warriors and their families were allowed to fall to the cracks they were often left to fend for themselves and housing however there was one thing that was never questioned during the scandal that had to do with the quality of medical care provided at walter reed it was and remains excellent one of our key concerns is that the current plan and the organizational  in adequate and that patient care wounded warrior care will suffer as a result chairman ortiz said it perfectly there is only one acceptable standard of care for our wounded warriors and that is the best we have had concerns about the plans for the walter reed national military medical center of the desert from the beginning in hearings and meetings we have had vice admiral madison tell us in effect not to worry that everything is on track but we have yet to be convinced that that is true and in fact we have yet to be convinced that the department takes our concerns seriously in last year's national defen authorization act we would choir did an independent design review down to validate the current plan and that review was completed just last summer and its results are simply unsettling among the troubling descriptions of the current plan were that it would not result in a world class facility that would not meet joint commission accreditation standards and that it was ambiguous about the visions the goals and expectations of the new center disconcerting as the independent design reviews findings were however they pale in comparison to the department's response to those findings and for example on this was mentioned already development quote development of a world class medical facility is not a destination but rather a journey of continuous improvement unquote world class is most decidedly a destination one that congress expects new facility to arrive at before the center opens its doors the definition of world class will no doubt evolve over time but as the end been independent designer view has indicated the current plan does not meet today's definition and that is unacceptable as chairman or g s mention four years have passed since the brac recommendations were reported two years have passed since joint task force capital medicine was established still we do not know exactly who has overall responsibility for this project key decisions about funding staffing in the chain of command have yet to be made and we do not feel that the plan made all the requirements  law and the brac recommendation and we have an independent design review that is highly critical of the current plan and organizational structure since this is our first hearing since the findings of the independent designer view were released i would like to hear how the department plans to address the shortcomings identified i also look forward to hearing directly from the chair of the independent designer of your doctor can kaiser and hope that we will have a productive discussion about this incredibly important topic when the hearing ends today it's my desire that we leave with a better understanding of what needs to be done to ensure that the new walter reed national medical medical center at bethesda becomes i appreciate joining our good friends on the readiness subcommittee today led by chairman solomon ortiz and ranking member randy forbes for our hearing on the progress of the walter reed national military medical center i welcome the distinguished members of our witness panel i believe that there is nothing more important than providing the outstanding members of our military their families and our tyreese with world class health care delivered and world class medical facilities there is no question in my mind they deserve nothing less our family has experienced a quality of service with two grandsons born at the national naval medical center and a granddaughter born at portsmouth naval hospital the department of defense has  assured us on several occasions that merging walter reed army medical center and the national naval medical center but the two icons of military medicine would result in a single world class medical center that would provide improved access access to medical care for our troops and their families and veterans in the national capital region now i understand that the national capital and closure health systems advisory subcommittee of the defense health board has issued a report that calls into question whether the department's plan to merge these two facilities will result in a world class facility further i'm aware that the defense health board has expressed concerns regarding the department of defense's corrective action plan published in response to the findings and recommendations of the board it appears that there is still doubt about the new facility being world class before we hear testimony from our witnesses this morning let me be very clear that the new walter reed national military medical center opening as a national military medical center and to build a new community hospital for belvoir virginia by the deadline of september fifteenth two thousand the military system health system must fulfill a sacred responsibility to care for our nation's servicemen and women their families and those who have served before us i am grateful for the many dedicated men and women who have answered the call to duty are working to ensure that we create a health care facilities well positioned to meet our service men and women's veterans and wars in the national c throughout the country as principal adviser to the secretary of defense for the department's health care program the office of the assistant secretary of defense for health care and maintains oversight of the clinical brac actions including the transformation of the national capital region currently under way i'm pleased to report that we are on track to implement the brac recommendations by the statutory deadline of fifteen september two thousand and eleven however we must acknowledge that completion of construction activity represents only part of the story we sincerely appreciate the efforts of the defense health board subcommittee and acknowledge that their findings and recommendations county help us in our quest to be world class in the national capital region and throughout the military health system addressing the complexity and resolving the challenges of brac transformation in the national capital region clearly necessitates the knowledge and insight that the members of the health system of advisors subcommittee possess executing brac in creating an extraordinary health care delivery system in the national capital region is in a relatively short period of time is certainly one of the most difficult takings in the history of the military l system the joint task force cap med was created to lead this clinical transformation in the national capital region despite the challenges and complexities inherent in this task we should not lose sight of the great progress made today the single act of consolidating to medical centers into one and constructing a new robust community hospital in proximity to the majority of beneficiaries is a major accomplishment the creation of the cap as the overarching more commander has been poured into this effort and cough and they were hit in honored to appear before you to discuss the question of the new walter reed are we on the right track i am the deputy undersecretary of defense for installations and environment i've been in that position since july march was greatly appreciated and to the meetings that we've had since then i've certainly provided the guidance and direction that we needed like the command dr kaiser the defense health board subcommittee on the n c r for their work in defining world class and then their recommended steps to achieve that world class the attribute that they talk about in the world class institutions do not all exist in any one place that i know of in the world they are goals that we must strive to achieve and there are many of those attributes of world class that exist today at walter reed not just world class but best in class best in the world want prosthetics care walter reed is the place that you want to be today if you have an open traumatic brain injury then but the place that you want to be those are examples of some of the quality of care that's going to go on wounded warriors we now have a new standard just established within the last two months we've had the defense health board report to be able to work on where not disagree with any of the recommendations that the defense health board has made we are committed to achieving world class standards at the new walter reed national military medical center and the fort belvoir community hospital the capital region medical brac projects in the journey to world class  synchronize the current efforts that are going on both with the brock and then those those other efforts that will be needed to achieve as many as possible of the attributes of world class that we pal so well laid out that master plan will you i've told you about our progress towards the initial outfitting and transition contract that contract was awarded last week and we have highly competent group of general contractors that will be performing that activity that was one of the last contractual pieces that will have to meet in terms of the construction outfitting to be able to achieve that deadline and there are no data points i'll reiterate again there are no data points that thank you again for your interest and support in the transformation we're committed to providing health care not just to our wounded with all of our beneficiaries your support and overside have made a measurable contributions to this process department will continue to work with the military services to make this integrated regional health care system the first in the country within the military health system we look forward to a fruitful and collaborative partnership with this committee thank you for the opportunity to be with you today how we got here this morning not taking the time to make comments in that regard and i thank you for including my written testimony in the record i would like to use my allocated time  for comments two main points that will augment my written testimony first in your consideration about the evolution of all to read to become a world class medical facility it is important to keep in mind that the committee's work to date has reviewed only the design plans for the visible architecture of the new walter reed national military medical center that is we have reviewed only the design plans for the physical structure of the facility it is not yet possible to review the invisible architecture of the facility architecture i mean the values and culture of the organization the attitude and morale of the staff and other less tangible design features of the new facility that will in the long run be the most important determinant of whether the new wal performs at a level of actual length that would make it world class no matter how new or modern or sophisticated the visible architecture of a facility the physical structure alone can never make a world class medical facility importantly however prevent a facility from becoming world class a second point i would like to highlight is that  commented on by others that there does not appear to be any significant disagreement about the that have been identified in the plan nor about ultimately what needs to be done to correct them f the committee for it does not provide sufficient detail or specificity to determine whether the planned corrective actions are on the right track or will be reasonable time or at a reasonable cost in my committee's judgment i believe that the committee would feel more confident that things were on the right track if the statements about commitment were companied by detailed plans for fixing the problems those plans milestones and deadlines and if it were clear that someone had the necessary authority and control to execute those plans until these  problems are fixed sooner rather than later in closing let me say that i believe there are a few issues more important to readiness and military personnel than our troops knowing that the best possible health care will be there for them when they are harmed in the defense of our nation i am reminded of this by frequent health care related questions from my daughter who is r and she not infrequently picks up the phone and says dad what about this frankly when we send our children into harm's way we have a responsibility to ensure that they have the peace of mind of knowing that they will have world class medical care should they need it and anything less than that is simply not good enough representing the committee that has produced the report that you are familiar with we would urge that whatever necessary action whatever action is necessary be taken to ensure that the new walter reed national military medical center and indeed our entire military health care system everywhere obtaining i mean i think they are but i'd like to hear from you and when do you expect to obtain this capability and it was cost maybe you can enlighten the committee on my meant to bring that capability on on board as soon as we possibly could the addition of water treatment centers the enhancements that we're making with the centers of excellence as you're well aware of the involvement of the intrepid foundation and putting in another center of excellence up there as a donation to the government i think all speak to the commitment that we've all made to make this world class i think that what we have to do is realize that within the brac confinement  be doing brac we want to get that capability on board as soon as we can we know it but that's going to be six sixty six single rooms for example modern first class rooms up there we know that there's a lot of other  there that we're going to have to get back to and renovate and as dr ro bind said we can't tear the whole thing apart at one time we know down to fort belvoir we're building perhaps the finest community hospital that's been built in this country in terms of its capabilities in terms of what's go happen in that facility and still itself i think that the commitment is there but i am reminded of dr carter's comments that the six domains of world class only one of which is core infrastructure there are other core there are other parts of being world class and there are plenty of examples in this country of operations that are not necessarily in first class facilities but are world class operations and so our commitments to both we want to do the facilities at a time phase we will have to go beyond the brac deadline in order to do occurs during bracken goes after brett and then there are things we'll have to do after brac not go back and redo what we've done to use that space as a leverage point then to launch if we build a new bell board ten years ago we would have that as a leverage spot that we could do but we're going to get that all the same time   and i can understand dr saying that maybe we could try to do it all at the same time now i'm pretty sure we're going to hear some complaints from some of our cost the families so that when the warriors when they're assigned to the new facility in new operating rooms versus the old ones  came to brief the deputies response to the d h b report we had a number of questions about the coordination of the renovation plan that the navy is doing on the o evolve those operating rooms as we go so the three new operating rooms are certainly extraordinarily large being built in the new construction and we will arrive at a vision that will help us to move towards the world class in terms of the operating rooms that currently exist in the renovations that are there that will potentially leave us with a shortfall of operating rooms we can either make that up through changing the our schedules that is start times extend well into the day to do the same number of work and potentially look at new or construction in the future but we are committed to moving ahead and moving towards that world class powdered you know at this part of the brac recommendation and that will deliver a integrated health care delivery system in the national capital region that is superior to what we have now it will not be everything represent actual additional expansion and additional improvements of the kinds of things that mr middleton talked about that were not originally part of the brac the bro figure that out thank you thank you very much i want to talk a little bit about the structure and dr kaiser you mentioned in your comments that you would be confident if there were more detailed plans and  whether or not you were certain that you could get there with the necessary authority and control and and i wanted to turn to you mr millet and ask about that because part of the concerns have been around those issues the military health system operates with the assistant secretary of defense of the top and that's the way it's structured today not necessarily making a judgment about that but that's way it structured how does the current arrangement with cap meds fit into that structure by several mattison reports directly to the deputy secretary of defense that there's really been question about who's the arbiter when there's disagreement between health affairs and men between the services and men who are the the arbiter there is everything need to be handled by deputy deputy secretary lynn and then we go over to the staffing as well will the services still be responsible for programming and budgeting personnel for the facilities under the control of cat med cat medicine to this responsibility i know that that's that's been a concern could you help us better under than concerns what are the issues we haven't had that meeting for some time because we haven't had a series of issues that require that it's back to the authorities question we worked through last year and i know dr madison can articulate this better than i a series of meetings in order to articulate their authority over the personnel we worked on manning documents for the military personnel and we have still an issue about the personnel and the title authorities to dr madison would have over those folks there remains i think still the issue of the ultimate budgeting issues that occur within that those facilities are thirty seven facilities within the national capital area that's a lot of that's a lot of facilities and they cross three different accounting and finance systems so this gets more complicated the deeper you get into it on how you actually do that's what we i tried to do is provide the staff with all the transparency and where the resources occur in terms of the differences i will tell you that there haven't been many differences between health affairs and the cap bad on moving forward so it's a very complicated matter that i don't think is yet resolved i think that's we're about to do in the next in the next several months is to work through these issues of authorities we have a lingering issue as to what would forces is that part of the problem that there are obviously multiple services here as well i think you know that i would say is that in the master plan itself i mean we've we've asked you to to create a master plan are some of the do these decisions beyond the ability of the department should somebody else know something but i don't know of any authorities that we don't have to make those to make the decisions there are some some matters around title five authorities get a little thorny or second third order issues about auditing and things like that but i think we have the authority to do it but i defer that to dr chairwoman davis as part of the master plan that's due back authorities issue is one of the threads that we're in are we being we have a group that's working specifically on all the ortiz issues and as far as i know there are none that are outside the authorities of the department is it that congress you know had asked for this master plan do you think that that kind of of work would have gone on  irrespective of that request yes ma'am absolutely the that in fact those are two of those or three of them are pending decisions left for the deputy secretary that we've had identified  we have the manpower and civilian personnel issues the other three that are still pending are the force next between the two hospitals the resources out of the resources flow which is highly technical and we will come to an answer on that then ultimately what's the patient care and why master plan for the walter reed facility itself there is need for a master plan of the campus where the walter reed facility located or proximity to multiple other the hard to understand how you're going to deal with the funding issue and until the funding issues dealt with hard to understand how you're going to deal with the master plan issue and then you get into all of the specifics about operating rooms and single rooms and position and what authority do you currently have to direct funds to resolve the design and construction issues that have been raised by the defense health board and of course has been a reference several times and again second ago and accelerate was to start renovation of those rooms and conversion and single patient rooms still fifty four will remain at fifty two will remain at the end of rock and the question is what what to do with those rooms not  disagreeing with you know the need and the movement in the country the country is moving towards a single patient room standard that will require renovation of those remaining rooms and since there is no space in the construction left i would likely require new construction we're also taking a look at the on the fundamental demographics of the population and their demands as we work towards integrated delivery system to validate the the number of beds that we would need and integrate that into the master plan as well and i hope again that and i know you are looking into that  warriors and the transition at the new walter reed in need three hundred barracks rooms for these soldiers please explain the plan for a company not only the army population but the navy and marine recovering wounded warriors as well in addition please explain the plans for accommodating the families of the and it was at the bethesda campus well i don't think i'm the right person to to answer that question since  was not apparent from the plants that we saw and this is all of course part of what is needed in the master plan i would just add to the prior question to the populations change technologies change care prices of change and we really need a more forward looking demand analysis to guide the master plan and other design pieces manages the warrior transition and in particular the non medical attendance as well as family members and each of the services has a different requirement generations mechanism that they used to take a look at that we are at at this moment also to the best of my knowledge very few people had been assigned to the service academies it's also been the intention of chairman skelton to expand this to the different programs with the thought that the service academies are limited to colorado   how can we do a better job of making these opportunities available to folks who can stay on the to do meaningful work for their nation continue to wear the uniform and do something worthwhile for their nation which is what their desire is and give them those you know give them a seamless transition should their decision to be go back to the private sector a seamless transition back to the private sector buy them some time what can we do need to do to get that word out  thank you mr taylor it's it's it's you know wonderful things going on now we've we've moved into the rehabilitation capabilities based rehabilitation model in the services that really didn't exist before these current operations in iraq and afghanistan and so they're based on the capabilities that the individuals have the limbs that they've lost and where they might be able to go i know that almost everybody would like to have them work  n and their areas and work with them one of the opportunities opportunities that will have at the walter reed national military medical center is a area that we where we will jointly be able to provide information to to all of those folks since most of the since all of the the amputees as they go through rehabilitation will be at walter reed we will be able to disseminate that through each of the service mechanisms in a more comprehensive and joint way we are we are committed as well to making sure that they understand all the opportunities that they have been policy for well over a year and again not one of these young people that are taking tours of the capitol has been made aware of it and so again i do understand that you have a lot of responsibilities but i would make this request face to face that that you you you know we're headed towards an integrated delivery system for the first time within the military health system national capital region is the largest concentration of military medical forces and beneficiaries that we have in the country five hundred thousand beneficiaries  we have in the country in the state and what we need to do it'll be both be a referral medical center and a specialty medical center for the area the community hospital at fort belvoir will provide  general specialty services to the what is now the majority of the area's population which is shifting south over the last couple of years and so those things will come together as part of the integrated delivery system in terms of the vision itself a for for what i'm happy happening at walter reed or taking a look at an integrated not just the current terrific capabilities amputee care of traumatic brain injury there's also designation for all of our beneficiaries that will be the first within the military health system and in each of the areas that we're moving towards we're looking towards achieving world class we're we're in a particularly good location we're right across the street from the national institutes of health and we have a medical school right on our campus and as part of this strategic plan we're looking at how to bring together the medical center and medical school in a new model for academic medicine for the country so those are some of the things that we're doing i don't know if that answers your questions for you but let me follow up and then i'll open back up to the panel when you say integration do you mean assigning air force physicians  providers to maybe facilities vice versa or are we looking at integrating all providers into one service what can you elaborate on that the facilities themselves will be the personnel will be jointly assigned that is that personnel from all of the services will be at both of the facilities in terms of the enter gratian from the patient perspective what we're looking at is having them see an integrated delivery system you'll see joint providers providers from all the are only a few areas in the country where there is more than one service hospital the national capital region san antonio are the two biggest so it's unlikely that you'll see much of this anywhere else   and had the opportunity to delve into all these and i would say that there are very different cultures in the services and integrating into a single joint armed forces medical culture is not an operational definition for what world class should be taken i mean so much of the work of the subcommittee that i chaired was in the report that we issued actually had to do with defining an operational and functional terms what world class subcommittee a world class medical facility is one that goes above and beyond compliance with professional accreditation and certification standards where there is a palpable commitment environment of inquiry and discovery and one that creates an ambience or an atmosphere that inspires trust and communicates confidence i think it world class facility constantly thank you it's a it's a great challenge you know we have the probably one of the world's largest databases for the military and the central data repository where we have tremendous amounts of information so we do have some expertise our platform is challenges in its old architecture and things like that we recognize that in our own we in the department working on a way ahead for a new architecture or in the process of that actually picking folks to be part of that team to move forward with that we have a but it's time for a change as i'm sure you're familiar with also have the national standards in standards that are evolving we're going to do some programs some pilot programs perhaps some civilian activities to see if we can share information between the departments as you know the medical center and the things that are the inability to manage the capital region and also have a have any impact at other locations in the united states and how do  frankly the way we're doing it in bethesda has allowed us to actually meet those needs timelines have gone to some traditional methodology would have been struggling so we've been fortunate in that i think we have to learn the lesson of how we deal with are our agents the corps of engineers and in effect we have over the last couple of years built a series of criteria for evidence based design which is buzzword for the kinds of facilities that you want to build and so back in two thousand and seven we put together a package that articulated what those design features ought to be and we held a conference in two thousand and eight with the civilian activities to articulate those kinds of world class facilities issues around evidence based design things like natural lighting and enhance privacy for infection control as mr wilson talked about single rooms  patient safety features that are built in the way in which we observe the patients in the rooms and the way in which cleaning has occurred in the kind of technology that we can advance all of those are part of where we go in the future so everything that we do it for bel not have been part of my question is is there an ongoing process for a clinician input into the communities of interest essentially that occur within hospitals and one of the concerns  the delivery of care there are differences of opinion organization when we move towards a comprehensive cancer center there were a number of desirable attributes of that form of care for instance the consolidation of cosmetic services consolidation of psychological counseling for cancer members that sometimes seemingly conflicted with the independent provision  be continuing to work with those questions about organization to make sure that they feel they're able to provide the best care but that our patients are getting integrated care across the system but one of the problems that we have is that as we focus into vidual lan here then we sometimes lose focus on the integrated delivery of care for the other problems that they may or may not have so we're struggling with that i think we come up with a good model because i think it's certainly the people that are have  have to modernize their facility and we a long way from the architecture that we built many many years ago modern technology there's all kinds of things now that are for us an opportunity to make it better and make it even more operable and i think that's what i want to make sure that  identified to address and fix the concerns of the independent review and i just wanted to turn to this middleman and dr about is that true i mean as far as you you know i have those identified that can address the concerns of the review let me clarify if you're one of the ones that are identified where with the ongoing construction for anything that required new construction in the master plan those funds have not been identified so