the United States
and abroad to servicemembers, former servicemembers, and other
beneficiaries, and, when called upon, to provide urgent, lifesaving
medical care on the battlefield and medical support to U.S. armed
forces.
Providing military medical care for ongoing operations in Iraq and
Afghanistan presents other challenges. For instance, as the number and
mix of medical personnel specialists decreases in Iraq, in line with
the theaterwide reduction of forces, the military must continue to
provide medical support while adapting to reduced numbers of medical
personnel. At the same time, medical units deployed to Afghanistan
face logistical challenges created by geography and the lack of
physical infrastructure such as roads and utilities that complicate
their ability to provide advanced medical care to warfighters.
In our past reports, we have highlighted several issues concerning
military medical personnel requirements. For example, in September
2006, we reported that some combat support and combat service support
skills, including medical, were in particularly high demand to meet
requirements for operations in Iraq and Afghanistan.[Footnote 2] That
report also found that medical and other support skills, which reside
primarily in the Army's reserve components,[Footnote 3] were in
increasingly short supply due to restrictions on the length and
frequency of reserve deployments. In April 2009, we noted that DOD
faced challenges in accessing and retaining medical officers, such as
the limited supply and high demand for qualified medical
professionals; the lower pay generally offered to them by the military
compared to the private sector; the stress, length, and frequency of
deployments; and the length of required service commitments.[Footnote
4] In July 2010, we reported that the services' collaborative planning
efforts regarding requirements determination for medical personnel
working in fixed military treatment facilities have been limited.
[Footnote 5] We also noted that the services' requirements processes
are not always validated and verifiable, as DOD guidance requires.
In response to the congressional committees' continued interest in the
medical and dental personnel requirements of the military services,
including their reserve components, needed to, among other things,
meet their medical missions in support of contingency operations and
deliver high-quality health care to eligible beneficiaries, we agreed
to undertake additional work on issues related to DOD's medical
personnel. For this report, we focused on military medical support for
contingency operations in Iraq and Afghanistan, and as such, we
evaluated the extent to which (1) DOD has assessed its need for
military medical personnel to support ongoing operations, (2) the Army
has adapted the composition and use of its medical units to provide
advanced medical care, and (3) the Army fills medical personnel gaps
that arise in theater.
For our first objective, we analyzed DOD's policies and processes that
govern the medical personnel requirements determination process and
compared DOD guidance and theater-level guidance regarding medical
care for deployed DOD civilians and noted how they differed. For our
second objective, we evaluated Army doctrine and the organization of
medical units and assessed the extent to which they capture current
practices in Iraq and Afghanistan regarding the use and composition of
these units. For our third objective, we reviewed the approaches used
by Army theater medical commanders to meet medical personnel
requirements when gaps in needed personnel coverage occurred in Iraq
and Afghanistan. We also analyzed Army guidance for deploying medical
personnel in its reserve components and assessed Army data to
determine the extent to which medical units of the Army reserve
components had their authorized numbers of medical personnel from
January 2008 to July 2010, given this is the time period in which the
Army had data. We assessed the reliability of the data by interviewing
the agency official responsible for collecting and summarizing the
data and determined that the data were sufficiently reliable for the
purposes of this report. For all three objectives, we augmented our
document analysis by interviewing DOD and service officials, including
officials from United States Forces-Iraq and United States Forces-
Afghanistan; U.S. Central Command; Joint Forces Command; Joint Staff;
Office of Secretary of Defense for Health Affairs; Offices of the
Surgeons General for the Army, the Navy, and the Air Force; and U.S.
Marine Corps Headquarters. Throughout the engagement we relied upon
our staff in Baghdad, Iraq to conduct extensive field work and
interviews with officials in Iraq. For details on our scope and
methodology, see appendix I. We conducted this performance audit from
August 2009 through January 2011 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:
At the end of July 2010, over 10,000 military medical personnel were
deployed to Iraq and Afghanistan, 70 percent of whom were Army
servicemembers. Of that number, about 4,000 medical personnel were in
Iraq and about 6,000 were in Afghanistan. The United States' military
presence in Iraq is scheduled to end no later than December 31, 2011,
and, according to administration estimates, as of September 2010,
about 104,000 U.S. military personnel were deployed in Afghanistan.
Figure 1 shows the breakdown of all military medical personnel in Iraq
and Afghanistan by service at the end of July 2010.[Footnote 6]
Figure 1: Breakdown of Military Medical Personnel in Iraq and
Afghanistan by Service as of July 2010:
[Refer to PDF for image: pie-chart]
Army: 70.2%:
* Army (55.4%);
* Army National Guard (8.9%);
* Army Reserve (5.9%).
Navy: 20.3%:
* Navy (19.4%);
* Navy Reserve (0.9%).
Air Force: 9.4%:
* Air Force (8.3%);
* Air Force Reserve (0.8%);
* Air National Guard (0.4%).
Source: GAO analysis of Defense Manpower Data Center's Contingency
Tracking System.
[End of figure]
Levels of Medical Care in Iraq and Afghanistan:
DOD has established five levels of medical care to treat injured or
sick military personnel, extending from the forward edge of the battle
area to the continental United States, with each level providing
progressively more intensive treatment. Over the course of operations
in Iraq and Afghanistan, the military has integrated more advanced
medical care into the first three levels of care, which are typically
provided in theater, in order to provide the most comprehensive care
possible closest to the point of injury. Figure 2 illustrates the
different levels of medical care that may be provided to U.S.
servicemembers who become ill or injured while in theater.
Figure 2: Levels of Military Medical Care That May Be Provided to U.S.
Military Personnel:
[Refer to PDF for image: illustration]
Patient flow:
First responder care: Level 1;
Forward resuscitative care: Level 2;
Theater hospital care: Level 3;
Overseas definitive care: Level 4;
U.S. definitive care: Level 5.
Source: GAO analysis and Art Explosion; (clipart).
[End of figure]
* Level 1 - First responder care. This level provides immediate
medical care and stabilization in preparation for evacuation to the
next level, and treatment of common acute minor illnesses. Care can be
provided by the wounded soldiers, medics or corpsmen, or battalion aid
stations.
* Level 2 - Forward resuscitative care. This level provides advanced
emergency medical treatment as close to the point of injury as
possible to attain stabilization of the patient. In addition, it can
provide postsurgical inpatient services, such as critical care nursing
and temporary holding. Examples of level 2 units include forward
surgical teams, shock trauma platoons, area support medical companies,
and combat stress control units.
* Level 3 - Theater hospital care. This level provides the most
advanced medical care available in Iraq and Afghanistan. Level 3
facilities provide significant preventative and curative health care.
Examples include Army combat support hospitals, Air Force theater
hospitals, and Navy expeditionary medical facilities.
* Level 4 - Overseas definitive care. This level provides the full
range of preventative, curative, acute, convalescent, restorative and
rehabilitative care, most typically outside of the operational area.
An example of a level 4 facility is Landstuhl Regional Medical Center
in Germany.
* Level 5 - U.S. definitive care. This level provides the same level
of care as a level 4 facility, but most typically is located in the
continental United States. Examples include Walter Reed Army Medical
Center in Washington, D.C.; National Naval Medical Center in Bethesda,
Maryland; and Brooke Army Medical Center at Fort Sam Houston, Texas.
Not all patients progress through all five levels of care, and
patients being evacuated may skip one or more levels of care as
appropriate. In addition, joint and service definitions for each level
of care vary marginally due to service-specific support requirements,
but they essentially align with one another. For purposes of this
report, we focused primarily on level 2 and level 3 facilities and
their personnel, which provide the most comprehensive and advanced
medical care in Iraq and Afghanistan.
Organizational and Command Structure of Medical Forces in Iraq and
Afghanistan:
The U.S. command structure in Iraq and Afghanistan has evolved over
time. In 2009, the designation of U.S. troops in Afghanistan became
United States Forces-Afghanistan. In 2010, the designation of U.S.
troops in Iraq became United States Forces-Iraq. The commanding
generals of United States Forces-Iraq and United States Forces-
Afghanistan both are advised by a lead surgeon on medical policy and
procedures, according to theater medical officials. Each theater also
has a medical task force--the Task Force 1st Medical Brigade and its
successor, the Task Force 807TH Medical Brigade in Iraq and the Task
Force 30TH Medical Command and its successor, Task Force 62nd Medical
Command in Afghanistan--that, according to theater medical officials,
consist of professional staff members who coordinate care in theater
and directly command medical-only units in theater, such as forward
surgical teams and combat support hospitals. The theater surgeon and
medical task forces command mostly Army medical facilities. According
to a DOD official, the other services maintain and operate additional
medical facilities in theater that may be outside the direct command
of the medical task force but under the direction of United States
Forces-Iraq and United States Forces-Afghanistan. For example, the Air
Force operates a theater hospital in Balad, Iraq but coordinates
closely with the task force medical brigade in Iraq. The United States
Forces-Iraq Surgeon and staff collaborate closely with the task force
medical brigade commander and staff in Iraq to coordinate medical
policy and care. The positions of United States Forces-Afghanistan
Surgeon and the commander of the task force medical command in
Afghanistan are filled by the same individual.
DOD Uses Its Global Force Management Process to Meet Medical Personnel
Requirements:
According to DOD officials, DOD meets theater medical personnel
requirements through its Global Force Management process. DOD designed
the Global Force Management process to provide insight into the
availability of U.S. military forces to deploy, including medical
personnel. Figure 3 depicts the process and the key participants in
Global Force Management.
Figure 3: DOD's Process to Meet Personnel Requirements in Support of
Operations in Iraq and Afghanistan:
[Refer to PDF for image: illustration]
Theater Commander:
1. Identifies a gap in the ability of existing capabilities to meet
medical mission and develops request for forces.
Central Command:
2. Coordinates with its service components, to determine if request
for forces is valid. Approves request for forces.
Joint Chiefs of Staff:
3. Reviews request for forces.
Joint Forces Command:
4. Tasks its service components to provide potential solutions to fill
request for forces.
Air Combat Command:
Army Forces Command:
Marine Corps Forces Command:
Fleet Forces Command:
5. Provides a solution to filling the request and a risk assessment
which describes the readiness of the services‘ medical personnel.
Joint Forces Command:
6. Evaluates available solutions to fill request for forces from all
services and provides courses of action with recommendation.
Joint Chiefs of Staff:
7. Chooses course of action and makes final recommendation of services‘
medical force to be deployed.
Secretary of Defense:
8. Approves recommendation and service is ordered to send medical unit
to operations in theater.
Orders:
9. Service selected deploys medical unit.
Deploy:
Source: GAO analysis.
[End of figure]
Once the Secretary of Defense designates a service to meet a medical
requirement, that service identifies and selects units and personnel
to fill the requirement. While the procedures and systems used by each
service to select medical personnel vary, the services' processes for
filling requirements[Footnote 7] all result in units and personnel
deploying to an operational theater to carry out a mission.
Identifying and selecting medical personnel and units to fill
requirements can often be challenging due to shortages[Footnote 8] of
medical personnel, but DOD officials told us they have been able to
fill almost all medical personnel requirements since the Global Force
Management process was established in 2005. More information on the
Global Force Management process and the services' personnel filling
processes can be found in appendix II.
Theater Commanders Continually Assess Medical Personnel Requirements,
but DOD's Directive on Routine Medical Care for DOD Deployed Civilians
Is Not Consistent with In-theater Guidance:
Medical officials in theater continually assess the number and the
types of military medical personnel they need to support ongoing
contingency operations in Iraq and Afghanistan. Theater officials also
analyze gaps in medical care and the associated risks given different
potential scenarios. However, it is unclear what level of care
deployed DOD civilian employees can expect in theater because a DOD
directive governing medical care for DOD deployed civilians is
inconsistent with in-theater guidance with regard to eligibility for
routine medical care for deployed DOD civilian employees. In response
to congressional interest about deployed civilians, the Secretary of
Defense reported to Congress in April 2010 that with each new mission,
the need for new civilian skills have resulted in an increase in the
number of deployed civilians and that these civilians are not immune
to the dangers associated with contingency operations. Although we did
not learn of any DOD deployed civilians turned away for care in
theater during the period of our review, officials in theater did say
this could be a concern if the number of civilians increased, and at
that time they would assess the impact of a civilian increase on the
need for more medical personnel. At the conclusion of our audit, an
Army official agreed that if there is an inconsistency between
departmental guidance and theater guidance, it should be clarified.
Thus, by examining inconsistencies in departmental guidance compared
to theater guidance on the level of routine medical care, DOD could
reduce the uncertainty about the level of routine care these deployed
civilians can expect in theater. In response to a draft of this
report, DOD mentioned to us that its operating units have sufficient
organic medical support and the medical needs of deployed civilians
are being met. DOD also agreed that the Commander of U.S. Central
Command should revise its guidance to clarify the level of care that
deployed civilians should receive.
Theater Officials Analyze Mission Plans and Medical Data to Assess
Their Need for Medical Personnel:
Theater operational and medical officials determine how many and the
types of medical personnel needed to support operations in Iraq and
Afghanistan through an ongoing assessment, which includes an
evaluation of the operational mission and other planning factors, such
as historical injury statistics and medical workload data. In their
assessment, theater officials also analyze gaps in medical care given
different potential scenarios and the associated risks. This ongoing
assessment takes place in theater and allows theater officials to
identify new medical personnel requirements and regularly reevaluate
existing medical personnel requirements. Further, theater operational
and medical officials also consider operational limitations when
developing their medical personnel requirements, including the limit
on the total number of forces in theater and shortages of and high
demand for certain medical personnel.
In determining the number of military medical personnel and the
medical specialties needed, theater operational and medical officials
told us that they begin by evaluating various mission planning
factors, such as the number and dispersion of U.S. forces, the
expected intensity of combat, capabilities of the adversary to inflict
harm, geography, and climate. Officials said that this information
allows them to determine the level and structure of medical care they
expect to need to support missions throughout the theater of
operations. For example, in planning for the increase of U.S. forces
in Afghanistan beginning in early 2010, officials with the U.S.
Central Command requested additional medical personnel to provide
medical care to the increased number of U.S. military personnel in
theater, including a theater hospital and a preventative medicine
unit. In addition, during the offensive in Bastion, Afghanistan,
officials with the Task Force 30TH Medical Command told us that they
relocated some mental health providers in Afghanistan to Bastion for
the duration of the heightened operational tempo so this type of care
could be better provided in the area experiencing hostilities.
To further assess the need for specific types of medical specialists
in a given unit and across the theater, medical officials analyze data
from the Joint Theater Trauma Registry, the Joint Medical Work
Station, and service and joint data on disease and non-battle injuries
to determine trends in medical workload. Officials use this
information to increase or decrease the number of medical personnel in
line with demand for medical services. For example, DOD medical
officials conducted an analysis to determine the need for
cardiovascular specialists in Iraq and Afghanistan based on, among
other variables, the volume of cardiovascular-related medical
evacuations in theater. Officials also analyze gaps and risks in the
medical care structure under different possible scenarios. For
example, the Task Force 1st Medical Brigade in Iraq conducted an
analysis that identified possible requirements for additional medical
personnel with certain specialties, such as general surgeons, at
locations in northern Iraq given the possibility of adverse weather
conditions that would prohibit medical evacuation of patients to more
advanced medical care facilities. Further, when confronted with a need
for additional medical personnel, the theater commanding general can
submit a request for forces through DOD's Global Force Management
process. For example, we learned of two Army sustainment brigades--the
82nd and the 43RD Regional Support Commands--that deployed to
Afghanistan with their authorized medical personnel but did not have
enough medical personnel to provide full support to their convoys and
forward locations. In response, Task Force 62nd Medical Command in
Afghanistan requested additional forces for these two brigades.
Officials told us that DOD met this requirement by deploying 22 Air
Force medics to Afghanistan.
Additionally, medical officials in Iraq and Afghanistan told us that
they must consider two operational limitations which affect how many
medical personnel they formally request. First, the cap on the total
number of U.S. forces allowed in Iraq and Afghanistan requires theater
commanders to balance the number of medical personnel they request
with many other types of forces needed to conduct and support ongoing
operations. For instance, officials in Afghanistan told us that when
they initiate requests for additional personnel, the requesting unit
is asked to offset the increase in forces on a one-to-one basis within
the unit. If they are unable to do so, operational and medical
officials determine if the request for additional medical forces takes
precedence over the need for other types of personnel already in
theater, and if so they decide which personnel will redeploy out of
theater to stay within the authorized force cap. Second, shortages of
and high demand for medical personnel in certain specialties also
plays a role in decisions about whether to request medical forces. For
example, officials in Iraq determined that 16 additional veterinary
food inspectors were needed for food safety inspections, but they did
not formally initiate that request due to the current shortage of
these specialists.
The Level of Care That Deployed DOD Civilian Employees Can Expect in
Theater is Unclear:
Although DOD primarily provides both emergency life-saving medical
care as well as routine medical care to U.S. military personnel in
Iraq and Afghanistan, it is unclear what level of routine medical care
deployed DOD civilian employees can expect in theater. DOD relies on
its own deployed civilians to carry out or support a range of
essential missions, including logistics support, maintenance,
intelligence collection, criminal investigations, and weapon systems
acquisition. About 2,600 DOD civilian employees were deployed to Iraq,
and about 2,000 DOD civilian employees were deployed to Afghanistan
according to DOD's April 2010 report[Footnote 9] to Congress on
medical care for injured or wounded deployed U.S. federal civilians.
In response to congressional interest, DOD reviewed the department's
existing policies for medical care for DOD deployed civilians and
federal civilian employees that might be injured or wounded in support
of contingency operations and reported to Congress on the results in
April 2010. DOD noted in its report that with each new mission, the
need for new civilian skills has resulted in an increase in the number
of deployed civilians and that these civilians are not immune to the
dangers associated with contingency operations, since they too incur
injuries or wounds in their efforts to support the missions in Iraq
and Afghanistan.
Although DOD guidance clearly provides that deployed DOD civilians
will receive life-saving emergency care, it is unclear to what extent
DOD civilians can expect routine medical care in theater because a DOD
directive and theater guidance differ with regard to their eligibility
for routine medical care. Specifically, DOD Directive 1404.10[Footnote
10] states that the department's civilian employees who become ill,
are injured, or are wounded while deployed in support of U.S. military
forces engaged in hostilities are eligible to receive health care
treatment and services at the same level and scope provided to
military personnel. However, theater guidance for Iraq and
Afghanistan,[Footnote 11] which provides detailed information on
medical care to deployed civilians, among others, states that DOD
civilians are eligible for emergency care but most routine care for
them is subject to availability. This differs from the DOD directive
that states care should be at the same level and scope provided to
military personnel. In addition, we found that the theater guidance
document for care in Afghanistan[Footnote 12] provided additional
guidance that is inconsistent with both the DOD directive and with
guidance provided elsewhere in the document as to the level of care to
be provided to DOD deployed civilians. Specifically, one section of
the guidance stated routine care for all civilians was to be provided
subject to availability while another section of the same guidance
stated routine care was to be provided for deployed DOD civilians in
accordance with a previous issuance of DOD Directive 1404.10.[Footnote
13] The previous version of DOD Directive 1404.10 indicated that
civilians designated as emergency essential employees would be
eligible for care at the same scope provided to military personnel,
while the current January 2009 DOD directive extends the provision of
routine medical care to a much wider group of DOD deployed civilians.
Medical officials in Afghanistan told us that they provide routine
medical care to U.S. federal civilians on a space-available basis, and
that they would not turn away any person with injuries that presented
a danger to life, limb, or eyesight, regardless of the employment
status of an individual. This issue has received continuing
congressional interest. For example, in April 2008 the House Armed
Services Committee Subcommittee on Oversight and Investigations issued
a report on deploying federal civilians and addressed the medical care
provided to them when they are wounded, ill, or injured while in a war
zone.[Footnote 14] Furthermore, DOD's report to Congress on deployed
DOD civilians stated that the department believes it is imperative
that each federal civilian understands where, when, and how they can
receive medical treatment in theater. Although we did not learn of any
deployed DOD civilians being turned away from receiving routine care
in theater during the time of our review, officials in theater said it
could be a concern if the number of DOD civilians that deploy
increases, and that theater medical officials would assess the impact
of any increase on the planning process for determining medical
personnel requirements. However, if theater officials concluded that
they needed more medical personnel due to increases in numbers of DOD
deployed civilians, we recognize that an increase in medical resources
would have to be balanced against other high-priority needed resources
due to the force cap limiting the overall numbers of military
personnel that can be in theater. For example, the former commander
who oversaw military medical units in Afghanistan noted to us that
while there is no medical-specific force cap, including a limit on the
number of medical personnel within the larger force cap, any
additional military personnel needed in theater must be balanced by
the loss of other military personnel in other areas, such as a
transportation unit, and that the force cap has played a role in their
decisions in determining medical personnel requirements. Additionally,
the current commander who oversees military medical units in
Afghanistan stated that local base commanders can request additional
medical personnel if they believe that the number of U.S. soldiers or
civilians merits an increase. The official stated that an increase of
about 800 to 1500 civilians would have to occur before they would
consider revising military medical personnel requirements. At the
conclusion of our audit, an Army official agreed that if there is an
inconsistency between departmental guidance and theater guidance, it
should be examined. As long as theater guidance differs from the
requirements of departmental directives, uncertainty about deployed
civilians' eligibility for routine care in theater will remain and the
military medical personnel requirements planning process may not be
fully informed by department-level expectations.
Medical Units Are Being Reconfigured to Provide Advanced Emergency
Care More Quickly and Over Broader Geographical Areas, but Army
Doctrine Does Not Fully Reflect These Reconfigurations:
Theater commanders in Iraq and Afghanistan are providing quicker
access to advanced emergency medical care by placing more medical
units in more geographical areas to save lives. However, Army
doctrine,[Footnote 15] which is the starting point for defining and
planning a unit's capabilities, has not been updated fully to reflect
these changes in theater. Also, the organizational design[Footnote 16]
of these medical units used in theater, which indicates the number and
mix of skilled medical personnel these units should have, has not been
updated to reflect current practice in theater. Specifically,
commanders in Iraq and Afghanistan have been splitting or
reconfiguring medical units typically designed to operate in one
location into multiple smaller units to cover a wider geographical
area. For example, as of December 2009 the Task Force 28TH Combat
Support Hospital in Iraq--a field hospital typically designed to be in
one location--was split to be at three separate sites in Iraq--
Baghdad, Tallil, and Al Kut--to better cover this large operational
area. Theater medical commanders split these units because they found
that the field hospital's standard design configuration was no longer
suitable for the model of care that has evolved in Iraq, which
requires access to more advanced medical care--particularly surgical
care--over large geographical distances to better save lives.
Splitting medical units, such as level 3 combat support hospitals and
level 2 forward surgical teams, in order to locate them in more areas
increases the opportunities to provide advanced emergency care quicker
and could save more lives. According to documents from the 28TH Combat
Support Hospital, the number of surgical sites has increased due to
the emphasis on providing troops access to surgical care within 60
minutes of being injured. DOD has stated that by providing advanced
life-saving emergency medical care quicker, generally within 60
minutes of injury, survival rates increase significantly. In fact,
studies show that for those severely injured or wounded, 90 percent do
not survive if advanced medical care is not provided within 60 minutes
of injury, thus creating urgency for rapid access to the wounded.
Medical officials in Iraq acknowledged that Army doctrine and the
organizational design of medical units were top issues that needed to
be updated to better reflect the current practice of splitting medical
units such as combat support hospitals. For example, in a December
2009 Mid-Tour Report, the Task Force 1st Medical Brigade--the medical
unit that provided oversight over medical units in Iraq before being
replaced by Task Force 807th Medical Brigade--noted that the
organization for combat support hospitals, including the list of
needed medical specialties, should be redesigned to reflect the actual
use of combat support hospitals across multiple locations and that
certain lessons learned could be considered in the redesign.
Specifically, Task Force 1st Medical Brigade reported that splitting
full-sized combat support hospitals into smaller parts can create
medical personnel gaps in certain specialties, including those related
to the operation of pharmacies, laboratories, and patient
administration. The medical brigade's report also went on to note that
personnel with these smaller combat support hospitals are spread so
thinly that when personnel take leave or are evacuated out of theater
due to injury, the medical brigade has to make difficult decisions on
where to find needed personnel to mitigate coverage gaps. Given these
lessons learned, officials with the Task Force 1st Medical Brigade
told us that they were concerned about outdated policies, guidance,
doctrine, and field manuals related to the determination of medical
personnel requirements in theater and stated specifically that the
current design of combat support hospitals is not flexible enough to
accomplish what they are now being asked to do. As such, they now have
to continuously use what is referred to as specialized personnel
documents to manage staffing rather than staff as indicated in
established doctrine and the organization design of these units.
Specifically, officials with the Task Force 1st Medical Brigade noted
to us that staffing of medical units is now done in a "very non-
doctrinal fashion" and that they had similar concerns about splitting
area support medical companies and using them in theater in a non-
doctrinal fashion, given these area support medical companies now
function as two separate level 2 troop medical clinics when they are
staffed to function as one. Finally, the Task Force 1st Medial Brigade
report went on to recommend that the organizational composition of
combat support hospitals be redesigned to include redundant capability
to accommodate expected attrition in staff.
Additionally, officials with the U.S. Forces-Iraq Surgeon Office told
us in a separate interview that medical doctrine, specifically the
organizational design for both personnel and equipment, should be
assessed and updated given the current experience in Iraq. These
officials said that the splitting of combat support hospitals and
forward surgical teams has gained acceptance over time but should be
examined given how counterinsurgency doctrine is implemented in Iraq.
These officials with the Surgeon Office in Iraq also said that
flexibility in the doctrine is critical, but that doctrine needs to
reflect the realities of operations on the ground and the degree to
which current practice of splitting medical units has filtered into
medical doctrine has been limited.
Recognizing these lessons learned in an environment that is continuing
to evolve to provide advanced medical care to save more lives,
officials with the Army Medical Department Center and School who are
responsible for updating medical doctrine and the organizational
design of medical units recently updated the forward surgical team
field manual, noting that changes in the number and mix of specialists
that make up a forward surgical team might be necessary if such teams
are to operate as smaller stand-alone units. However, the updated
manual did not specifically suggest what those changes in the number
and mix of medical specialists that make up a forward surgical team
should be if the team is providing advanced emergency care as a stand-
alone unit. We were told that Army planners have adjusted medical
personnel requirements for forward surgical teams to account for
changes in these smaller nonstandard medical unit reconfigurations by
increasing the number of personnel assigned to those units, but the
updated field manual still does not specify what the number and mix of
medical specialists should be. Furthermore, by splitting or dividing
the standard traditional design for combat support hospitals, DOD has
also had to adjust the number and mix of medical personnel in those
units as well. Instead of relying on the standard traditional doctrine
design for medical units in theater, Army medical officials have been
developing specialized personnel documents to staff these medical
units to identify the medical skill sets now needed to operate split
medical units across multiple locations for counterinsurgency
operations. Specifically, officials with the Task Force 1st Medical
Brigade told us these specialized personnel documents allow for more
up-to-date establishment of personnel requirements to address gaps
caused by splitting medical units. However, the process is difficult
and it came about because current doctrine and organizational design
were not sufficient to address the capabilities needed for splitting
medical units such as combat support hospitals and area support
medical companies.
Although the Army medical officials we spoke with said that they
believe splitting and reconfiguring units in theater is necessary and
helps to increase survival rates by providing advanced life-saving
emergency medical care generally within 60 minutes of injury, the Army
has not fully incorporated these current practices into Army doctrine
and organizational documents, which ordinarily determine the size,
composition, and use of these units. In response to a draft of this
report, DOD explained to us that Army leadership has recognized that
split hybrid operations and the dispersed environment in the theater
of operations have generated a requirement for additional medical
structure. According to an Army regulation, the Army maintains a
lessons learned program to, among other things, systematically update
Army doctrine to enhance the Army's preparedness to conduct current
and future operations.[Footnote 17] By updating Army doctrine and
organizational documents for the design of medical units that could be
used in other theaters, the Army could benefit from incorporating its
lessons learned, where appropriate, and be better assured the current
practice of splitting medical units to quickly provide advanced life-
saving emergency medical care to those severely injured or wounded
does not lead to unnecessary staffing challenges.
Theater Commanders Have Used Two Approaches for Filling Medical
Personnel Gaps:
When medical personnel gaps unexpectedly arise in Iraq or Afghanistan,
Army commanders have used two approaches to fill those gaps, according
to medical officials in theater. Gaps in medical capabilities can
occur when medical providers do not deploy as expected for reasons
such as resignation, or a medical provider is determined to be
medically nondeployable. Medical personnel gaps can also occur when
individual medical personnel need to leave the unit for reasons such
as an emergency situation at home or if they become seriously sick or
injured in theater. According to medical officials in theater, when
these gaps occur, Army commanders have used two approaches to fill
these gaps: backfilling and cross-leveling.
* Backfilling involves the identification and deployment of medical
personnel into theater from the United States or elsewhere who were
not originally scheduled to deploy overseas at that time, according to
medical officials in theater. For example, a dentist assigned to a
brigade combat team in southern Iraq was evacuated out of theater for
medical reasons. Given the backlog of needed dental work, commanders
expressed concern about losing a dentist. In response, Army Forces
Command initiated an effort to identify another dentist not in Iraq
who was eligible to deploy to fill this need. DOD officials told us
that selecting and deploying an active component medical provider to
backfill a position typically takes about 45 days.
* Cross-leveling involves the temporary relocation of personnel from
one unit in theater to another, according to DOD officials. Medical
officials in theater told us that cross-leveling is often used as an
interim measure to minimize risk when a gap in medical personnel
coverage occurs. For example, an operating room nurse assigned to a
forward surgical team in Iraq had an unexpected medical situation and
was evacuated out of theater. It was critical that this personnel
requirement be filled in a timely manner, given that the forward
surgical team was staffed with only one operating room nurse. Theater
officials requested a replacement from U.S. Army Forces Command and
U.S. Army Reserve Command, but the individual identified as a
replacement could not deploy for at least 30 days. Recognizing the
high priority need for a forward surgical team to have an operating
room nurse, Task Force 1st Medical Brigade identified an operating
room nurse that it could borrow from another unit in theater until the
replacement arrived. After the replacement nurse arrived in theater,
the operating room nurse on loan returned to the unit the individual
came from.
Personnel gaps that occur in theater cannot always be prevented and
when gaps do occur, theater commanders assess the risk associated with
the gap and decide on an appropriate course of action, according to
officials with Task Force 1st Medical Brigade. Cross-leveling in
particular requires the assessment of risk associated with the
personnel gap and the gap that would be created by the relocation of a
medical provider from another unit. According to theater commanders we
spoke with, cross-leveling, while temporary, is not an ideal solution
and can present risk to medical operations in theater, especially when
conducted on a recurring basis. We recognize that risk cannot be
eliminated; it can only be managed. Army officials told us that they
are willing to accept some risks in order to mitigate other risks they
believe are higher.
According to medical officials, when medical personnel gaps in an Army
reserve component medical unit occur, it can be challenging to fill
the gap before the start of the next 90-day rotation,[Footnote 18]
given it can take around 120 to 180 days to identify, notify, and then
mobilize an Army reservist to fill an unfilled requirement by which
time the next expected 90-day medical provider has already arrived.
The Army's 90-day rotation policy--while intended to ease the
financial burden of deploying reserve medical personnel and help
retain them--has presented some challenges for the Army in quickly
filling these gaps when a medical provider is not able to deploy. For
example, the 9l5th Forward Surgical Team”-an Army reserve medical
unit”-was authorized to deploy to Iraq in September 2009 with three
general surgeons, according to theater medical officials. Instead, it
deployed with only one surgeon for the first 90-day rotation, despite
efforts to identify two other deployable general surgeons. The Army
Reserve identified a doctor to fill one of the two vacancies; however
this individual could not deploy due to an inability to be
credentialed as a general surgeon. The Army Reserve then identified
another surgeon for deployment, but this individual had educational
requirements issues, and yet a third identified surgeon resigned. By
the time the Army Reserve was able to identify a surgeon who could
deploy, the 9l5th Forward Surgical Team had been in Iraq for a month
out of its first 90-day rotation. Further, the Army was unable to
identify the third authorized surgeon for the 9l5th Forward Surgical
Team before the end of that 90-day rotation given another identified
surgeon scheduled for deployment resigned, and the replacement surgeon
turned out to be nondeployable for medical reasons. In fact, the 9l5th
Forward Surgical Team did not have one out of its authorized three
general surgeons for the first three 90-day rotations”approximately
270 days. Moreover, the 915th Forward Surgical Team was expected to
operate as two smaller units at two separate locations in southern
Iraq, but it was unable to provide surgical capabilities in both
locations as expected without three authorized general surgeons. As a
result of the personnel gaps, Task Force 1st Medical Brigade
temporarily relocated medical personnel already in theater from other
medical units to the 9l5th Forward Surgical Team so it could meet its
mission.
Although we found examples of the 915th Forward Surgical Team not
having all of its medical personnel before the end of each 90-day
rotation, Army data show the magnitude of these unfilled gaps or late
arrivals for the reserve components ranged from about 3 percent to 7
percent from January 2008 to July 2010. Specifically, Army data showed
that about 4 percent of mobilized Army reserve component 90-day
medical rotators (21 medical providers out of 594) did not deploy to
theater or arrive in theater on time for 2008. In 2009, that figure
reached 7 percent (38 medical providers out of 519) and through the
first 6 months of 2010, this figure was over 3 percent (8 medical
providers out of 236).[Footnote 19] Unfilled reserve component
personnel requirements can have serious consequences depending on the
needed medical specialty. Therefore, medical commanders in theater
typically cross-level to fill short-term temporary personnel gaps,
although medical officials in Iraq we spoke with said cross-leveling
is a less than ideal approach to fill these medical personnel gaps.
Conclusions:
DOD has continued to assess its need for medical personnel in theater
based on the requirements of the mission and a variety of medical data
and has made adjustments to meet specific theater needs to achieve the
goal of providing advanced life-saving care quickly. DOD has noted
that, increasingly, deployed civilians also face dangerous
circumstances in ongoing contingency operations. While DOD has stated
that deployed civilians will receive emergency care whenever needed,
the extent of routine medical care available to DOD deployed civilians
is unclear due to inconsistent guidance. Inconsistent guidance could
potentially impact the medical personnel requirements planning process
if medical officials in theater are uncertain about deployed DOD
civilian employees' access to routine medical care. While we did not
learn of any deployed DOD civilians being turned away for medical care
in theater during the time of our audit, DOD could still benefit by
assessing the implications the inconsistencies in guidance could have
if there were a sizable increase in the number of DOD deployed
civilians in theater.
Conducting counterinsurgency operations in often uncertain, dangerous
environments such as Iraq and Afghanistan, Army theater commanders
have reconfigured the composition of field hospitals and forward
surgical teams by breaking them down into smaller stand-alone units to
better position them to give the severely wounded or injured, such as
the casualties of blast-type injuries, the advanced emergency medical
care needed to save lives. By being in more geographical areas, these
critical life-saving medical units are better able to achieve their
goal of providing advanced emergency medical care within 60 minutes of
injury to increase survival rates. Acknowledging the current practice
of splitting medical units, the medical brigade that provided
oversight over medical units in Iraq reported that one of its top
issues was advocating for updates to the doctrine and organizational
redesign of these split units that govern its use and personnel
allocation. By leveraging lessons learned collected from this
practice, especially the needed number and mix of medical personnel,
the Army could benefit from integrating these lessons systematically
into Army doctrine and the design of these medical units. Updating
doctrine and organizational design of these split medical units used
in theater could help to assure that these units will be resourced
with the needed number and mix of medical personnel to continue
providing critical life-saving capabilities for counterinsurgency
operations in other theaters and in the future.
Recommendations for Executive Action:
To better understand the extent to which deployed DOD civilian
employees have access to needed medical care, as appropriate, we
recommend that the Secretary of Defense direct the Combatant Commander
of U.S. Central Command to clarify the level of care that deployed DOD
civilian employees can expect in theater, including their eligibility
for routine care.
To enhance medical units' preparedness to conduct current and future
operations given the changing use of combat support hospitals and
forward surgical teams in Iraq and Afghanistan, we recommend that the
Secretary of the Army direct the Army Medical Department to update its
doctrine and the organization of medical units concerning their size,
composition, and use.
Agency Comments and Our Evaluation:
In written comments provided in response to a draft of this report,
DOD generally concurred with our findings and recommendations. DOD
fully concurred with our first recommendation that the department
clarify the level of care that deployed DOD civilian employees can
expect in theater. DOD partially agreed with our second recommendation
that the Army Medical Department update its doctrine and the
organization of medical units concerning their size, composition, and
use. DOD noted that there is an unquestionable need to formally update
doctrinal publications. DOD also noted that the Army is constantly
reviewing and assessing medical capability, the use of those
capabilities and the organization of medical units, and updating
doctrine to evolving staffing requirements. As an example, DOD
mentioned in its official response that a recent review of medical
capability indicated the need for additional medical personnel, and
the Army responded with guidance to increase the number of enlisted
health care specialists assigned to Army Brigade Combat Teams. The
department also noted that the Army continues to capture lessons
learned and input from commanders to ensure use of medical personnel
meets requirements. We recognize that the Army continues to capture
lessons learned and input from the commanders, and we noted in our
report that the Army Medical Department Center and School has updated
its forward surgical team field manual although updates to this field
manual did not specifically note changes in the number and mix of
medical specialists that make up a forward surgical team if the team
is providing advanced emergency care as a stand-alone unit. Thus, we
still believe the Army would benefit by fully updating the
organization of medical units concerning their size, composition and
use, as applicable, to incorporate current practices of splitting and
reconfiguring deployed medical units in theater. DOD also provided
technical comments that we incorporated as appropriate.
We are sending copies of this report to the Secretary of Defense, the
Secretary of the Army, and appropriate DOD organizations. In addition,
this report will be available at no charge on GAO's Web site at
[hyperlink, http://www.gao.gov]. If you or your staffs have any
questions about this report, please contact me at (202) 512-3604 or by
e-mail at 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 major contributions to the
report are listed in appendix IV.
Signed by:
Brenda S. Farrell:
Director, Defense Capabilities and Management:
[End of section]
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 Howard P. McKeon:
Chairman:
The Honorable Adam Smith:
Ranking Member:
Committee on Armed Services:
House of Representatives:
The Honorable C.W. Bill Young:
Chairman:
The Honorable Norman D. Dicks:
Ranking Member:
Subcommittee on Defense:
Committee on Appropriations:
House of Representatives:
[End of section]
Appendix I: Scope and Methodology:
We examined the Department of Defense's (DOD) efforts to identify and
fill its military medical personnel requirements in support of
operations in Iraq and Afghanistan. Specifically, we evaluated the
extent to which (1) DOD has assessed its need for military medical
personnel in Iraq and Afghanistan, (2) the Army has adapted the
composition and use of its medical units to provide advanced medical
care, and (3) the Army fills medical personnel gaps that arise in
theater. During our evaluation, we contacted DOD and service
officials, including officials from United States Forces-Iraq and
United States Forces-Afghanistan; U.S. Central Command; U.S. Joint
Forces Command; Joint Staff; Office of Secretary of Defense for Health
Affairs; Offices of the Surgeons General for the Army, the Navy, and
the Air Force; and U.S. Marine Corps Headquarters.
For the first objective--to evaluate the extent to which DOD has
assessed its need for military medical personnel in Iraq and
Afghanistan to support ongoing operations--we analyzed DOD and service
policies and processes that govern the determination of medical
personnel requirements, including service doctrine, DOD guidance, and
current theater-level guidance regarding medical care in Iraq and
Afghanistan. Specifically, we compared a current DOD directive
regarding medical care for DOD civilian employees and theater-level
guidance regarding medical care for U.S. federal civilians, including
DOD civilian employees, and noted how they differed. To augment our
analysis, we interviewed officials, including representatives from the
theater medical task forces and Surgeons' offices in Iraq and
Afghanistan about how they assess their military medical personnel
needs in Iraq and Afghanistan and possible effects of differences in
guidance that govern medical care in theater.
For the second objective--to evaluate the extent to which the Army has
adapted the composition and use of its medical units to provide
advanced medical care in Iraq and Afghanistan--we reviewed reports
from the medical task forces in theater, Army documentation of the
composition of medical units in Iraq and Afghanistan, theater-level
publications regarding medical care in Iraq and Afghanistan, Army
medical doctrine, and Army field manuals for medical units. We
interviewed officials, including officials with the medical task
forces and Surgeons' offices in Iraq and Afghanistan about the current
use and composition of medical units in theater, and the extent to
which they are captured within official Army documentation of doctrine
and the organization of medical units. In addition, we interviewed
representatives from the Army Medical Department Center and School,
Directorate of Combat and Doctrine Development about the relevance of
doctrine and the organization of medical units and the role lessons
learned in Iraq and Afghanistan might play in any plans to update
doctrine and the organization of medical units in the future.
For the third objective--evaluate the extent to which the Army fills
medical personnel gaps that arise in Iraq and Afghanistan--we reviewed
the approaches used by Army theater medical commanders to meet medical
personnel requirements when gaps in needed personnel coverage occurred
and interviewed officials with the theater-level medical task forces
and Surgeons' offices in Iraq and Afghanistan regarding reasons why
unexpected medical personnel needs arose and the approaches used to
address those needs in theater. When possible, we obtained and
reviewed supporting documentation, and interviewed other officials
involved in these efforts, including officials with the U.S. Army
Forces Command, to fill unexpected medical personnel needs in theater.
We also reviewed policies and guidance for meeting medical personnel
needs that arise in theater for both the active and reserve
components, specifically the Army's 90-day deployment policy for
reservists applicable to physicians, dentists, and nurse anesthetists.
To determine the extent to which the Army's reserve component medical
units deployed their authorized medical personnel in 2008, 2009, and
through the first 6 months of 2010 to Iraq and Afghanistan, we
reviewed Army's deployment data on late deployments of medical
providers from the reserve components. We assessed the reliability of
the data by interviewing the agency official responsible for manually
collecting and summarizing the data. We determined that the data were
sufficiently reliable for the purposes of this report.
Additionally, to better understand how military medical personnel
requirements are met, we obtained information on DOD's Global Force
Management process and how the services identify medical units and
personnel to fill these requirements. We interviewed officials with
the Joint Staff, U.S. Joint Forces Command, and the military services'
force providers to include U.S. Army Forces Command, U.S. Fleet Forces
Command, U.S. Air Combat Command, and U.S. Marine Forces Command, as
well as officials with the Army Medical Command, the Navy Bureau of
Medicine and Surgery, and the Air Force Personnel Center about their
processes for filling in-theater military medical personnel
requirements. For a more comprehensive listing of the organizations
and offices we contacted, see table 1.
Table 1: Organizations and Offices Contacted During Engagement:
Air Force:
Name of organization or office: Air Combat Command Headquarters;
Location: Langley Air Force Base, VA.
Name of organization or office: Air Force Office of the Surgeon
General;
Location: Washington, D.C.
Name of organization or office: Air Force Medical Service;
Location: Washington, D.C.
Name of organization or office: Air Force Personnel Center;
Location: Washington, D.C.
Name of organization or office: Air Force Central Command;
Location: Washington, D.C.
Name of organization or office: Air National Guard;
Location: Washington, D.C.
Army:
Name of organization or office: Army Central Command;
Location: Fort McPherson, GA.
Name of organization or office: Army Forces Command;
Location: Fort McPherson, GA.
Name of organization or office: Army Medical Command;
Location: San Antonio, TX.
Name of organization or office: Army Medical Department;
Location: San Antonio, TX.
Name of organization or office: Army Office of the Surgeon General;
Location: Falls Church, VA.
Name of organization or office: Army Reserve Command;
Location: Fort McPherson, GA.
Name of organization or office: Army Reserve Office of the Chief;
Location: Washington, D.C.
Name of organization or office: Army National Guard;
Location: Arlington, VA.
Marine Corps:
Name of organization or office: Marine Corps Forces Command;
Location: Norfolk, VA.
Name of organization or office: Marine Corps, Headquarters;
Location: Washington, D.C.
Navy:
Name of organization or office: U.S. Fleet Forces Command;
Location: Norfolk, VA.
Name of organization or office: Navy Office of the Surgeon General;
Location: Falls Church, VA.
Name of organization or office: Navy Bureau of Medicine and Surgery;
Location: Washington, D.C.
Name of organization or office: Office of the Chief of Naval
Operations;
Location: Washington, D.C.
Office of the Secretary of Defense:
Name of organization or office: Office of the Assistant Secretary of
Defense, Health Affairs;
Location: Washington, D.C.
Name of organization or office: Office of the Deputy Assistant
Secretary of Defense for Force Health Protection and Readiness;
Location: Washington, D.C.
Other Department of Defense Organizations:
Name of organization or office: Central Command Office of the Surgeon
General;
Location: Tampa, FL.
Name of organization or office: Joint Chiefs of Staff;
Location: Washington, D.C.
Name of organization or office: Joint Forces Command;
Location: Norfolk, VA.
Name of organization or office: Task Force 1st Medical Brigade;
Location: Iraq.
Name of organization or office: Task Force 807th Medical Brigade;
Location: Iraq.
Name of organization or office: Task Force 30th Medical Command;
Location: Afghanistan.
Name of organization or office: Task Force 62nd Medical Command;
Location: Afghanistan.
Source: GAO.
[End of table]
We conducted this performance audit from August 2009 through January
2011 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: The Global Force Management Process and Service Processes
to Identify and Select Medical Personnel to Fill Requirements for
Deployment to Iraq and Afghanistan:
The Department of Defense (DOD) uses its Global Force Management
process to meet its requirements, including those for medical
personnel and units. For ongoing operations, this process periodically
examines requirements for rotational forces as well as emerging
requirements as they arise. In addition, the services each use unique
yet similar processes to identify and select medical units and
personnel to fill requirements for Iraq and Afghanistan.
DOD's Global Force Management Process:
DOD designed the Global Force Management process to provide insight
into the global availability of U.S. military forces. For the
rotational force management process, requirements are identified 2
years in advance. The rotational force management process is
facilitated through Global Force Management Boards, which are
typically held on a quarterly basis. The Global Force Management Board
brings together general officers from interested parties--Office of
the Secretary of Defense, the Joint Staff, the combatant commanders,
the services, and the joint force providers--to specifically lay out
known requirements, review and endorse sourcing recommendations and
associated risk and risk mitigation options, and then to prioritize
and meet the requirements as appropriate. The product of these Global
Force Management Boards is the Global Force Management Allocation
Plan, a document that is approved by the Secretary of Defense, which
authorizes force allocations and deployment of forces in support of
combatant commander rotational requirements. In both Iraq and
Afghanistan, medical personnel and unit requirements are included in
the Global Force Management Allocation Plan, which provides an
approach for U.S. Central Command, the services, and the services'
force providers[Footnote 20] to manage the sourcing of rotational
requirements, including requirements for medical personnel and units,
such as the Balad Theater Hospital in Iraq or a combat support
hospital in Afghanistan.
For requirements, including medical personnel and units, that are not
known in advance, DOD used the emergent force management process
extensively to meet requirements through requests for forces.
Generally, the parties involved in this process have separate,
sequential roles in the process. Requests for forces are generated by
combatant commanders and submitted to the Joint Staff for validation,
[Footnote 21] and then to the joint and service force providers
[Footnote 22] to identify potential sourcing solutions to fill
requirements before being transmitted to the Secretary of Defense for
approval. In sourcing requests through the emergent process,
requirements are prioritized according to a force allocation decision
model.[Footnote 23] While emergent requirements are considered within
the model's general framework, each request for forces is individually
evaluated as it is received, meaning that officials focus on whether
or not forces are ready and available to fill the request rather than
trying to determine the relative priority of the request, as is done
at the Global Force Management Boards for rotational requirements. As
part of providing and evaluating potential solutions for the request
for forces, the services' force providers often conduct risk
assessments to provide information on the availability and readiness
of both active and reserve forces. These risk assessments include
violations of the services' rotation policies regarding the required
time at home for servicemembers and the impact to current missions and
operations, such as the staffing of U.S. military treatment facilities
in the case of medical personnel, if a service is selected to meet the
requirement. In addition, each of the services maintains a list of
specialties that are in high demand relative to available personnel.
All of the services identified critical care nurse, physician
assistant, psychiatry, and clinical psychology as high-demand
specialties.
Service Processes to Identify and Select Medical Personnel to Fill
Requirements:
The services use unique yet similar processes to identify and select
medical units and personnel to fill requirements for Iraq and
Afghanistan.[Footnote 24] Once the Secretary of Defense designates a
service to meet an emergent or rotational requirement, the service's
force provider then begins the process of filling the requirement with
personnel. While the procedures and systems used by each service to
select the appropriate medical personnel vary, the services' processes
for filling requirements all result in a unit and its personnel
deploying to an operational theater to carry out a mission. The
identification of individual medical personnel to fill the
requirements is important because medical personnel across the
services typically are assigned to fixed military treatment facilities
caring for active duty personnel, their dependents, and retirees.
However, in wartime, each service's medical personnel processes allow
for the deployment of medical personnel from fixed military treatment
facilities to support contingency operations, such as Iraq and
Afghanistan, while considering potential impacts on the medical
mission of the fixed military treatment facilities. In addition, the
processes attempt to distribute the burden of deployments within and
across medical specialties (e.g., orthopedic surgeons, critical care
nurses, and psychiatrists), to comply with service guidelines, such as
required time at home for servicemembers, to maintain a healthy
inventory of medical specialists.
[End of section]
Appendix III: Comments from the Department of Defense:
Office Of The Assistant Secretary Of Defense:
Health Affairs:
1200 Defense Pentagon:
Washington, DC 20301-1200:
January 26, 2011:
Ms. Janet St. Laurent:
Management Director:
Defense Capabilities and Management:
U.S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Ms. St. Laurent:
This is the Department of Defense (DoD) response to the GAO Draft
Report, "GAO-11163C, "Military Personnel: DoD Addressing Challenges in
Iraq and Afghanistan but Opportunities Exist to Enhance the Planning
Process for Medical Personnel Requirements," dated January 2011 (GAO
#351393).
Thank you for the opportunity to review the draft report and provide
comments, Overall, I concur with the findings and recommendations. My
specific comments on the draft report recommendations are attached. I
would like to specifically address that the title and scope of this
report does not agree. The report title and opening comments state
"DoD" and "medical personnel requirements" yet the focus of the report
is clearly on Army (and Army Reserve) medical personnel requirements.
Recommend the verbiage in the report more accurately reflect the
actual scope and remove references to "DoD" in favor of "Army" or
"Army Reserve."
My points of contact on this issue are Mr. Mike Hopper (Functional)
who can be reached at (703) 681-3900 or Mr. Gunther Zimmerman (Audit
Liaison) who can be reached at (703) 6814360.
Sincerely,
Signed by:
George Peach Taylor, Jr., M.D.
Acting Principal Deputy:
Enclosure: As stated:
[End of letter]
GAO Draft Report Dated January 2011:
GAO-11-163C (GAO Code 351393):
"Military Personnel: DoD Addressing Challenges in Iraq and Afghanistan
but Opportunities Exist to Enhance the Planning Process for Medical
Personnel Requirements,"
Department Of Defense Comments To The GAO Recommendation:
Recommendation 1, DOD Response: Concur.
Recommendation 2, DOD Response: Partially concur. The Army is
constantly reviewing capability and doctrine to evolving manpower
requirements. As an example, a recent review of medical capability
indicated the need for additional medical manning and the Army
responded with guidance to increase the number of enlisted Health Care
Specialists assigned to Army Brigade Combat Teams. It is unnecessary
to direct such a review, as the Army continues to capture lessons
learned and input from commanders to ensure employment of medical
assets to meet requirements. There is however, an unquestionable need
to formally consolidate and update doctrinal publications. The
following suggested is offered to replace the current recommendation:
"...we recommend that the Secretary of the Army direct the Army
Medical Department to continue to assess medical capabilities,
employment of those capabilities and the organization of medical
units; updating doctrine as warranted."
[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 contact above, Laura Talbott, Assistant Director;
John Bumgarner; Susan Ditto; K. Nicole Harms; Stephanie Santoso; Adam
Smith; Angela Watson; Erik Wilkins-McKee; Michael Willems; and
Elizabeth Wood made major contributions to this report.
[End of section]
Footnotes:
[1] For purposes of this report, we use the term "medical personnel"
to refer to U.S. military health care officers including physicians,
dentists, nurses, and others, as well as enlisted personnel such as
medics, hospital corpsmen, and dental technicians.
[2] GAO, Force Structure: DOD Needs to Integrate Data into Its Force
Identification Process and Examine Options to Meet Requirements for
High-Demand Support Forces, [hyperlink,
http://www.gao.gov/products/GAO-06-962] (Washington, D.C.: Sept. 5,
2006).
[3] DOD's reserve components are the Army National Guard of the United
States, the Army Reserve, the Naval Reserve, the Marine Corps Reserve,
the Air National Guard of the United States, the Air Force Reserve,
and the Coast Guard Reserve.
[4] 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.: Apr. 16,
2009).
[5] GAO, Military Personnel: Enhanced Collaboration and Process
Improvements Needed for Determining Military Treatment Facility
Medical Personnel Requirements, [hyperlink,
http://www.gao.gov/products/GAO-10-696] (Washington, D.C.: July 29,
2010).
[6] This figure excludes Army, Navy, and Air Force active and reserve
component medical personnel deployed to U.S. military medical
facilities in nearby countries, such as Kuwait, Bahrain, and Qatar.
Navy medical personnel support the Marine Corps, and Navy medical
personnel within Marine Corps units are included in the Navy totals.
[7] These processes include the Army's Professional Filler System; the
Navy's Health Services Augmentation Program; and the Air Force's Air
and Space Expeditionary Force methodology for deployment. The Navy
provides medical personnel to support the Marine Corps through the
Navy's Health Services Augmentation Program.
[8] Shortages of medical personnel occur when the level of available
personnel is below the service's authorized medical personnel levels.
[9] Department of Defense, Report to Congress, Medical Care for
Department of Defense and Non-Department of Defense Federal Civilians
Injured or Wounded in Support of Contingency Operations.
[10] DOD Directive 1404.10, DOD Civilian Expeditionary Workforce (Jan.
23, 2009).
[11] U.S. Forces-Iraq Operational Order 10-01, Annex Q, Appendix 2,
Tab A (Jan. 1, 2010) and Task Force 62nd Medical Base Order 10-02,
Annex Q, Appendix 4, Tab D (Aug. 5, 2010).
[12] Task Force 62nd Medical Base Order 10-02, Annex Q, Appendix 4,
Tabs B and D (Aug. 5, 2010).
[13] DOD Directive 1404.10, Emergency-Essential (E-E) DOD U.S. Citizen
Civilian Employees (Apr. 10, 1992).
[14] U.S. House of Representatives, Committee on Armed Services,
Subcommittee on Oversight and Investigations, Deploying Federal
Civilians to the Battlefield: Incentives, Benefits, and Medical Care
(April 2008).
[15] Doctrine describes how DOD fights, trains, and sustains its
forces and is generally the starting point for assessing capabilities.
According to an Army official, doctrine includes publications such as
Field Manuals and Tactics, Techniques, and Procedures.
[16] Organization refers to the design of units--how many and what
types of personnel and materiel (equipment) a unit needs to provide a
specific capability--and is defined by their Table of Organization and
Equipment.
[17] Army Regulation 11-33: Army Lessons Learned Program (Oct. 17,
2006).
[18] Personnel in the Army reserve component medical corps, dental
corps, and nurse anesthetists are to be deployed in theater for no
longer than 90 days at a time unless the individual volunteers for a
longer deployment, according to the Army's 90-day rotation policy
(Assistant Secretary of the Army (Manpower and Reserve Affairs)
Memorandum, Army Medical Department Reserve Components' 90-day
Rotation Policy, Oct. 2, 2003). This policy was developed after a DOD
study found that physicians could deploy for up to 90 days without
substantial financial impact to their civilian medical practices.
Typically, the Army would need to deploy four different reserve
component medical providers for successive 90-day rotations to fill a
single 1-year personnel requirement.
[19] These figures include deployments to Iraq and Afghanistan, as
well as deployments to Kuwait, Kosovo, and Africa.
[20] Army Forces Command, Air Force Air Combat Command, Navy Fleet
Forces Command, and Marine Corps Forces Command are the force
providers for medical personnel and units.
[21] According to the Global Force Management Implementation Guidance
for FY 2010-2011, validation may include the following: (1)
prioritization of requirements in relation to other existing
priorities; (2) capability and/or force availability guidance on
alternate sourcing strategies to include coalition, DOD, or other
options; (3) any required legal and policy review; (4) latest arrival
date feasibility assessment; and (5) sourcing method suitability
including evaluating alternative sourcing processes.
[22] The President has designated U.S. Joint Forces Command as the
primary joint force provider for conventional forces. As such, it is
responsible for identifying and recommending sourcing solutions in
coordination with the military departments and other combatant
commands. U.S. Joint Forces Command service components are responsible
for identifying and recommending their respective service's sourcing
solutions to the Joint Forces Command and serve as the primary contact
for all service sourcing matters. While Joint Forces Command is the
primary joint force provider for conventional forces, U.S.
Transportation Command, U.S. Strategic Command, and U.S. Special
Operations Command are also joint force providers.
[23] In 2008, DOD issued its Guidance for Employment of the Force,
which attempted to balance the competing priorities of ongoing
operations with other validated needs, including the needs for
homeland defense and rapid response capabilities.
[24] These processes include the Army's Professional Filler System,
the Navy's Health Services Augmentation Program, and the Air Force's
Air and Space Expeditionary Force methodology for deployment. The Navy
provides almost all medical personnel to support the Marine Corps
through the Navy's Health Services Augmentation Program.
[End of section]
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