Defense Infrastructure
The Navy Needs Better Documentation to Support Its Proposed Military Treatment Facilities on Guam Gao ID: GAO-11-206 April 5, 2011The Navy determined that its current hospital on Guam does not meet modern facility standards. Moreover, the military population on Guam is expected to grow from 15,000 to over 39,000 due to DOD plans to move Marine Corps units from Okinawa, Japan to Guam and expand other on- island capabilities. The Navy plans to construct a new hospital and two outpatient clinics as part of its facility solution to replace the current hospital and accommodate additional health care requirements. This report (1) describes the Navy's plans for developing its military treatment facility solution to meet the expected increases in the military population on Guam, and (2) examines the extent to which the Navy is assured that its proposed military treatment facility solution on Guam will sufficiently meet the requirements for the expected increase in military population. To address these objectives, GAO reviewed documentation including the Navy's plans for its military treatment facility solution and interviewed key officials within the Military Health System
To accommodate the additional inpatient and outpatient requirements resulting from the expected increase in military population to Guam, the Navy plans to expand inpatient and outpatient care in the replacement hospital and move primary outpatient and dental care to two new branch health clinics. Primary outpatient care generally includes caring for acute and chronic illnesses, disease prevention, screening, patient education and follow-up care from hospitalization. The replacement hospital will be located on the site of the current hospital, while one of the new branch health clinics will replace medical and dental clinics currently in operation on Naval Base Guam, and the other clinic will be located in North Finegayan on the site of a proposed Marine Corps base. According to Navy officials, the development of the requirements for the clinics allowed the Navy to retain the size and footprint of an initially planned version of the replacement hospital, which was already programmed and approved prior to the announcement of the proposed military buildup on Guam. The two outpatient primary care clinics are to be funded by the government of Japan as part of the agreement to realign Marine Corps units from Okinawa, Japan to Guam, and DOD will fund the new hospital. The Navy's proposed military treatment facility solution on Guam expands on the health care services currently offered on Guam, but in instances when patients require care not offered on Guam, the Navy determined that it will continue to medically evacuate them to other military treatment facilities, such as Naval Hospital Okinawa, Tripler Army Medical Center in Hawaii, or Naval Medical Center San Diego. GAO found that the Navy's documentation used to support its recommended military treatment facility solution for Guam does not clearly demonstrate how the Navy determined the size and configuration of the proposed branch health clinics, nor could Navy officials adequately explain their analyses or assumptions. Navy officials indicated that the Navy's health care requirements analysis report was the basis for decisions regarding the size and configuration of the proposed military treatment facilities. The Navy's health care requirements analysis report estimates the overall health care workload for the services the Navy intends to offer on Guam following the realignment, but does not show how this workload translates into the size and configuration of the Navy's proposed facilities. Therefore, it is difficult for stakeholders to be fully assured that the facility solution will be the most cost- effective solution to meet beneficiary health care needs following the realignment. Without clear documentation of key analyses and identification of risks, the Navy cannot fully demonstrate that it is making the most cost-effective decisions with its proposed military treatment facility solution on Guam. GAO recommends that Navy clearly document the basis for health care workload and staffing on Guam. In commenting, DOD generally concurred and said that more information on the branch health clinics' planning has been developed by the Navy and is under review.
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: Brian J. Lepore Team: Government Accountability Office: Defense Capabilities and Management Phone: (202) 512-4523GAO-11-206, Defense Infrastructure: The Navy Needs Better Documentation to Support Its Proposed Military Treatment Facilities on Guam
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United States Government Accountability Office:
GAO:
Report to Congressional Committees:
April 2011:
Defense Infrastructure:
The Navy Needs Better Documentation to Support Its Proposed Military
Treatment Facilities on Guam:
GAO-11-206:
GAO Highlights:
Highlights of GAO-11-206, a report to congressional committees.
Why GAO Did This Study:
The Navy determined that its current hospital on Guam does not meet
modern facility standards. Moreover, the military population on Guam
is expected to grow from 15,000 to over 39,000 due to DOD plans to
move Marine Corps units from Okinawa, Japan to Guam and expand other
on-island capabilities. The Navy plans to construct a new hospital and
two outpatient clinics as part of its facility solution to replace the
current hospital and accommodate additional health care requirements.
This report (1) describes the Navy‘s plans for developing its military
treatment facility solution to meet the expected increases in the
military population on Guam, and (2) examines the extent to which the
Navy is assured that its proposed military treatment facility solution
on Guam will sufficiently meet the requirements for the expected
increase in military population. To address these objectives, GAO
reviewed documentation including the Navy‘s plans for its military
treatment facility solution and interviewed key officials within the
Military Health System.
What GAO Found:
To accommodate the additional inpatient and outpatient requirements
resulting from the expected increase in military population to Guam,
the Navy plans to expand inpatient and outpatient care in the
replacement hospital and move primary outpatient and dental care to
two new branch health clinics. Primary outpatient care generally
includes caring for acute and chronic illnesses, disease prevention,
screening, patient education and follow-up care from hospitalization.
The replacement hospital will be located on the site of the current
hospital, while one of the new branch health clinics will replace
medical and dental clinics currently in operation on Naval Base Guam,
and the other clinic will be located in North Finegayan on the site of
a proposed Marine Corps base. According to Navy officials, the
development of the requirements for the clinics allowed the Navy to
retain the size and footprint of an initially planned version of the
replacement hospital, which was already programmed and approved prior
to the announcement of the proposed military buildup on Guam. The two
outpatient primary care clinics are to be funded by the government of
Japan as part of the agreement to realign Marine Corps units from
Okinawa, Japan to Guam, and DOD will fund the new hospital. The Navy‘s
proposed military treatment facility solution on Guam expands on the
health care services currently offered on Guam, but in instances when
patients require care not offered on Guam, the Navy determined that it
will continue to medically evacuate them to other military treatment
facilities, such as Naval Hospital Okinawa, Tripler Army Medical
Center in Hawaii, or Naval Medical Center San Diego.
GAO found that the Navy‘s documentation used to support its
recommended military treatment facility solution for Guam does not
clearly demonstrate how the Navy determined the size and configuration
of the proposed branch health clinics, nor could Navy officials
adequately explain their analyses or assumptions. Navy officials
indicated that the Navy‘s health care requirements analysis report was
the basis for decisions regarding the size and configuration of the
proposed military treatment facilities. The Navy‘s health care
requirements analysis report estimates the overall health care
workload for the services the Navy intends to offer on Guam following
the realignment, but does not show how this workload translates into
the size and configuration of the Navy‘s proposed facilities.
Therefore, it is difficult for stakeholders to be fully assured that
the facility solution will be the most cost-effective solution to meet
beneficiary health care needs following the realignment. Without clear
documentation of key analyses and identification of risks, the Navy
cannot fully demonstrate that it is making the most cost-effective
decisions with its proposed military treatment facility solution on
Guam.
What GAO Recommends:
GAO recommends that Navy clearly document the basis for health care
workload and staffing on Guam. In commenting, DOD generally concurred
and said that more information on the branch health clinics‘ planning
has been developed by the Navy and is under review.
View [hyperlink, http://www.gao.gov/products/GAO-11-206] or key
components. For more information, contact Brian Lepore at (202) 512-
4523 or leporeb@gao.gov.
[End of section]
Contents:
Letter:
Background:
The Navy Plans to Replace the Current Hospital and Construct Two New
Branch Health Clinics to Meet Increased Health Care Demand on Guam:
The Navy Did Not Fully Document Its Analyses Supporting Its Proposed
Guam Military Treatment Facility Solution:
Recommendation for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: Comments from the Department of Defense:
Appendix III: GAO Contact and Staff Acknowledgments:
Related GAO Products:
Table:
Table 1: Expected Change in Dedicated Hospital Space for Services at
Naval Hospital Guam:
Figures:
Figure 1: Current Military Health System Organizational Structure:
Figure 2: Timeline Leading up to the Development of the Navy's
Military Treatment Facility Solution on Guam:
Figure 3: Medical Treatment Facilities Post-Buildup on Guam:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
April 5, 2011:
The Honorable J. Randy Forbes:
Chairman:
The Honorable Madeleine Z. Bordallo:
Ranking Member:
Subcommittee on Readiness:
Committee on Armed Services:
House of Representatives:
The Honorable Joe Wilson:
Chairman:
The Honorable Susan A. Davis:
Ranking Member:
Subcommittee on Military Personnel:
Committee on Armed Services:
House of Representatives:
The Navy currently operates a hospital, an outpatient clinic, and a
dental clinic on Guam, a U.S. territory located in the western Pacific
Ocean. These military treatment facilities provide health care
services to servicemembers, their families, and others entitled to
Department of Defense (DOD) health care. The hospital is centrally
located on the island, while the outpatient clinic and dental clinic
are located on Naval Base Guam in the southern part of the island. The
Navy has determined that the current hospital is outdated and does not
meet modern facility standards as it was constructed in 1954 using
1940s design criteria.
While the Navy was initially developing requirements for a replacement
hospital on Guam, separately the United States and Japan began a
series of sustained security consultations, referred to as the Defense
Policy Review Initiative, which were aimed at reducing the burden of
the U.S. military presence on Japanese communities and strengthening
the U.S.-Japan security alliance. By 2006, these consultations
established the framework for the future U.S. force structure in
Japan, including the relocation of U.S. military units from Okinawa,
Japan to Guam. DOD plans to move about 8,600 Marines and their
estimated 9,000 dependent family members to Guam as part of the
Defense Policy Review Initiative. As a result of this realignment from
Japan to Guam and other DOD plans to expand the capabilities and
presence of the Army, Navy, and the Air Force on Guam over the next
several years, the military population on Guam is expected to grow by
over 160 percent, from 15,000 to over 39,000 by 2020. DOD estimates
the cost of developing facilities and infrastructure for the Marine
Corps relocation to Guam to be approximately $10.27 billion. The
government of Japan is anticipated to provide $6.09 billion, in U.S.
fiscal year 2008 dollars, of this amount.[Footnote 1] Part of this
funding will be used to enhance DOD's current infrastructure on Guam,
including the construction of new military treatment facilities. In
addition to the realignment, the other military services are planning
to expand their operations and presence on Guam. For instance, the
Navy plans to enhance its infrastructure, logistic capabilities, and
waterfront facilities; the Air Force plans to develop a global
intelligence, surveillance, and reconnaissance strike hub at Andersen
Air Force Base; and the Army plans to place a ballistic missile
defense task force on Guam. As a result of the realignment and DOD's
other plans for Guam, the total DOD increase on the island is expected
to cost (including costs to be covered by the government of Japan)
over $13 billion.
In August 2009, we were requested to review and assess the proposed
replacement of the naval hospital on Guam to determine whether the
size and scope of the hospital will be sufficient to support the
current and projected military mission requirements as well as the DOD
beneficiary population on Guam. This report (1) describes the Navy's
plans for developing its military treatment facility solution to meet
the expected increases in the military population on Guam, and (2)
examines the extent to which the Navy is assured that its proposed
military treatment facility solution on Guam will sufficiently meet
the requirements for the expected increase in military population.
To describe the Navy's plans for its proposed military treatment
facility solution of a replacement hospital and two branch health
clinics that will account for the expected increases in military
population on Guam, we obtained documents detailing the Navy's plans
for its proposed facilities, such as budget justifications, economic
analyses, health care requirements analyses, construction estimates,
cost estimates, and facility designs. We reviewed DOD's Draft Guam
Joint Military Master Plan and compared it with the Navy's military
treatment facility requirements. We also obtained and reviewed the
contract issued for the replacement hospital. To examine the extent to
which the Navy is assured that its proposed military treatment
facility solution will adequately meet the requirements for the
expected increase in military population, we focused on the timeframe
from which TRICARE Management Activity approved the Navy's initial
replacement hospital proposal in 2004 prior to the announcement of the
Defense Policy Review Initiative and planned military buildup on Guam
through the final approval in 2008, which followed the announcement of
the Defense Policy Review Initiative.[Footnote 2] We obtained and
reviewed applicable legal and departmental guidance, including DOD
instructions and directives, and compared them with the Navy's
documented assumptions, methods, and economic cost analyses used to
develop its proposed military treatment facilities requirements on
Guam. To describe the Navy's plans for its proposed military treatment
facility solution, and to examine the extent to which the Navy is
assured that its proposed military treatment facility solution will
adequately meet increased requirements, we also interviewed officials
from the Navy Bureau of Medicine and Surgery, Navy Medicine West,
Naval Hospital Guam, Headquarters Marine Corps, Marine Corp Forces
Pacific, Naval Facilities Engineering Command Marianas, Naval
Facilities Engineering Command Medical Facilities Design Office,
Andersen Air Force Base 36th Medical Group, Joint Guam Program Office,
and TRICARE Management Activity. Although we did not independently
assess the data DOD used for planning purposes, we discussed its
reliability with DOD officials and determined that the data were
sufficiently reliable to meet the objectives of this engagement.
We conducted this performance audit from February 2010 through March
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:
DOD operates one of the largest and most complex health care systems
in the nation and has a dual health care mission--readiness and
benefits. DOD's health care system is referred to as the Military
Health System. The readiness mission provides medical services and
support to the armed forces during military operations and involves
deploying medical personnel and equipment as needed to support
military forces throughout the world. The benefits mission provides
medical services and support to members of the armed forces, their
family members, and others eligible for DOD health care, such as
retired service members and their families. DOD's health care mission
is carried out through military hospitals and clinics throughout the
United States and overseas, commonly referred to as military treatment
facilities, as well as through civilian health care providers.
Military treatment facilities comprise DOD's direct care system for
providing health care to beneficiaries.
The Assistant Secretary of Defense (Health Affairs) is responsible for
ensuring the effective execution of DOD's health care mission and
exercises authority, direction, and control over medical personnel
authorizations and policy, facilities, funding, and other resources
within DOD.[Footnote 3] The Director of TRICARE Management Activity,
as seen in figure 1, reports to Health Affairs. TRICARE Management
Activity develops and maintains the facilities planning, design, and
construction criteria in support of DOD's health care mission, and
serves as the focal point for all issues pertaining to the
acquisition, sustainment, renewal, and modernization of the full range
of facilities within the Military Health System. Figure 1 displays the
organizational structure of the Military Health System.
Figure 1: Current Military Health System Organizational Structure:
[Refer to PDF for image: organizational structure]
Top level:
Secretary of Defense.
Second level, reporting to the Secretary of Defense:
* Under Secretary of Defense for Personnel and Readiness;
- Assistant Secretary of Defense (Health Affairs);
- Director, TRICARE Management Activity:
-- TRICARE contractors;
* Secretary of the Army;
* Secretary of the Navy;
* Secretary of the Air Force.
Third level, reporting to the Secretary of the Army:
* Army Chief of Staff;
* Army Surgeon General;
* Army Medical Command;
* Regional commands;
* Military treatment facilities.
Third level, reporting to the Secretary of the Navy:
* Commandant of the Marine Corps;
* Chief of Naval Operations;
* Navy Surgeon General;
* Bureau of Medicine and Surgery;
* Regional commands;
* Military treatment facilities.
Third level, reporting to the Secretary of the Air Force:
* Air Force Chief of Staff;
* Air Force Surgeon General;
* Air Force Medical Operations Agency;
* Air Force major commands;
* Military treatment facilities.
Source: GAO analysis of DOD data.
[End of figure]
TRICARE Management Activity is responsible for the acquisition of all
military health care facilities worldwide, including the development
and issuance of medical facility policy, programming, budgeting,
design, and construction of all projects.[Footnote 4] Moreover, it is
responsible for the development, issuance, and maintenance of health
care facilities planning and technical criteria as well as the
management of financial resources for all planning, design, and
construction of projects.
The Navy Bureau of Medicine and Surgery, the headquarters command for
Navy Medicine, oversees the delivery of health care for the Navy and
Marine Corps. It exercises direct control over naval hospitals,
clinics, medical centers, dental centers, and preventative medicine
units within the United States and overseas, and provides professional
and technical guidance for the design, construction, staffing, and
equipping of medical assets. Navy Medicine West is the regional
command that helps manage and plan for the Navy's health care delivery
and military treatment facilities in the Pacific region. Under Navy
Medicine West's responsibility are all Navy military treatment
facilities on the West coast, in Hawaii, Japan, and Guam.
DOD's Unified Facilities Criteria 4-510-01 (Unified Facilities
Criteria) provide mandatory design and construction criteria for
facilities in DOD's medical military construction program.[Footnote 5]
This subpart of the Unified Facilities Criteria is primarily focused
on how military treatment facilities are to be designed and
constructed, but also requires that the military services submit
planning documentation as part of the pre-design considerations that
TRICARE Management Activity uses to issue a design authorization and
approve a proposed project for funding.[Footnote 6] This planning
documentation includes a DD Form 1391 (Military Construction Project
Data), project narrative, program for design, equipment planning,
project books and an economic analysis. Design authorizations are
issued to a design agent, which is designated by the Secretary of
Defense as being responsible for the design and construction of
proposed facilities.[Footnote 7] In the case of Guam, Naval Facilities
Engineering Command is the designated design agent responsible for
military construction.
In addition to the above policy guidance and criteria for the planning
of military treatment facilities, Office of Management and Budget
guidance requires federal agencies to develop and implement internal
controls to ensure, among other things, that programs achieve their
desired objectives; and that programs operate and resources are used
consistent with agency missions, in compliance with laws and
regulations, and with minimal potential for waste, fraud, and
mismanagement.[Footnote 8] Internal control, in its broadest sense,
includes the plan of organization, policies, methods and procedures
adopted by program management to meet its goals.
In addition to the standards for internal control identified by Office
of Management and Budget, GAO has also identified standards for
internal controls, which include (among other things) control
activities.[Footnote 9] Control activities include policies,
procedures, techniques, and mechanisms that enforce management's
directives, which can include a wide range of activities such as
approvals, authorizations, verifications; and documentation, which
should be readily available for examination.
Medical Facilities on Guam:
The current Naval Hospital Guam and its associated military treatment
facilities, including a branch medical clinic and branch dental clinic
on Naval Base Guam, help support the operational readiness of the
United States and allied forces operating in the Pacific region. These
facilities have been in operation for over 50 years. The naval
hospital provides services for active duty servicemembers and their
family members stationed on Guam. Transient active duty
servicemembers, military retirees (transient and living on Guam) and
their family members, National Guard members, and officials from other
federal agencies also receive health care from the naval hospital.
In addition to the Navy-operated military treatment facilities on
Guam, the Air Force's 36th Medical Group located at Andersen Air Force
Base operates a medical and dental clinic, renovated in 2006, that
delivers primary medical and dental care to DOD beneficiaries in and
around Andersen Air Force Base, which is on the northern part of the
island.
A civilian hospital--Guam Memorial Hospital--as well as community
health clinics are also on Guam. According to Navy planning documents,
Military Health System beneficiaries typically do not use the services
of Guam Memorial Hospital or the community health clinics, and will
only be referred there by Naval Hospital Guam in the case of an
emergency that occurred in closer proximity to Guam Memorial Hospital.
Military Buildup:
The United States and Japan held a series of sustained security
consultations, referred to as the Defense Policy Review Initiative,
which were aimed at reducing the burden of the U.S. military presence
on Japanese communities and strengthening the U.S.-Japan security
alliance. By 2006, these consultations established the framework for
the future U.S. force structure in Japan, including the relocation of
military units from Okinawa, Japan to Guam. An estimated 8,600 Marines
and their estimated 9,000 dependents are expected to relocate from
Okinawa, Japan to Guam. In addition, the United States plans to expand
the capabilities and presence of the Army, Navy, and Air Force on Guam
over the next several years. As such, the military population on Guam
is expected to grow by over 160 percent, from 15,000 to over 39,000 by
2020.
The Deputy Secretary of Defense established the Joint Guam Program
Office to facilitate, manage, and execute requirements associated with
the relocation of U.S. Marine Corps assets from Okinawa, Japan to
Guam. The Joint Guam Program Office is also expected to lead the
coordinated planning efforts and synchronize the funding requirements
between DOD components, and to work closely with other stakeholders,
such as the government of Japan. The Joint Guam Program Office
receives planning assistance from the Naval Facilities Engineering
Command in conducting analyses and developing an acquisition strategy
for infrastructure needed to support DOD operational requirements. The
Naval Facilities Engineering Command executes contracts for
construction and infrastructure projects including those funded by
contributions from the government of Japan.
The Navy Plans to Replace the Current Hospital and Construct Two New
Branch Health Clinics to Meet Increased Health Care Demand on Guam:
To accommodate the additional inpatient and outpatient requirements
resulting from the expected increase in the military population on
Guam, the Navy plans to expand inpatient and outpatient care in the
replacement hospital and move primary outpatient and dental care to
the two new branch health clinics.[Footnote 10] According to Navy
officials, the development of the requirements for the clinics allowed
the Navy to retain the size and footprint of the initially planned
version of the replacement hospital, which was already programmed and
approved by TRICARE Management Activity in 2004, prior to the
announcement of the Defense Policy Review Initiative. The hospital
will be funded through DOD military construction appropriations, while
the two outpatient primary care clinics are to be funded through a
special Department of the Treasury account established to hold funds
contributed by the government of Japan as part of the agreement to
realign military units from Japan to Guam. Although the Navy's
proposed military treatment facility solution on Guam expands on the
health care services currently offered on Guam, the Navy determined
that patients requiring care not offered on Guam will continue to be
medically evacuated to other military treatment facilities, such as
Naval Hospital Okinawa, Tripler Army Medical Center in Hawaii, or
Naval Medical Center San Diego.
Plans for the Navy's Replacement Hospital on Guam Changed Following
the Announcement of the Realignment:
The Navy determined that to accommodate the additional inpatient and
outpatient requirements for active duty and family member populations
on Guam following the military buildup, it would need to construct
three military treatment facilities consisting of a replacement
hospital and two branch health clinics. However, prior to the
announced realignment of troops from Okinawa, Japan to Guam, the Navy
had already determined that the current hospital was outdated and did
not meet modern facility standards such as efficient space
configurations, and the building's structure does not meet modern
seismic codes. Additionally, Navy planning documents show that from a
functional perspective, the current hospital is poorly designed to
provide efficient health care delivery. Navy officials said that
preliminary planning efforts for replacing Naval Hospital Guam started
in the 1990s, but it was not until early 2004 that planning began in
earnest. By 2005, the Navy was in the process of designing a
replacement hospital. The Navy's original plans for a replacement
hospital were predicated on a beneficiary population of around 19,700
and were to include all outpatient primary care, including dental
care, within the hospital, while closing the current branch medical
clinic and branch dental clinic on Naval Base Guam.
When the military realignment was subsequently announced in 2006, Navy
officials said all design plans were put on hold in accordance with
direction from TRICARE Management Activity, and the Navy reassessed
its health care requirements for Guam. An estimated 8,600 Marines and
their estimated 9,000 dependents are expected to relocate from
Okinawa, Japan to Guam. With the United States' additional plans to
expand the capabilities and presence of the Army, Navy, and Air Force
on Guam over the next several years, the military population on Guam
is expected to grow by over 160 percent, from 15,000 to over 39,000 by
2020. When other types of Military Health System beneficiaries, such
as DOD civilians and military retirees are taken into account, the
eligible beneficiary population for the naval hospital is expected to
grow to about 46,000 people.
The hospital will replace the current hospital with expanded inpatient
and outpatient care, while the new branch health clinics are to
provide primary outpatient and dental care. Figure 2 provides a
timeline leading up to the Navy's recommended military treatment
facility solution to meet the requirements of the expected increase in
military population.
Figure 2: Timeline Leading up to the Development of the Navy's
Military Treatment Facility Solution on Guam:
[Refer to PDF for image: timeline]
March 2004:
Navy develops plans for initial naval hospital replacement project.
This included initial health care requirements assessment. Proposed
cost is $191.2 million and size is approximately 296,666 gross square
feet.
September 2005:
Replacement naval hospital project put on hold due to Defense Policy
Initiative Review and potential changes in the future military
population on Guam.
May 2006:
The United States and Japan reach an agreement to relocate Marine
Corps units from Okinawa to Guam.
February 2008:
TRICARE Management Activity issues design authorization for
replacement naval hospital.[A] Project programmed for $448 million
from fiscal year 2010 to fiscal year 2012.
December 2008 - January 2010:
Hospital design based on the Navy's updated health care requirements
resulting from the military buildup.
September 2010:
Naval Facilities and Engineering Command Pacific awards construction
contract in the amount of $158.1 million.
March 2010 - October 2010:
Branch health clinic on Naval Base Guam designed based on updated
requirements. Design funded by government of Japan.
2011:
Branch health clinic in North Finegayan expected to be designed based
on updated requirements. Design to be funded by government of Japan.
June 2013:
Expected completion of branch health clinic on Naval Base Guam.
October 2014:
Expected completion of replacement hospital.
Summer - Fall 2015:
Expected completion of branch health clinic in North Finegayan.
Source: GAO analysis of DOD data.
[A] A design authorization refers to TRICARE Management Activity
approval to proceed with the design of a proposed Military Health
System facility project, including selection of an architecture and
engineering firm. It usually designates the project, project fiscal
year, project location, programmed amount, scope of the project (size
in square feet), deviations from the submittal requirements in the
Unified Facilities Criteria, and whether or not TRICARE Management
Activity wishes to participate in selecting the architecture and
engineering firm.
[End of figure]
The replacement hospital will be located on the site of the current
hospital, while a new branch health clinic will replace the medical
and dental clinics currently in operation on Naval Base Guam, and a
new branch health clinic will be located in North Finegayan. In
addition to these facilities, the Air Force 36th Medical Group
operates a medical and dental clinic on Andersen Air Force Base, and
Guam Memorial Hospital is the island's only civilian hospital. Figure
3 shows the location of medical treatment facilities on Guam following
the military buildup.
Figure 3: Medical Treatment Facilities Post-Buildup on Guam:
[REfer to PDF for image: map of Guam]
The following are depicted on the map of Guam:
Andersen Air Force Base Clinic:
Branch Health Clinic: Naval Base Guam:
Branch Health Clinic: North Finegayan:
Guam Memorial Hospital: Civilian:
Naval Hospital Guam: Agana:
Source: GAO.
Note: The replacement hospital and branch health clinics on Naval Base
Guam and North Finegayan comprise the Navy's recommended military
treatment facility solution. In addition, Andersen Air Force Base
medical and dental clinic is also available to DOD beneficiaries. Guam
Memorial Hospital is the island's only civilian hospital.
[End of figure]
The Navy determined that the branch health clinic in North Finegayan
was needed to serve the Marine Corps beneficiaries that are to be
housed at or near the proposed Marine Corps base. Moreover, the Navy
determined that the need for expanded inpatient and outpatient
capabilities at the replacement naval hospital displaced the primary
care capacity to such a degree that it necessitated a need for a new
branch health clinic on Naval Base Guam. The Navy expects to begin
construction on the Naval Base Guam branch health clinic before the
North Finegayan branch health clinic. According to Navy officials, the
development of the clinics also allowed the Navy to maintain the size
and footprint of the replacement hospital, the initial version of
which had already been programmed and approved by TRICARE management
activity.
The Navy requested that since the proposed branch health clinics were
required as a result of the military buildup, the government of Japan
should fund the design and construction of the two facilities. The
government of Japan agreed to fund the design and construction of the
two clinics as part of its anticipated $6.09 billion to help develop
facilities and infrastructure for the Marine Corps' relocation to
Guam. The DD Form 1391 (Military Construction Project Data) prepared
for each of the branch health clinics show the total cost to construct
the two clinics to be currently estimated at about $226 million.
The Navy's Military Treatment Facility Solution Provides Additional
Capacity for Health Care Services Currently Offered on Guam:
The planned hospital that will replace the current hospital is
primarily focused on providing inpatient and specialty care, while the
branch health clinics are to provide primary outpatient and dental
care. Navy officials said that the footprint of the replacement
hospital was based on the Navy's original 2004 design for a
replacement hospital because the Navy did not want to change the
overall size of the hospital since significant changes would have
likely delayed construction. As such, the amount of primary care
available in the hospital is expected to fall below that needed for
the expanded beneficiary population. However, the majority of such
care is now intended to be provided by the proposed branch health
clinic on Naval Base Guam and the proposed branch health clinic in
North Finegayan.
The replacement hospital's configuration includes the following:
Increased number of beds: Navy planning documents show that the number
of inpatient beds will increase to 42 beds to accommodate the expected
increase in the service member and family populations. The Navy's
planning documents for the initial proposal of the replacement
hospital show that the replacement hospital prior to the announcement
of the military buildup was to house 30 inpatient beds. The Navy's
updated planning documents for the replacement hospital developed in
response to the buildup show that the Navy used its initial plans for
30 beds as a minimum starting point and then developed requirements
for an additional 10 beds. Navy planning documents also showed that
two additional intensive care beds were added to the proposed hospital
subsequent to an accident aboard the U.S.S. Frank P. Cable in December
2006 which, according to the Navy, greatly taxed the capabilities of
the current hospital. This resulted in a final requirement of 42
inpatient beds in the proposed replacement hospital.
Expanded services: Navy officials explained that the replacement
hospital will further expand its current capabilities by providing
more robust orthopedic services, mental health services, and
obstetrics and gynecology services. In addition, the replacement
hospital will add an onsite Magnetic Resonance Imaging capability.
Table 1 below shows key changes, by square footage, for the services
that are to be provided at the replacement naval hospital. The Navy
believes that this configuration of space and services will best meet
the health care needs of the increased military population following
the buildup.
Table 1: Expected Change in Dedicated Hospital Space for Services at
Naval Hospital Guam:
Department name: Urology;
Square footage (SF): Current: 1,140 SF;
Square footage (SF): Replacement: 4,256 SF;
Percentage change in department space: 273%.
Department name: Radiology;
Square footage (SF): Current: 5,562;
Square footage (SF): Replacement: 15,280;
Percentage change in department space: 175%.
Department name: Internal Medicine/Cardiology/Respiratory Therapy;
Square footage (SF): Current: 2,519;
Square footage (SF): Replacement: 6,321;
Percentage change in department space: 151%.
Department name: Ear, Nose, and Throat/Audiology;
Square footage (SF): Current: 1,662;
Square footage (SF): Replacement: 3,983;
Percentage change in department space: 140%.
Department name: Dermatology Clinic;
Square footage (SF): Current: 946;
Square footage (SF): Replacement: 1,904;
Percentage change in department space: 101%.
Department name: Mental Health;
Square footage (SF): Current: 2,313;
Square footage (SF): Replacement: 4,116;
Percentage change in department space: 78%.
Department name: Dental/Oral Surgery;
Square footage (SF): Current: 2,115;
Square footage (SF): Replacement: 3,255;
Percentage change in department space: 54%.
Department name: Laboratory;
Square footage (SF): Current: 6,345;
Square footage (SF): Replacement: 9,575;
Percentage change in department space: 51%.
Department name: Orthopedics/Podiatry/Chiropractic/Sports Medicine;
Square footage (SF): Current: 3,926;
Square footage (SF): Replacement: 5,152;
Percentage change in department space: 31%.
Department name: Pharmacy;
Square footage (SF): Current: 3,815;
Square footage (SF): Replacement: 4,638;
Percentage change in department space: 22%.
Department name: Obstetrics and Gynecology;
Square footage (SF): Current: 7,570;
Square footage (SF): Replacement: 8,042;
Percentage change in department space: 6%.
Department name: Preventative Medicine[A];
Square footage (SF): Current: 2,572;
Square footage (SF): Replacement: 2,400;
Percentage change in department space: -7%.
Department name: Pediatrics[A];
Square footage (SF): Current: 6,383;
Square footage (SF): Replacement: 5,762;
Percentage change in department space: -10%.
Department name: General and Specialty Surgical Clinics[A];
Square footage (SF): Current: 5,421;
Square footage (SF): Replacement: 4,487;
Percentage change in department space: -17%.
Department name: Ophthalmology/Optometry[A];
Square footage (SF): Current: 8,023;
Square footage (SF): Replacement: 5,222;
Percentage change in department space: -35%.
Department name: Physical Therapy[A];
Square footage (SF): Current: 5,017;
Square footage (SF): Replacement: 3,138;
Percentage change in department space: -37%.
Department name: Primary Care/Family Practice[A];
Square footage (SF): Current: 12,170;
Square footage (SF): Replacement: 1,679;
Percentage change in department space: -86%.
Source: DOD.
[A] According to the Navy, decreases in some department space are due
to increased efficiencies in the design of the replacement hospital,
and several services, including primary care and family care, are to
be provided at the proposed branch health clinics.
[End of table]
Navy planning documents show that the size of the replacement hospital
will actually decrease from 306,000 square feet of the current
hospital's size to 282,000 square feet. According to the Navy, the
compact footprint of the replacement hospital will improve proximity
between related departments and increase staff efficiency as patient
travel distances and facility congestion will be reduced by organizing
high traffic clinic and ancillary areas closer to main entrances
thereby enhancing patient care and permitting the smaller size without
compromising services. In addition, clinics and inpatient activities
with lower patient volume will be located on the upper floors.
Updated seismic design: Navy planning documents show that there are
primary life safety issues as yet unresolved in the current facility
related to seismic design deficiencies. Navy plans show that the
replacement hospital will be up-to-date on all applicable seismic
standards and codes. Since Guam is in a region where typhoons occur,
the replacement facility will also be current on all standards and
codes relating to the impact from heavy winds.
Flexibilities: The replacement hospital will consist of "flexible
rooms" which allow for the conversion of medical/surgical rooms into
intensive care rooms and vice versa. The replacement hospital will
also have the flexibility to convert doctors' offices into exam rooms
and exam rooms into offices. Thus, in times of contingency or surge
operations, the replacement hospital will have the flexibility to
temporarily expand to up to 60 beds.
The proposed branch health clinics are to provide a variety of
outpatient services including the majority of primary care for the
Navy's proposed military treatment facility solution on Guam. As
demonstrated in table 1 above, the majority of the primary care has
been removed from the replacement hospital--it decreased by 10,491
square feet from 12,170 square feet to 1,679 square feet or by 86
percent. The 48,599 square foot Naval Base Guam branch health clinic
is expected to offer several outpatient services including primary
care and family practice, a pharmacy, a dental clinic, mental health
services, a physical therapy clinic, preventive medicine and acute
care. The 64,078 square foot North Finegayan branch health clinic will
be slightly larger than the Naval Base Guam branch clinic but will
offer similar services including primary care and family practice, a
pharmacy, a dental clinic, mental health services, a physical therapy
clinic, and preventive medicine. The Navy has completed the design of
the Naval Base Guam branch health clinic and expects to begin
construction on it before the North Finegayan branch health clinic,
although no construction contracts have been awarded at this time for
either of the two branch health clinics.
The Navy's proposed military treatment facility solution on Guam
expands on the health care services currently offered on Guam, but in
instances when patients require care not offered on Guam, the Navy
determined that it will continue to medically evacuate them to other
military treatment facilities, such as Naval Hospital Okinawa, Tripler
Army Medical Center in Hawaii, or Naval Medical Center San Diego.
The Navy Did Not Fully Document Its Analyses Supporting Its Proposed
Guam Military Treatment Facility Solution:
The Navy's documentation used to support its recommended facility
solution does not clearly demonstrate to stakeholders, including
TRICARE Management Activity, how the Navy determined the size and
configuration of the proposed branch health clinics. To account for
the population increase and support the conclusions regarding the size
and configuration of the recommended facility solution, the Navy
developed its health care requirements analysis report for Guam.
[Footnote 11] Navy officials indicated that the health care
requirements analysis clearly justifies the need for a replacement
hospital and two outpatient clinics. However, although the Navy's
health care requirements analysis accounts for the expected increase
in health care workload by multiplying the health care utilization
rates observed in a base year for different types of beneficiaries and
health care services by the anticipated beneficiary population, it
does not show how this workload translates into the size and
configuration of the Navy's proposed facilities because it omits
documentation on the methods and criteria for how the Navy reached
staffing decisions for its proposed facilities and does not show the
workload expected to be performed at each facility. Since TRICARE
Management Activity is responsible for the construction of all
military health care facilities worldwide as provided for in the
Unified Facilities Criteria, it needs reasonable assurance that the
Navy's plans for its military treatment facility solution on Guam,
including the proposed branch health clinics, meet Military Health
System goals of having appropriately sized and configured facilities
to meet the health care needs of military beneficiaries in a cost-
effective manner. Detailed and appropriate documentation is a key
component of internal controls.[Footnote 12] In addition,
documentation must be clear and readily available for examination for
stakeholders to make effective decisions about programs or operations.
Further, without clear documentation of key analyses, stakeholders
lack reasonable assurance that the Navy's proposed military treatment
facility on Guam will provide health care capacity sufficient to meet
the expected increase in military population and whether the Navy is
making the most cost-effective decisions.
The Navy Only Partially Documented How It Determined the Size and
Configuration of Its Proposed Guam Military Treatment Facilities:
Generally, the combination of health care workload and staffing
requirements are key considerations when determining the size and
configuration of military treatment facilities according to the Navy's
health care requirements analysis report. DOD space planning guidance
shows that, among other things, workload and staffing are used to size
and configure facilities to help ensure appropriate facility space
[Footnote 13]. DOD Instruction 6015.17 describes the procedures to be
used by the military departments to prepare project proposals for
military treatment facilities.[Footnote 14] This instruction also
identifies the types of documentation needed to support a project
proposal. Navy officials provided the results of their health care
requirements analysis as part of their response to DOD Instruction
6015.17 when determining the size and configuration of their military
treatment facilities on Guam. However, the Navy did not clearly
document all the health care and staffing analyses that would support
its conclusions for the size and configuration of its proposed
military treatment facility solution.
The Navy's Health Care Requirements Analysis Report Provided
Projections for Health Care Workload, Staffing, and Bed Size for its
Proposed Military Treatment Facilities on Guam Following the
Realignment:
We were told that many of the Navy's decisions regarding the size and
configuration of its proposed military treatment facilities on Guam
are justified and supported by its health care requirements analysis.
The purpose of the health care requirements analysis was, in part, to
develop the size and configuration of the Navy's proposed military
treatment. The Navy's health care requirements analysis also provides
an overview of the types of health care services currently offered on
Guam. The health care analysis also estimates the overall health care
workload for the services the Navy intends to offer on Guam following
the realignment. The workload is categorized by the type of health
care service and includes outpatient visits, inpatient bed-days, and
ancillary workload (i.e., pharmacy prescriptions and laboratory and
radiology procedures) required by the anticipated beneficiary
population. In addition, workload estimates are organized into
different beneficiary categories including active duty per military
service, expected family members per military services, and retirees,
among others. The health care requirements analysis uses the overall
estimated workload to recommend the types of health care services to
be provided at the replacement hospital, the number of staff needed to
provide these services, as well as the overall bed requirements for
the hospital.
The Navy's Health Care Requirements Analysis Report Omitted Details
That Help Support the Navy's Determination Regarding the Size and
Configuration of Its Proposed Facilities on Guam:
The Navy's health care requirements analysis report omits details that
would help better document and support how the Navy determined the
size and configuration of its recommended facility solution on Guam.
Moreover, Navy officials could not adequately explain the reasons for
the omissions nor how the analysis that was documented led logically
to the conclusions arrived at for the Guam military health facility
solution. For example, the Navy's analysis did not contain the break
down of the forecasted health care workload by each proposed facility
to clearly show the portions of the DOD beneficiary population that
are expected to receive primary care at each clinic, or the number of
outpatient visits and the ancillary workload that are expected to be
provided at each clinic. Therefore, the health care requirements
analysis does not show how the Navy determined the size of the
proposed outpatient clinics, given that workload is a key component of
facility space requirements.
In addition, the Navy's health care requirements analysis did not
include the Navy's reasoning for continuing to meet demands for
certain specialty services not provided at the naval hospital, such as
neonatal intensive care, by flying patients to other military
treatment facilities in the region such as those in Okinawa, Japan;
Honolulu, Hawaii; or San Diego, California. Forecasting the expected
health care workload for just those specific health care services
expected to be offered on Guam may suffice for the purposes of sizing
military treatment facilities, however it does not show the total
health care requirement for DOD beneficiaries on Guam, demonstrate how
the total health care requirement will be met, or provide a business
case justification for the mix of services to be offered at the
proposed military treatment facilities on Guam as opposed to those
offered off island. Navy officials told us that in deciding what
health care services to provide on Guam, they held discussions with
pertinent medical officials and considered factors such as the size of
the beneficiary population, the expected workload, and the
availability of staff. Nonetheless, the Navy's documentation provided
to support these decisions shows that the Navy assumed no new
inpatient services would be provided on Guam and only neurology would
be added to outpatient care. However, this documentation does not
easily allow for external stakeholder examination by TRICARE
Management Activity and other stakeholders--a key aspect of internal
controls--in that it does not clearly show why certain health care
services were assumed to be included or excluded.
The Navy reported the staffing requirements for its recommended
facility solution in its health care requirements analysis, but the
methods and criteria for how the Navy reached decisions are not
clearly documented. DOD policy requires that manpower requirements
generally (including staffing for military treatment facilities) be
established at the minimum level necessary to accomplish mission and
performance objectives.[Footnote 15] In the health care requirements
analysis report, the Navy noted that they determined the additional
staffing needs to meet health care requirements associated with the
military buildup on Guam through a series of discussions with Navy
headquarters, regional, and Guam medical commands. However, when we
asked for additional information on how staffing requirements were
determined for the proposed facilities, the Navy could not provide
documentation or explain what was discussed at these meetings or the
decision process leading up to their staffing requirement decisions
other than stating that the limited number of available medical
specialists was a key factor that influenced staffing requirements
decisions for the proposed military treatment facilities on Guam.
During the course of our review, we asked Navy officials to explain
the assumptions used in health care requirements analysis as well as
how the health care requirements analysis was used to determine the
size of the replacement hospital and clinics. In some instances, the
officials could not provide an explanation and said that they will
request that future health care requirements analyses clearly
illustrate all the steps and calculations used to determine facility
requirements. In other instances, the Navy's explanations and
additional supporting documentation did not match the results of the
health care requirements analysis. For example, DOD space planning
guidance notes that the annual number of births of the projected
beneficiary population is used, among other things, to help determine
the size and configuration of labor and delivery units. However, the
Navy's health care requirements analysis used a different metric (the
number of obstetrics inpatient visits). Existing documentation does
not clearly demonstrate how the Navy determined the projected number
of births or how the results of the health care requirements analysis
report's number of obstetrics visits would translate to the size of
the replacement hospital's labor and delivery units. Navy officials
told us that the health care requirements analysis was still up-to-
date, though we found that the report does not currently reflect the
design plans for the proposed clinic on Naval Base Guam. For example,
the design plans of the proposed clinic on Naval Base Guam indicate a
projected visit rate of 64,271 visits per year. It indicates that the
number of visits was derived from the health care requirements
analysis. However, the health care requirements analysis does not
break down the workload per facility. Therefore it is unclear how this
number is supported. In addition the design plans show that 65 staff
members will be working at the Naval Base clinic, whereas the health
care requirements analysis projects a need for 25 staff members.
Since the Navy's health care requirements analysis is not sufficiently
documented, specifically with regard to health care and staffing
requirements, both the Navy and TRICARE Management Activity may not be
sufficiently assured that (1) Navy's military treatment facility
solution of the replacement hospital and two branch health clinics
will be adequate to meet the demand of the military population on Guam
and (2) result in the most cost-effective facility solution that will
meet the expected increase in military population on Guam.
TRICARE Management Activity Issued the Design Authorization for the
Navy's Replacement Hospital but Not the Two Clinics Funded by the
Government of Japan:
TRICARE Management Activity is responsible for, among other things,
the acquisition of all military health care facilities worldwide,
including the planning, design, and construction of all military
health care projects.[Footnote 16] The Unified Facilities Criteria
also provide for a process for TRICARE Management Activity to approve
the design of a proposed military treatment facility project. TRICARE
Management Activity issued the design authorization of the Navy's
replacement hospital in May 2008. However, according to TRICARE
Management Activity officials, they were not responsible for issuing
the design authorization for each clinic since the design and
construction of the clinics is to be funded by the government of
Japan, and TRICARE Management Activity stated that it is responsible
only for projects which it funds. Since funding for the design and
construction of the clinics is provided by the government of Japan,
these officials said that the Joint Guam Program Office would lead the
acquisition team and be responsible for ensuring compliance with the
Unified Facilities Criteria. This would include issuing the design
authorizations for the clinics.
Conversely, officials from the Joint Guam Program Office said that
projects to be constructed with government of Japan funding should
follow procedures outlined in the Unified Facilities Criteria. In
addition, these officials noted that the design authorizations for the
clinics were provided by Naval Facilities Engineering Command
headquarters, which is the design agent for military construction on
Guam. However, the Unified Facilities Criteria indicate that TRICARE
Management Activity is to provide design authorizations to the design
agent. Moreover, the design agent is not to pursue any level of design
beyond what is authorized by TRICARE Management Activity. In the case
of the clinics, the design agent, Naval Facilities Engineering
Command, issued its own design authorization, thereby calling into
question whether the policies and procedures of the Unified Facilities
Criteria were followed.
Although TRICARE Management Activity did not issue the design
authorizations for the clinics, the activity's officials said they
reviewed the requirements for the clinics based on results of the
Navy's health care requirements analysis. However, as stated earlier,
the Navy's health care requirements analysis did not fully document
key analyses such as the forecasted workload for each of the proposed
clinics and the methods and criteria for how the Navy reached the
staffing decisions, raising questions about the basis for TRICARE
Management Activity's review. Conclusions:
The Navy determined that to accommodate the additional inpatient and
outpatient requirements of the increased military population on Guam
following the military buildup, it would need to construct three
military treatment facilities consisting of a replacement hospital and
two branch health clinics. However, the Navy's health care
requirements analysis report does not clearly document the analyses
and assumptions used by the Navy to determine its military treatment
facility requirements, including forecasting health care demand and
determining health care workload and staffing requirements nor could
Navy officials adequately explain their analyses or assumptions. Such
documentation facilitates external stakeholder examination and can
lead to reasonable assurance of the adequacy of facilities to meet
mission requirements. Without such documentation, the Navy cannot
fully demonstrate to TRICARE Management Activity and other
stakeholders that its conclusions about the size and configuration of
its military treatment facility solution result in the most cost-
effective solution in meeting the health care needs of the expected
increase in military population on Guam.
Recommendation for Executive Action:
In order to ensure that the Navy's proposed branch health clinics on
Guam are properly reviewed and are consistent with Military Health
System goals of having appropriately sized and configured facilities
to meet the health care needs of military beneficiaries in a cost-
effective manner, we are recommending that the Secretary of Defense
direct the Secretary of the Navy to provide clearly documented
analyses to TRICARE Management Activity as part of DOD's process for
issuing design authorizations for military treatment facilities. These
analyses should, at a minimum, provide details of the basis for its
health care workload and staffing requirements on Guam. These
documented analyses should also include the specific health care
requirements to be met at each of the branch health clinics, and the
methods and criteria for how staffing decisions for each facility were
made.
Agency Comments and Our Evaluation:
In written comments to a draft of this report, the Assistant Secretary
of Defense (Health Affairs) agreed with our recommendation to have the
Secretary of Defense direct the Secretary of the Navy to provide
additional analyses to ensure that the Navy's proposed branch health
clinics on Guam are properly reviewed and are consistent with the
Military Health System goals of having appropriately sized and
configured facilities to meet the health care needs of military
beneficiaries in a cost-effective manner. DOD notes that since the
draft report was issued, the Navy Bureau of Medicine and Surgery has
already provided additional information to the Office of the Assistant
Secretary of Defense (Health Affairs) related to the planning for the
two branch health clinics. In addition, the Office of the Assistant
Secretary of Defense (Health Affairs) is reviewing this information
and will validate the Navy analysis within the next 30 days to ensure
the branch health clinics have been appropriately sized and located to
meet the beneficiary health care needs. The Assistant Secretary of
Defense (Health Affairs) also noted that the insights gained from this
audit will be applied to future health care planning efforts for other
Military Treatment Facilities throughout DOD.
DOD's comments also included input from the Navy Bureau of Medicine
and Surgery to the Office of the Assistant Secretary of Defense
(Health Affairs). The Bureau countered that the replacement hospital
augmented by two new clinics is a highly efficient solution and that
their documentation supported that conclusion. They also note that the
Navy concept of care for Guam is clearly documented in the health care
requirements analysis report dated February 2007, which provides the
foundation for the Medical Facilities Master Planning Study, detailing
the proposed facility solutions. As stated in our report, we believe
that the Navy's documentation used to support its recommended military
treatment facility solution for Guam does not clearly demonstrate how
the Navy determined the size and configuration of the proposed branch
health clinics. The Bureau noted that its Medical Facilities Master
Planning Study draws specific planning methods and data sources from
the health care requirements analysis. The Medical Facilities Master
Planning Study states that the health care requirements analysis
provides documentation of beneficiary health care requirements and
resulting facility space needs. However, as we note in our report, the
health care requirements analysis does not show how these requirements
translate into the size and configuration of the Navy's proposed
facilities because it omits documentation on the methods and criteria
for how the Navy reached staffing decisions for its proposed
facilities. Further, the Navy's documentation, including the Medical
Facilities Master Planning Study, did not contain the break down of
the forecasted health care workload by each proposed facility to
clearly show the portions of the DOD beneficiary population that are
expected to receive primary care at each clinic, or the number of
outpatient visits and the ancillary workload that are expected to be
provided at each clinic, thus the need for our recommendation.
DOD also provided technical and clarifying comments, which we
incorporated as appropriate into this report. DOD's comments are
reprinted in their entirety in appendix II.
We are sending copies of this report to the appropriate congressional
committees. We are also sending copies to the Secretary of Defense;
the Secretaries of the Army, the Navy, and the Air Force; the
Commandant of the Marine Corps; and the Director of the Office of
Management and Budget. This report also is available at no charge on
our Web site at [hyperlink, http://www.gao.gov].
If you or your staff have any questions, about this report, please
contact me at (202) 512-4523 or leporeb@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 this report are listed in appendix III.
Signed by:
Brian J. Lepore:
Director, Defense Capabilities and Management:
[End of section]
Appendix I: Scope and Methodology:
Our objectives were to (1) describe the Navy's plans for developing a
military treatment facility solution to meet the expected increases in
the military population on Guam, and (2) examine the extent to which
the Navy is assured that its proposed military treatment facility
solution on Guam will adequately meet the requirements for the
expected increase in military population.
To describe the Navy's plans for its proposed military treatment
facility solution for Guam following the realignment, consisting of a
replacement hospital and two branch health clinics, we reviewed Navy
planning documents and interviewed relevant Department of Defense
(DOD) officials. These planning documents included studies and
analyses prior to the announced realignment of Marine Corps units from
Okinawa, Japan to Guam, and were used by the Navy to determine the
condition of existing naval military treatment facilities, and to
select potential sites for the new facilities. We also reviewed the
Navy's 2007 Final Report on Health Care Requirements Analysis for Guam
Navy Medical and Dental Facilities, which updated and reassessed prior
Navy analyses to reflect the military population increases resulting
from the proposed realignment. In addition, we obtained and reviewed
the DD Form 1391 (Military Construction Project Data) for the
replacement hospital and each branch health clinic. We also obtained
and reviewed the Navy's final design of the replacement hospital prior
to construction and compared it with the replacement hospital
construction contract issued by Naval Facilities Engineering Command.
Further, we reviewed DOD's Draft Guam Joint Military Master Plan and
compared it with the Navy's military treatment facility requirements.
To corroborate the information obtained in these Navy planning
documents we interviewed relevant officials from the Navy Bureau of
Medicine and Surgery, Navy Medicine West, Naval Hospital Guam,
Headquarters Marine Corps, Marine Corp Forces Pacific, Naval
Facilities Engineering Command Marianas, Naval Facilities Engineering
Command Medical Facilities Design Office, Andersen Air Force Base 36th
Medical Group, Joint Guam Program Office, and TRICARE Management
Activity.
To examine the extent to which the Navy is assured that its proposed
military treatment facility solution on Guam will adequately meet the
requirements for the expected increase in military population, we
obtained and reviewed applicable legal and departmental guidance,
including DOD instructions and directives, and compared them with the
Navy's documented assumptions, methods, and economic cost analyses
used to develop its proposed military treatment facilities
requirements on Guam. We reviewed DOD Instruction 1100.4, Guidance for
Manpower Management, and compared this guidance with the documentation
provided to us by the Navy to support its staffing decisions for the
replacement hospital and proposed branch health clinics. To determine
the extent to which the Navy's conclusions regarding the size and
configuration of its proposed military treatment facilities on Guam
were clearly documented to allow for external stakeholder examination,
we reviewed internal control standards as described in the GAO report
Internal Control: Standards for Internal Control in the Federal
Government.[Footnote 17] We also reviewed Office of Management and
Budget guidance that defines management responsibilities for internal
controls for executive branch agencies.[Footnote 18] The primary Navy
document we reviewed was the Navy's 2007 Final Report on Health Care
Requirements Analysis for Guam Navy Medical and Dental Facilities. The
Health Care Requirements Analysis was developed to support the Navy's
decisions concerning its proposed military treatment facility solution
and its purpose was to determine the projected facility
characteristics required to support the health care needs of Military
Health System beneficiaries on Guam following the proposed military
buildup. As part of this review, we attempted to replicate and
reproduce key calculations presented in the documentation so as to
verify the planning assumptions used by the Navy and substantiate the
Navy's conclusions about the size and configuration of the facilities
that comprise its facility solution.
We also reviewed information used in the Navy's economic analyses that
was submitted to TRICARE Management Activity for approval of the
replacement hospital. We did not independently assess the data DOD
used for planning purposes; however, we discussed its reliability with
DOD officials and determined that the data were sufficiently reliable
to meet the objectives of this review. Additionally, to corroborate
the information above, we interviewed relevant DOD officials from the
Navy Bureau of Medicine Surgery, Navy Medicine West, Naval Hospital
Guam, Headquarters Marine Corps, Marine Corp Forces Pacific, Naval
Facilities Engineering Command Marianas, Naval Facilities Engineering
Command Medical Facilities Design Office, Andersen Air Force Base 36th
Medical Group, Joint Guam Program Office, and TRICARE Management
Activity.
We conducted this performance audit from February 2010 through March
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: Comments from the Department of Defense:
The Assistant Secretary of Defense:
Health Affairs:
1200 Defense Pentagon:
Washington, DC 20301-1200:
March 24, 2011:
Mr. Brian J. Lepore:
Managing Director:
Defense Capabilities and Management:
U.S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Mr. Lepore:
This is the Department of Defense (DoD) response to the Government
Accountability Office (GAO) Draft Report, "GAO-11-206, "Defense
Infrastructure: The Navy Needs Better Documentation to Support Its
Proposed Military Treatment Facilities on Guam," dated February 16,
2011 (GAO # 351440). Thank you for the opportunity to review the draft
report and provide comments. This engagement has been both informative
and valuable. We acknowledge there were shortcomings in providing GAO
the documentation to support the proposed branch health clinics.
I concur with comment regarding the recommendation to have the
Secretary of Defense direct the Secretary of the Navy to provide
additional analyses. Since the draft report was issued, the Navy
Bureau of Medicine and Surgery (BUMED) has already provided additional
information to the Office of the Assistant Secretary of Defense
(Health Affairs) (OASD(HA)) related to the planning for the two branch
health clinics. OASD(HA) is reviewing this information and will
validate the Navy analysis within the next 30 days to ensure the
branch health clinics have been appropriately sized and located to
meet the beneficiary health care needs. If additional information is
required, OASD(HA) will coordinate directly with BUMED.
The insights gained from this interaction will be applied to future
health care planning efforts for other Military Treatment Facilities
throughout DoD. We thank you for your careful review and analyses of
these requirements.
Our points of contact are Mr. Clayton Boenecke (Functional) who can be
reached at (703)681-4329, or via Clayton.Boenecke@tma.osd.mil. Mr.
Gunther Zimmerman (Audit Liaison) may be reached at (703) 681-4360, or
via e-mail at Gunther.Zimmerman@tma.osd.mil.
Sincerely,
Signed by:
[Illegible] for:
Jonathan Woodson, M.D.
Attachment: Navy Bureau of Medicine Comments to the Government
Accountability Office Recommendations.
[End of letter]
Government Accountability Office Draft Report Dated February 16, 2011:
GAO-11-206 (GAO Code 351440):
"Defense Infrastructure: The Navy Needs Better Documentation To
Support Its Proposed Military Facilities On Guam"
Navy Bureau Of Medicine Comments To The Government Accountability
Office Recommendations:
Recommendation: In order to ensure that they Navy's proposed branch
health clinics on Guam are properly reviewed and are consistent with
the Military Health System goals of having appropriately sized and
configured facilities to meet the health care needs of military
beneficiaries in a cost effective manner, we are recommending that the
Secretary of Defense direct the Secretary of the Navy to provide
clearly documented analyses to TRICARE Management Activity (TMA) as
part of Department of Defense (DoD) process for issuing design
authorizations for Military Treatment Facilities. These analyses
should, at a minimum, provide details of the basis for its health care
workload and staffing requirements on Guam. These documented analyses
should also include the specific health care requirements to be met at
each of the branch health clinics, and the methods and criteria for
how staffing decisions for each facility were made.
DoD Response: Navy Bureau of Medicine and Surgery Input to Office of
the Assistant Secretary of Defense (Health Affairs)/TMA Portfolio
Planning and Management Division (PPMD).
The Navy concept of care for Guam supports an integrated health care
delivery system with primary care medical/dental clinics operating at
the major DoD installations on the island. These branch clinics are
conveniently located near military family housing and other quality of
life services, while the Naval Hospital serves as the central island-
wide hub for inpatient and specialty care, advanced diagnostic
imaging, emergency medicine, and hospital services. Navy planning
studies and project documentation provided to TMA PPMD clearly
validated the plan to construct two new primary care medical/dental
clinics properly sized and staffed to deliver required primary care
and dental services to beneficiaries at Naval Station Apra Harbor and
future Marine Corps Base Finegayan.
Navy planning documentation submitted to TMA PPMD adheres to the high
standards for health facility planning identified by Defense Health
Program guidance and instructions. The Navy concept of care for Guam
is clearly documented in the Health Care Requirements Analysis (HCRA)
prepared by Altarum in February 2007, which provides the foundation
for the Medical Facilities Master Planning Study, detailing the
proposed facility solutions. The study draws together specific
planning methods and data sources from HCRA in relation to the
location and facility scope of the hospital and clinics. HCRA
population forecasts drive primary care clinic requirements in
relation to expected population distribution and alignment with Guam
installations. The requirements are expressed by space plans developed
using the DoD Space and Equipment Planning System to define clinical,
ancillary, and support spaces by department to create a Program for
Design (PFD), which incorporates staffing. The HCRA provider staffing
reflects expected primary care and dental provider empanelment ratios
in relation to projected clinic beneficiaries. Navy coordinated with
TMA PPMD officials to re-verify the submitted studies and
documentation, as approved by TMA, fully addressed TMA requirements,
including the final clinic PFD and DD 1391 project forms. Defense
Health Program Military Construction funding of the robust replacement
hospital augmented by two new clinics is a highly efficient solution
that ensures convenient patient access to care, while mitigating
traffic impacts on Guam. The Government of Japan (GOJ) funding of the
two clinics will accrue beneficial cost avoidance by eliminating any
GOJ need to build a separate hospital.
[End of section]
Appendix III: GAO Contact and Staff Acknowledgments:
GAO Contact:
Brian Lepore, (202) 512-4523 or leporeb@gao.gov:
Acknowledgments:
In addition to the contact named above, Harold Reich, Assistant
Director; Grace Coleman; Josh Margraf; Heather May; John Van Schaik;
Kyle Stetler; and Michael Willems made key contributions to this
report.
[End of section]
Related GAO Products:
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.
Defense Infrastructure: Guam Needs Timely Information from DOD to Meet
Challenges in Planning and Financing Off-Base Projects and Programs to
Support a Larger Military Presence. [hyperlink,
http://www.gao.gov/products/GAO-10-90R]. Washington, D.C.: November
13, 2009.
Defense Infrastructure: DOD Needs to Provide Updated Labor
Requirements to Help Guam Adequately Develop Its Labor Force for the
Military Buildup. [hyperlink, http://www.gao.gov/products/GAO-10-72].
Washington, D.C.: October 14, 2009.
Defense Infrastructure: Planning Challenges Could Increase Risks for
DOD in Providing Utility Services When Needed to Support the Military
Buildup on Guam. [hyperlink, http://www.gao.gov/products/GAO-09-653].
Washington, D.C.: June 30, 2009.
Defense Infrastructure: High-Level Leadership Needed to Help Guam
Address Challenges Caused by DOD-Related Growth. [hyperlink,
http://www.gao.gov/products/GAO-09-500R]. Washington, D.C.: April 9,
2009.
GAO Cost Estimating and Assessment Guide: Best Practices for
Developing and Managing Capital Program Costs. [hyperlink,
http://www.gao.gov/products/GAO-09-3SP]. Washington, D.C.: March 2,
2009.
Defense Infrastructure: Opportunity to Improve the Timeliness of
Future Overseas Planning Reports and Factors Affecting the Master
Planning Effort for the Military Buildup on Guam. [hyperlink,
http://www.gao.gov/products/GAO-08-1005]. Washington, D.C.: September
17, 2008.
Defense Infrastructure: High-Level Leadership Needed to Help
Communities Address Challenges Caused by DOD-Related Growth.
[hyperlink, http://www.gao.gov/products/GAO-08-665]. Washington, D.C.:
June 17, 2008.
Defense Infrastructure: Planning Efforts for the Proposed Military
Buildup on Guam Are in Their Initial Stages, with Many Challenges Yet
to Be Addressed. [hyperlink, http://www.gao.gov/products/GAO-08-722T].
Washington, D.C.: May 1, 2008.
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.:
October 12, 2007.
Internal Control Standards: Internal Control Management and Evaluation
Tool. [hyperlink, http://www.gao.gov/products/GAO-01-1008G].
Washington, D.C.: August 1, 2001.
Internal Control: Standards for Internal Control in the Federal
Government. [hyperlink,
http://www.gao.gov/products/GAO/AIMD-00-21.3.1]. Washington, D.C.:
November 1, 1999.
[End of section]
Footnotes:
[1] The government of Japan is expected to contribute $740 million in
financing for the development and construction of utility
infrastructure to be used by the Marine Corps and which is to be
repaid by the United States. Japan will also contribute $2.55 billion
in financing, of which $2.1 billion would be repaid by the United
States for the development and construction of family housing for
Marine Corps dependents. In addition, the government of Japan is also
expected to provide $2.8 billion in direct cash contributions to
develop facilities and infrastructure to enable the relocation of the
Marines, which is not planned to be repaid.
[2] TRICARE Management Activity is a DOD field activity of the Under
Secretary of Defense (Personal and Readiness) and operates under the
authority, direction, and control of the Assistant Secretary of
Defense (Health Affairs).
[3] For purposes of this report, the Assistant Secretary of Defense
(Health Affairs) will be referred to as Health Affairs.
[4] For purposes of consistency in this report, we refer to military
health care facilities as military treatment facilities. Military
health care facilities refer to buildings or portions of buildings in
which medical, dental, psychiatric, nursing, obstetrical, or surgical
care is provided. These facilities include, but are not limited to,
hospitals, nursing homes, limited care facilities, clinics and dental
offices, and ambulatory care centers, whether permanent or movable.
[5] Under Secretary of Defense (Acquisition, Technology, and
Logistics) memorandum, Department of Defense Unified Facilities
Criteria (May 29, 2002). This memorandum states that the Unified
Facilities Criteria are to be used by the Military Departments for the
planning, design, construction, sustainment, restoration, and
modernization of facilities, regardless of funding source.
[6] DOD, Unified Facilities Criteria 4-510-01, Unified Facilities
Criteria: Medical Military Facilities (Feb. 18, 2009, incorporating
change 3 Nov. 19, 2009). A design authorization refers to TRICARE
Management Activity approval to proceed with the design of a proposed
Military Health System facility project, including selection of an
architecture and engineering firm. It usually designates the project,
project fiscal year, project location, programmed amount, scope of the
project (size in square feet), deviations from the submittal
requirements in the Unified Facilities Criteria, and whether or not
TRICARE Management Activity wishes to participate in selecting the
architecture and engineering firm.
[7] Design agents for military treatment facilities are responsible
for the design of projects following receipt of a design authorization
from TRICARE Management Activity.
[8] Office of Management and Budget, Circular A-123, Management
Accountability and Control, revised December 21, 2004.
[9] GAO, Internal Control: Standards for Internal Control in the
Federal Government, [hyperlink,
http://www.gao.gov/products/GAO/AIMD-00-21.3.1] (Washington, D.C.:
Nov. 1999).
[10] Primary outpatient care generally includes caring for acute and
chronic illnesses, disease prevention, screening, patient education,
and health promotion.
[11] Navy Facilities and Engineering Command, Healthcare Requirements
Analysis for Guam Navy and Dental Facilities Final Report (Washington,
D.C.: April 2007). The purpose of a health care requirements analysis
is to provide an assessment of the total demand for health care
services generated by the population of eligible beneficiaries in the
region served regardless of where they receive care. The health care
requirements analysis also describes the product lines and staffing
necessary to meet demand. The workload and staffing assessment in the
health care requirements analysis allows the estimation of key
facility spaces required in the military treatment facility.
[12] GAO, Internal Control: Standards for Internal Control in the
Federal Government. [hyperlink,
http://www.gao.gov/products/GAO/AIMD-00-21.3.1] (Washington, D.C.:
Nov. 1999).
[13] DOD, DOD Space Planning Criteria for Health Facilities.
(Washington, D.C.: Jan. 28, 2002).
[14] DOD Instruction 6015.17, Planning and Acquisition of Military
Health Facilities (Mar. 17, 1983).
[15] DOD Directive 1100.4, Guidance for Manpower Management (Feb. 12,
2005).
[16] DOD, Unified Facilities Criteria 4-510-01, Unified Facilities
Criteria: Medical Military Facilities.
[17] [hyperlink, http://www.gao.gov/products/GAO/AIMD-00-21.3.1].
[18] OMB Circular No. A-123.
[End of section]
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