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i

37–326 2008

[H.A.S.C. No. 110–64]

FINDINGS OF THE INDEPENDENT REVIEW

GROUP AND AN IN-PROGRESS REVIEW

OF ACTIONS AT WALTER REED

HEARING

BEFORE THE

MILITARY PERSONNEL SUBCOMMITTEE

OF THE

COMMITTEE ON ARMED SERVICES

HOUSE OF REPRESENTATIVES

ONE HUNDRED TENTH CONGRESS

FIRST SESSION

HEARING HELD

JUNE 26, 2007

(II)

MILITARY PERSONNEL SUBCOMMITTEE

VIC SNYDER, Arkansas, Chairman

MARTY MEEHAN, Massachusetts

LORETTA SANCHEZ, California

SUSAN A. DAVIS, California

NANCY BOYDA, Kansas

PATRICK J. MURPHY, Pennsylvania

CAROL SHEA-PORTER, New Hampshire

JOHN M. MCHUGH, New York, Chairman

JOHN KLINE, Minnesota

THELMA DRAKE, Virginia

WALTER B. JONES, North Carolina

JOE WILSON, South Carolina

DAVID KILDEE, Professional Staff Member

JEANETTE JAMES, Professional Staff Member

JOE HICKEN, Staff Assistant

(III)

C O N T E N T S

CHRONOLOGICAL LIST OF HEARINGS

2006

Page

HEARING:

Tuesday, June 26, 2007, Findings of the Independent Review Group and

an In-Progress Review of Actions at Walter Reed ............................................. 1

APPENDIX:

Tuesday, June 26, 2007 ........................................................................................... 57

TUESDAY, JUNE 26, 2007

FINDINGS OF THE INDEPENDENT REVIEW GROUP AND AN INPROGRESS REVIEW OF ACTIONS AT WALTER REED

STATEMENTS PRESENTED BY MEMBERS OF CONGRESS

McHugh, Hon. John M., a Representative from New York, Ranking Member,

Military Personnel Subcommittee ...................................................................... 2

Snyder, Hon. Vic, a Representative from Arkansas, Chairman, Military Personnel Subcommittee ........................................................................................... 1

WITNESSES

Cody, Gen. Richard A., Vice Chief of Staff, Department of the Army, U.S.

Army ...................................................................................................................... 27

Marsh, Hon. John O., Jr., Former Secretary of the Army, Co-Chair, Independent Review Group ................................................................................................. 5

Pollock, Maj. Gen. Gale S., Acting Surgeon General, Department of the Army,

U.S. Army ............................................................................................................. 28

Schoomaker, Maj. Gen. Eric B., Commander, North Atlantic Regional Medical

Command and Walter Reed Army Medical Center, U.S. Army ....................... 30

West, Hon. Togo D., Jr., Former Secretary of the Army, Former Secretary

of Veterans Affairs, Co-Chair, Independent Review Group .............................. 7

APPENDIX

PREPARED STATEMENTS:

Cody, Gen. Richard A. ...................................................................................... 76

Marsh, Hon. John O., Jr. ................................................................................. 67

McHugh, Hon. John M. .................................................................................... 64

Pollock, Maj. Gen. Gale S. ............................................................................... 81

Schoomaker, Maj. Gen. Eric B. ....................................................................... 91

Snyder, Hon. Vic ............................................................................................... 61

West, Hon. Togo D., Jr. .................................................................................... 72

DOCUMENTS SUBMITTED FOR THE RECORD:

Independent Review Group Members and Witnesses Biographies .............. 101

QUESTIONS AND ANSWERS SUBMITTED FOR THE RECORD:

Mr. McHugh ...................................................................................................... 119

(1)

FINDINGS OF THE INDEPENDENT REVIEW GROUP AND

AN IN-PROGRESS REVIEW OF ACTIONS AT WALTER

REED

HOUSE OF REPRESENTATIVES, COMMITTEE ON ARMED SERVICES, MILITARY PERSONNEL SUBCOMMITTEE, Washington, DC, Tuesday, June 26, 2007.

The subcommittee met, pursuant to call, at 1:05 p.m., in room

2118, Rayburn House Office Building, Hon. Vic Snyder (chairman

of the subcommittee) presiding.

OPENING STATEMENT OF HON. VIC SNYDER, A REPRESENTATIVE FROM ARKANSAS, CHAIRMAN, MILITARY PERSONNEL

SUBCOMMITTEE

Dr. SNYDER. The hearing will come to order.

The purpose of today’s hearing is for members to get an update

on what has happened at Walter Reed and in the military medical

program since the full Armed Services Committee hearing in

March.

To refresh everybody’s memory, in late February, The Washington Post published a story titled, ‘‘Soldiers Face Neglect, Frustration at Army’s Top Medical Facility.’’

In the following weeks, a series of shortcomings at Walter Reed

were revealed, such as substandard living conditions, inadequate

management of outpatient medical care, and poor follow-up from

the ill, recovering or wounded soldiers’ chain of command.

Many members were concerned that these problems were not

limited to Walter Reed, but this was actually a sentinel event that

raised a possibility of similar features across the military medical

system.

This concern was heightened by the fact that both this subcommittee and the full committee had expressed concern, though in

less dramatic manner, during earlier hearings dating back to 2005

about some of the same issues found at Walter Reed.

Since then, the Independent Review Group (IRG) set up by Secretary Gates following the revelation at the Walter Reed Army

Medical Center has completed its review and released its findings.

We are fortunate to have both of the Independent Review

Group’s co-chairs with us today: Mr. Togo West, the former secretary of Veterans Affairs, as well as the former secretary of the

Army. Mr. John Marsh is also a former secretary of the Army, as

well as a former member of this body.

Gentlemen, we appreciate you being here.

During this hearing, we will also get an update on what steps

the Army has taken to remedy conditions at Walter Reed and to

2

hear how the Army plans to address or preclude similar problems

at other medical facilities.

I should also mention that, while we have had Army leaders testify about Walter Reed before the committee previously, we have

here today new leaders.

With us on our second panel are: General Cody, vice chief of staff

of the Army, who has been tasked by the acting secretary of the

Army with oversight of the Army’s medical action plan; Major General Gale Pollock, the acting Army surgeon general; Major General

Eric Schoomaker, commander of the North Atlantic Regional Medical Command and Walter Reed Army Medical Center; Brigadier

General Michael Tucker, deputy commander of the North Atlantic

Regional Medical Command and Walter Reed Army Medical Center; and Colonel Terrence McKenrick, commander of the Warrior

Transition Brigade.

This entire episode has demonstrated the power of focus.

Throughout this process, virtually everyone—wounded soldiers, ill

soldiers, recovering soldiers, family members, commissioners—have

had nothing but good things to say about the quality of inpatient

care our wounded and ill soldiers have received at Army hospitals.

Our military hospitals are among the best in the world.

However, once soldiers leave the focused care environment of the

hospital and continue their treatment as outpatients, the system

has appeared unable to provide the same level of support.

The challenge for all of us to is to make sure the military healthcare system remains focused on the recovery of our wounded and

injured and ill soldiers across the continuum of care, not just at the

time of injury, not just at the time of public and press scrutiny, not

just at the time of great individual leadership and personality, but

all the time. And this hearing is part of that ongoing oversight.

I would now like to yield to my partner for the last several years,

Mr. McHugh.

[The prepared statement of Dr. Snyder can be found in the Appendix on page 61.]

STATEMENT OF HON. JOHN M. MCHUGH, A REPRESENTATIVE

FROM NEW YORK, RANKING MEMBER, MILITARY PERSONNEL SUBCOMMITTEE

Mr. MCHUGH. Thank you, Mr. Chairman. Let me, first of all,

thank you, Vic, for the great leadership that you have provided in

your time as chairman of this, I think, critical subcommittee, but

also for the partnership that you and I have shared over the previous six years, prior to that, in a leadership role.

And I have mixed emotions. I am excited about Ms. Davis, the

gentlelady from California, taking over the gavel, as she will here

in short order, but clearly we will miss the kind of insight that you

bring with your medical degree, with your compassion and your

passion for these issues. And I wish you all the best.

I don’t want to sound like we are saying something that is sending you on to the next life, but it is a different life. And you can

leave this subcommittee, Mr. Chairman, knowing that you have

made a tremendous difference, and the men and women who bravely serve this nation and its families that stand beside them are far

better off than when you came to your post.

3

So, thank you for that.

I also want to congratulate you on your decision to hold this

hearing.

I think we can all agree that the conditions and problems uncovered at Walter Reed are a dark chapter in what, as the chairman

suggested, is an otherwise stellar history and tradition of the fine

military medical institution that has served our nation’s warriors

so ably since 1909.

With that in mind, certainly, my goal today is to get a sense as

to whether or not the immediate issues have been resolved, but beyond that, also, that the policies and resources have been put in

place to prevent these problems from occurring again at Walter

Reed or, more to the point, any other military medical facility.

I have to tell you I am encouraged by the immediate—and I

think it is fair to describe them as aggressive—responses by the

Department of Defense (DOD), by the Army to the deficiencies that

existed, particularly in the outpatient medical system.

Secretary Gates is to be commended for establishing the Independent Review Group to identify those shortcomings and to make

the recommendations to improve the quality of life for our wounded

combat veterans and their families as they recover at Walter Reed

and the National Naval Medical Center at Bethesda.

I certainly look forward to hearing the findings and recommendations from, as you described so very aptly, Mr. Chairman, the distinguished members of the Independent Review Group for our first

panel.

I have to tell you that I have had the honor of serving on this

committee now for 15 years, and we have a habit of describing

every panel as distinguished, and most often they are. But rarely

have we assembled a group of individuals on both panels who have

served this nation more effectively and in more important times

and important roles than the first panel.

Gentlemen, thank you so much—and the second panel is not just

gentlemen, but in the first panel it is—for your service on this

panel, but also for what you have done for our nation and its warriors in your so-called previous lives.

I am equally encouraged by the Army medical action plan that

appears to be a roadmap for short-and long-term solutions to the

problems encountered by wounded and injured soldiers.

And with that said, my enthusiasm, I have to tell you, is tempered by continuing to hear from soldiers, as I suspect many of us

are, in the wounded transition units about problems, particularly

with the medical evaluation board (MEB) and physical evaluation

board (PEB) systems.

Most recently, during a session with committee and member staff

at Walter Reed, I heard about the kinds of challenges that continue

to persist. And I know we all want to try to overcome those, and

I look forward to discussing the details of the plan with the members of our second panel.

So with that, Mr. Chairman, I would yield back.

I would say, as a brief note, I do have to make an apology at the

firsthand. I have an amendment on the appropriations bill that is

on the floor presently that will come up that I do have to present.

When I get the call, I will have to slip out. I hope everyone underVerDate 22-MAR-2001 13:34 Jul 16, 2008 Jkt 037326 PO 00000 Frm 00007 Fmt 6633 Sfmt 6633 C:\DOCS\110-64\37326.TXT HNS1 PsN: HNS1
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stands, but I assure you I will be continuing to follow this issue

very, very closely.

And, again, Vic, Mr. Chairman, thanks for holding this hearing,

and more importantly, thank you for your service.

A special note of welcome back to Joe Schwarz, a former distinguished member of this august committee, who, too, has great

background in the medical field. And it is good to see him with us

here again today.

I yield back, Mr. Chairman.

[The prepared statement of Mr. McHugh can be found in the Appendix on page 64.]

Dr. SNYDER. Thank you, Mr. McHugh.

I want to give Susan Davis, our colleague from California, who

will be the incoming chair of this subcommittee when I take over

for Mr. Meehan when he leaves at the end of this month, for any

comments she might want to make at this time.

Ms. Davis.

Ms. DAVIS. Thank you, Mr. Chairman.

I really just want to take this opportunity, and I am sure I will

have several more, to thank you for your steady leadership of the

committee.

This is such a critical committee. Representing a community, a

military community like San Diego, I know how important it is

that we honor and respect our families and those who are serving

in the armed services. And we can only do that through our actions

and through what we actually produce on their behalf and the way

that we relate, and this committee is a very important vehicle for

that.

So I want to thank you for that leadership.

I want to thank Mr. McHugh, who I believe had to leave quickly,

but I will look to both of you, because you have been a tremendous

mentor. And I know that we are going to deliberate as we have in

the past, and I just look forward to all the work that we will be

doing on the committee.

And I know that the support is across the board in a very bipartisan fashion on this committee, and I welcome that as well.

Thank you all for the work that you have done, as it relates to

this issue. We know that, probably more than any other issue that

came before the citizens of this country, I think that Walter Reed

really captured people, made them think again about what the impact, what the consequences of going to war really are and how we

have to care for our troops.

And so you have brought that forward with, again, a very deliberate way, and we appreciate that. And I look forward to the hearing.

Thank you very much.

Dr. SNYDER. Thank you, Ms. Davis.

Let me introduce the first panel.

I understand that, Secretary Marsh and Secretary West, you will

be the two having formal opening statements. Is that correct? Then

you have got your sidekicks on each side when you get in trouble.

Is that the way we will handle this?

I want to introduce everyone: the Honorable John O. Marsh, Jr.,

former secretary of the Army and co-chair of the Independent ReVerDate 22-MAR-2001 13:34 Jul 16, 2008 Jkt 037326 PO 00000 Frm 00008 Fmt 6633 Sfmt 6633 C:\DOCS\110-64\37326.TXT HNS1 PsN: HNS1
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view Group; the Honorable Togo D. West, Jr., former secretary of

the Army and former secretary of Veterans Affairs, the co-chair of

the Independent Review Group; accompanied today by our friend—

it says John Schwarz, but it is Joe Schwarz, just to the folks here.

Joe, it is great to see you and have you back here.

Joe Schwarz, former Member of Congress and an Doctor of Medicine (M.D.) and a former member of this House Armed Services

Committee; Mr. Arnold Fisher, senior partner of Fisher Brothers;

General John Jumper, former Air Force chief of staff, now retired;

Command Sergeant Major Lawrence Holland, also retired, former

senior enlisted advisor to the assistant secretary of defense for reserve affairs.

Gentlemen, we are glad you are all here.

And, Secretary Marsh, is that the order we will go in? You all

decide that one.

Gentlemen, we have got six people with four microphones. If you

will pull that right in close to you, it will enable people like me to

hear you.

STATEMENT OF HON. JOHN O. MARSH, JR., FORMER SECRETARY OF THE ARMY, CO-CHAIR, INDEPENDENT REVIEW

GROUP

Secretary MARSH. Thank you, Mr. Chairman. I appreciate your

opening comments and the attention and interest of the committee.

We are very fortunate to have as our co-chair Togo West, who

has a very distinguished career both in law, in the Department of

Defense, in the field of legal affairs, as the secretary of the Army,

and then as a Cabinet officer in Veterans Affairs. And he brought

to our efforts, I think, an unusual combination of knowledge and

also interest and background.

I would like to thank you for doing this, for holding this hearing.

Ultimately, the armed forces of the United States is a joint responsibility between the executive branch and the congressional

branch and providing for some of the things that need to be done

in the American medical community of the Army cannot be accomplished by the Department of Defense nor can it be accomplished

by the executive branch, because they will require changes in law

in a number of instances to achieve the kind of medical delivery

systems that we would like to have.

I should mention to you that in pursuing this effort, we had complete cooperation from every area of the Department of Defense,

every service, the military. The departments fully cooperated in our

investigation, which really occurred in less than 40 days. We had

45 days to do that.

I would like to point out that it has been my experience, both

having served in the armed forces and having been associated in

civilian leadership, there is an American ethic in our armed forces

about care of wounded. And it is the finest care that is given to

members of the military of any nation in the world—the American

ethic of care of the wounded.

Now, I don’t want to diminish the role of the active forces, because we have to understand the enormous hardships that are

being visited on the families of guard and reservists. Their needs

are different sometimes than the needs of the active force, and I

6

would ask you to investigate and look into that. Their family support structures are different than those of the active force. But they

also play an equally important role in support of our soldiers and

sailors, Marines and airmen. And they also play a significant role

in sharing the burdens and hardship of being wounded.

We on the committee often referred in our deliberations to what

had happened at Walter Reed. It had encountered the perfect

storm, and by that we meant there came into confluence several

unforeseen difficult to deal with issues, not wholly the responsibility of the hospital.

The first of those is an increased casualty load of Iraq, which is

a very heavy casualty load, and you will find that the bulk of casualties are moved to Walter Reed Hospital.

Then there was the A–76 contracting out requirement which

comes from Office of Management and Budget (OMB), which, oh,

six or seven years ago, required Walter Reed to contract a series

of civilian occupations and jobs that were very integral to the operation of the hospital, and that competition dragged on and on and

on. And the hospital first won the bid, and it was appealed, and

then it lost the bid. But it introduced an era of uncertainty.

And then, finally, the Walter Reed Hospital, a decision was made

by the base re-alignment and closure (BRAC)—we did not take

issue to that; we did not get into that. But the BRAC decision had

significant impacts on the quality of medical care. It impacted on

issues that related to certification of physicians and retaining essential physicians on the staff of the hospital.

It boiled down to that we divided the issue and it would evolve

into sort of two issues.

One of those was trauma care, which occurred first on the battlefield, then the hospital in Baghdad, then evacuation to Landstuhl,

Germany, then evacuation to the United States, frequently to Walter Reed. Sometimes that occurred in less than 36 hours, unbelievably. That care was outstanding, and Walter Reed maintained the

standard of the trauma care. As Dr. Schwarz said, finest trauma

operation in the world.

But where the system broke down was for those soldiers who had

completed their hospitalization, ready for discharge from the hospital, but continued to have care needs, and they will become

known as holdovers. This was the major problem, and this was not

handled well. It was not sufficient, and it created enormous problems.

To correct this, as I pointed out, is not just the Department of

Defense. It is OMB, it is the Veterans Administration, and other

departments and agencies of government.

Now, ultimately, the Congress, in my view, can do more to correct this problem than anyone. I ask you to devote your time and

effort to pursue it, to have the persistence to pursue it, and to have

commitment. And through that congressional interest, which I

place enormous emphasis on, we will have a great American medical community and we will meet that standard of the American

ethic.

If I could close with—if you will forgive a personal statement, but

it gives some insights. Both of our sons were recalled to active duty

in Marine combat in the first Persian Gulf War. Our oldest son,

7

who had been a Green Beret, Special Forces 18 medic, had decided

to come back and study medicine. And he was with one of our very

significant lead forces in Somalia, and he was terribly wounded.

I went down to Andrews, and my wife, when the Medical Evacuation (MEDEVAC) arrived at Andrews. That MEDEVAC comes in

several times a week. If you have not done that, I would ask you

to do that and to go on and see on that aircraft. The care that those

young soldiers are receiving is awesome. The Air Force does an

enormous job on that.

I recall my son said to me, he said, ‘‘Dad, they told you this flight

was 11 hours.’’ He said, ‘‘It was 13 hours for us.’’ He is a doctor.

He said, ‘‘The last two,’’ he said, ‘‘we were strapped in two hours

before flight time.’’

The care that we get from the Air Force, their efforts to alleviate

the pain of those they bring back here to this hospital is a very significant thing.

Also, I invite you to go down to Andrews sometime and meet one

of those MEDEVACs and follow them out to Walter Reed. It will

be a very rewarding experience, and they will deeply appreciate it.

And I deeply appreciate the fact that you are demonstrating your

interest in this subject.

[The prepared statement of Secretary Marsh can be found in the

Appendix on page 67.]

Dr. SNYDER. Secretary West.

STATEMENT OF HON. TOGO D. WEST, JR., FORMER SECRETARY OF THE ARMY, FORMER SECRETARY OF VETERANS

AFFAIRS, CO-CHAIR, INDEPENDENT REVIEW GROUP

Secretary WEST. Thank you, Mr. Chairman and members of the

committee, for holding this hearing, and for not just your interest

today but for your continuing interest in the care and support of

our men and women in uniform, both as they perform their duties,

whether on the training fields or in the fields of combat, and once

they have completed their duties.

It is a pleasure to appear before you, appear before this subcommittee again, and for several of you with whom I have had the

opportunity to have interaction before.

Taking up from where my distinguished colleague, Secretary

Jack Marsh, left off, that plane, of course, comes in every day at

Andrews, about mid-afternoon, 3 or 4, except on Thursdays. And it

is one of several factors that has simply lent the weight of numbers

to the problem you address as much as anything else.

The numbers who come in, the plane comes in every day, except

one, the numbers, the percentages of those who are able to be

saved, who, in the past, could not have been saved, the numbers

of those who are saved but with complicated, more complicated injuries and more injuries and more of a variety of injuries than at

any other time of war in our history.

And perhaps just as significant as anything is the number three,

that we are able to get service members back from the theater of

combat in as little as three days from the time that they suffered

their injury on the field.

As Secretary Marsh said, the bulk of those come directly to Walter Reed, others to Bethesda, because that is where the most comVerDate 22-MAR-2001 13:34 Jul 16, 2008 Jkt 037326 PO 00000 Frm 00011 Fmt 6633 Sfmt 6633 C:\DOCS\110-64\37326.TXT HNS1 PsN: HNS1
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plicated, most sophisticated medical assistance, both whether civilian or military, is available to them.

And when their time, their clinical service, their clinical time is

done, many remain there in what we call an outpatient circumstance, but what is really a kind of outpatient/inpatient. They

are held nearby right on the campus for continuing rehabilitation

and for the beginning of their process.

That is at the heart of the report that we produced and at the

heart of what you review today.

You have my written statement. I will just touch on a few things,

because much of it has already been done by Secretary Marsh, and,

that way, I won’t take up your time with prepared statements and

you can get right to questions.

I would like to say a word about what is in our report, which we

published at the completion of our review, findings and recommendations on a wide range of things which I have lumped, for

convenience, into four groupings of four questions.

First, who are we as a country, as an Army, as an Army Reed

Medical Center, a place where care is delivered?

If you consider the reports that were being carried in the paper

and the press and elsewhere about the lapses in care, we would not

have been happy with the image that was produced. Indeed, we do

say much about ourselves as a nation by the way in which we display our care and our concern for those who have given of themselves in support of this nation, especially during the most vulnerable times of their lives.

And so, included in our report are a number of findings and recommendations in how we address that, assignment and training of

case workers, increases in the numbers of case workers, adjustment

of the case worker-patient ratio, assignments of primary care physicians, and attention to the nursing shortages.

Second, what are we to become or, perhaps more accurately, and

a larger question that requires study, what is our military healthcare system to become?

In this instance, I refer to something already raised by Secretary

Marsh, but I remind you of that larger question, and that is the

impact of A–76 and the BRAC recommendation on Walter Reed.

The twin effects of those caused almost incalculable damage certainly at Walter Reed. Obviously, we have concluded in our report

that the BRAC decision should proceed for a host of reasons, but

we have expressed concern and made recommendations with respect to the coordinated efforts between the two installations and

an increase for the pace of the transition to what would be the new

Walter Reed.

Third, the question of, how are our service members doing?

There are four signature injuries of this conflict that we identify

in our report and that are routinely discussed whenever one discusses what is happening in the two theaters of conflict in Afghanistan and Iraq: traumatic brain injury (TBI), post-traumatic stress

disorder (PTSD), amputations and burns.

And it is fair to say—in fact, it is an understatement to say—

that both our health-care system for veterans and our health-care

system for active military are still wrestling and having a great

deal of trouble with addressing traumatic brain injury and postVerDate 22-MAR-2001 13:34 Jul 16, 2008 Jkt 037326 PO 00000 Frm 00012 Fmt 6633 Sfmt 6633 C:\DOCS\110-64\37326.TXT HNS1 PsN: HNS1
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traumatic stress disorder. They are challenging both in terms of

how DOD and Department of Veterans Affairs (DVA) diagnose,

evaluate and treat them.

We believe there is need for greater and better coordinated research in this area. And we have made a detailed recommendation

in our report with respect to a center of excellence and increased

attention to cooperative efforts by both Cabinet departments.

And, I might say, there is evidence that the cooperative efforts

are at least resumed, if not perhaps reinvigorated. They have been

under way for some time and may have been reinvigorated.

The fourth I call, ‘‘how long?’’ I refer to this in my formal written

statement as one of the areas on which there is the greatest

amount of unanimity on an Independent Review Group that I think

can claim quite a bit of unanimity in what we have done. And that

is what I refer to as the horrors that are inflicted on our wounded

service members and their families in the name of physical disability review processes, known at the Department of Defense as the

MEB/PEB process, must be stopped. The horrors must be stopped;

that is, the process must be significantly improved.

It is no surprise to you and it was no surprise to us that every

part of government can make sound arguments to defend and explain why three—in the case of the Army, four—separate board

proceedings, with associated paperwork demands on service members and family, accompanied by delays and economic dislocation

for family members who are assisting, and characterized primarily

by differences in standards and results, could be justified.

We are a Nation to trust the common sense of our citizens, and

that common sense would say that this is simply too complicated

a process for wounded service members and their families to be

asked to tangle with, at least without significant assistance. And

even then, we have recommended that one combined physical disability review process for both DOD and VA be the objective of

planning by this government, this executive branch and with support from you.

Thus, every finding and recommendation we have made can be

traced back to these four concerns: leadership and attitude; the

transition from Walter Reed Army Medical Center to Walter Reed

National Medical Center, as commanded by BRAC; the extraordinary use of improvised explosive devices (IED) in the current theaters and their impacts on the brains and psyches of our service

members; and, fourth, the longstanding and seemingly intractable

problem of reforming the disability review process.

Let me remind us all, Mr. Chairman and members of the subcommittee, our report was issued in April. This is now late June.

That means that the Defense Department and the Army have been

able to get a number of steps under way in response not only to

our recommendations, but the recommendations of other review

bodies which have reported since then.

Much has been done, and I anticipate that you will hear much

about that as you proceed.

Certainly, from our point of view, three factors are important.

One, Secretary Gates has made this a personal priority. He said

so when he impaneled us. He said it again when he received our

10

report. And all of the Department of Defense, especially the Department of the Army, have taken that to heart.

Second, as I referred to earlier, the Department of the Army has

stepped out smartly in ways that I expect you will be hearing

shortly.

And, third, we are not the only body that has been doing this review and that I suspect is reporting to you. You are getting a lot

of attention to a problem that is much needed.

There is so much to do, Mr. Chairman and members, and, in

many ways, we are only part of the way along the road to our improved process, an ability to provide better care for service members and families, both for their health, but also for their futures.

This they are entitled to, and this you and I and we and the Department of Defense I believe are committed to helping them find.

Thank you.

[The prepared statement of Secretary West can be found in the

Appendix on page 72.]

Dr. SNYDER. Thank you both, Secretary Marsh, Secretary West.

What we will do, we will all go on the five-minute clock, including me and Mr. Kline. Mr. McHugh had to go to the House floor.

And the five-minute clock is for our benefit. If you all have something to say, we want you to say it. Don’t be constrained by that.

I want to start.

General Jumper, I want to start with you, if I might. I figure if

I call on the people who didn’t do opening statements, it will kind

of keep you keyed up there for future questions.

One of the issues, as you know, that you have had to deal with

in your career is, we Members of Congress are always willing to

try to fix things, and the hammer that can come down can be legislation. And we are aware that sometimes legislation can get in the

way of fixes.

And so you have the situation of you can bring in good people,

outstanding leaders to correct a problem. As time goes by, it may

not get the same kind of leadership focus in the military, and

things can slide.

As you look at this issue, as somebody who has just recently been

part of this whole system, do you see this as—well, how do you

think this can be solved? Is there a need for Congress to be stepping forward in a statutory way, oversight role? Or do you think

that the military, particularly the Army, is on the right track?

How do you see this, as we are looking ahead?

General JUMPER. Well, thank you for that question, Mr. Chairman. I think that is probably the relevant question in this entire

issue.

I will tell you, sir, that there is a role for legislation here, and

I will cover that in just a second.

First, though, I would like to say that the leadership of the

United States Army, as we have just been briefed, members of the

committee were briefed this morning, has done a magnificent job

of stepping out with what I call the first part of the continuum of

care, and that is the primary care. And the inpatient care we all

know and understand well what the faults were, that included taking care of families.

11

The medical care was never in question. It is that second part,

when you get to the outpatient and the rehabilitation, that all of

a sudden that system, to the average soldier, sailor, airman or Marine going through the process, that system turned suddenly adversarial and without explanation, and that is because we introduced

this process of disability evaluation.

And this process, to the soldier who is looking up at this mountain of bureaucracy, that bureaucracy has never been tackled or

cleaned up by the policy level of our government that would be

charged to do that.

In order to do that, Mr. Chairman, is where the legislative part

of this comes in. If you go through what they call the Veterans Administration Schedule for Rating Disability (VASRD) process and

you look at how diseases are coded, you discover very quickly that

the signature diseases discussed by Secretary West are not properly coded in the reference manuals that all of our medical teams

have to refer to, and this is a matter of legislation.

So I would implore the committee, sir, to stay after this in a persistent way to make sure that the signature diseases, once they are

properly understood, are indeed coded properly and put in a way

that you can reference these things and tie them to the disability

process.

This will require the committee’s attention.

As far as the steps taken by the Army, sir, I think that you will

hear today from the United States Army a very thorough system

that has been put into place that takes care of the issues that we

had addressing the families and the soldiers that had been lost

track of and the scheduling problems. I think those have been addressed in a commendable way.

I would also, and I discussed this with General Cody this morning, I would pay special attention to watching the budget of the

United States Army. The fixes that you will hear about from General Cody later on this morning were put in out of the Army’s

budget.

These are resources that are taken from other places in the

United States Army. There will, no doubt, over time, be a call to

get those resources back, because they are not part of the health

affairs budget. So that visibility will, I think, require constant attention.

Also, the final thing is the visibility that the services, the uniformed services have over the health affairs budget in the Department of Defense has been greatly improved and I think that visibility will help get through things like the building of the new hospital and issues that were difficult when we didn’t have—the uniformed services didn’t have the visibility they should have had over

the health affairs budget. I think those things are a lot better.

So that is, I think, the great improvement, sir. There are certain

things that legislation can help with.

Dr. SNYDER. Mr. Kline, for five minutes.

Mr. KLINE. Thank you, Mr. Chairman.

I would like to take several minutes to add my praise to your

work as the chairman. We are going to miss you. We will be delighted to work with Ms. Davis when she comes in.

12

But since I am on the five-minute clock, I am going to limit that

to just that.

Thank you, gentlemen, for being here. I have a number of questions, but I am going to cut to the chase here in just a minute, beyond the comment——

Dr. SNYDER. Mr. Kline, I should have pointed out we are going

to go around at least a second round, because I know members will

have more than one set of questions.

Mr. KLINE. Thank you. Ten seconds of my five minutes.

There was a conclusion, a finding and recommendation having to

do with fatigue, compassion fatigue of the nurses at Walter Reed.

I found that to be striking.

My wife started her Army nursing career in Walter Reed, in the

amputee ward, in the Vietnam era, working on a dirty ward. And

so I am very sensitive to that issue, and I guess that is probably

better for the next panel, but I just found that surprising that this

group noticed that and picked up on that.

And so I will not ask about that now, but just to you, to this particular group, I just want to point out that I found that to be very

striking and we have a compassion fatigue on nurses working at

Walter Reed.

What I do want to ask about is this issue of the evaluation

boards. Clearly, you all agree that it is a mess. We agree that it

is a mess.

I think you put your finger right on it, General Jumper, when

you said that this is an adversarial relationship. One of the things

that we have done with legislation in Congress was worked to put

into place these wounded warrior regiments and wounded warrior

battalions, in part, because we thought it was important that our

servicemen and women, as they go through this process, had an

ally, had people that knew them and understood their situation

and would be an ally for them as they go through this process, because it ought not to be adversarial, although I understand that it

is.

We have issues of compensation that go on for years and we have

people trying to be good stewards of the taxpayers’ dollar and we

have all of those things going on. But clearly we need to fix it.

Your recommendation is we overhaul it. I know there is a temptation probably for us just to tomorrow pass legislation that says

make one system and be done with it. I would guess that there is

some peril with that and I would like to ask any one of you to address that approach.

Your recommendation is overhaul it. I am not sure what that

means. We all know it is broken.

But I would like any comment, perhaps from the command sergeant major or General Jumper, anybody, about how this advocacy

on the part of the wounded warrior battalions might be working as

you saw in Walter Reed or anywhere and if you have any specific

recommendation about what we might do to ‘‘overhaul’’ it, and we

only have about a couple of minutes left.

Major HOLLAND. Sir, thank you very much for that question.

I gather the microphone is not working.

13

And I see a lot of change in the care and the attention at Walter

Reed, and as General Cody and them will tell you later, they have

spread this throughout the entire Army.

But please understand this is a total—as General Jumper laid it

out and Secretary West laid it out, this is total care from start to

finish, whether we send them back to duty, whether we send them

to the VA, whether we send them back to civilian life.

This is long care term and, you know, our cost of going to war

needs to be this kind of medical care and, in my opinion, from what

we have seen, that part was sort of left out.

When we look at the evaluation systems, they are so convoluted,

they are so complicated, there is only most probably a handful of

folks in the military that understand it. I just retired after 37 years

and do not ask me a question about them, because I have no clue.

That is an honest assessment, sir.

And so the message is let’s keep it simple, let’s keep it right on

target. I mean, an amputee that loses a hand through an explosion

and an amputee that loses a hand from burns is coded completely

different on the regular system.

In the VA system, it is characterized completely different, also.

So I think we need to look at the total system. I think our panel,

for sure, would like to see one system. Make it simple, make it fluent, and take them from one category to the other, but we must

have a very good, easy handoff between the services and the VA.

If we do that, we can make lots of improvements in whatever and

being the NCOIM, we are going to err on the side of the service

member and their family and take care of them, because these families must care for this service member for the rest of their life.

And when you look at the wounded we have and the age groups

of the wounded, 19 to 25, you look at that, that is a long life they

are going to have. That is a lot of care that that family—that we

are putting on that family to have, sir.

Mr. KLINE. Thank you, Sergeant Major.

Secretary MARSH. Mr. Congressman, let me mention something

to you, because it can be——

Mr. KLINE. Pull your microphone in there a little bit, if you

would, please, Mr. Secretary.

Secretary MARSH. A national guardsman is different than a reservist and a reservist is different from an active duty person and

the laws relating to them can be very, very difficult in handling or

administering medical care, particularly if you let the guardsman

or reservist, after a deployment, come back and be demobilized

with some lingering medicals.

He cannot get back into the system without great difficulty. So

whatever you do, please keep those distinctions in mind.

Dr. SNYDER. Ms. Drake.

Mrs. DRAKE. Thank you, Mr. Chairman. And I am not going to

take time thanking you.

First of all, gentlemen, thank you for your work, and you did it

very quickly, and we are very anxious to have you in here today.

Mr. Marsh, you have said it repeatedly that there is a distinction

between the guard and the reserve and we talk about that a lot in

this subcommittee and one thing I learned in 2005 was the military

thought they were doing what the guard and reserve wanted by

14

getting them close to their homes, where what we heard from the

guard and reserve is they felt like they were being gotten rid of.

And I did see, in some of our materials, that there is an effort

to make sure we get them as close to home as possible. And I

would just like to ask you to make sure you ask that service member what do they want. Do they want to remain at Walter Reed or

do they want to go back to their local communities, because I was

quite surprised by that conversation in this subcommittee a couple

of years ago.

But my question is for Secretary West and I am delighted that

you are here, as a former secretary of the VA, because one of the

things that we did in 2005 that I thought was very good was additional funding so that there would be a better interaction between

DOD and VA.

Now, this year, in the Defense Authorization Bill, we have also

addressed that issue. So my question is, what is wrong? What do

we need to do differently? Is it a matter of funding? Is it a matter

of, like we were talking about, both have a set that can work together?

Can you tell us what we need to do and how we bring that

about?

Secretary WEST. Thank you, Congresswoman Drake. There are

several different elements in that, and the first is this: the issue

of medical records and of getting them from the active duty components to the VA, the sort of seamless transfer we hope for.

The money that the Congress put into the VA a few years ago

did, in fact, help the VA and it has made significant strides in putting the medical records under its control, the ones that it has for

veterans, on computers. They have taken the off of papers.

It is a paperless process now and the records can be available.

Veterans don’t have to carry them around from place to place.

That system is trying to interface with the system at DOD that

is still a bit balkanized. Each of the services has a system, the

Army has two, and those systems don’t work as well with each

other.

Now, that is not to say that somehow VA has moved out smartly

and the department has not. The Department of Defense has a

much bigger problem to be resolved and it has to do with, frankly,

getting rid of legacy systems and doing the steps and exercising the

discipline to cause each of the systems at the department to standardize and make themselves able to be interoperable.

That will go a long way toward moving across from one status

to another.

I think your other question has been, ‘‘Well, but what about the

point Mr. Kline raised,’’ and that is the disparities in the disability

review processes, the fact that VA apparently is more liberal in its

criteria than, say, the services and that one service may be more

liberal than the other.

I think those are misleading terms. I apologize for using them,

but that is the impression that is out there. The fact is that,

though I mentioned it in my comments, that everyone can make an

explanation as to why their system has to be different, there actually are reasons.

15

Each of the services has a different need as it looks to the question of who can be returned to active duty from being wounded and

who cannot. The services do that well, each one for its own people.

It is then that the determination as to the percentage of disability, if they are not being returned to active duty, that has all the

disparities. If there was something we could do, if there was something you could do, it would be if we let the services and DOD do

what they do best and what they need to do—make the determination as to who can return to the jobs they have.

Once that determination is made, force the VA to do what it was

established to do—determine the percentage of disability and how

much this nation needs to provide to each of those service members

who can no longer serve to make their lives in the future lives they

can live, lives that can be productive, and in which they can continue to be citizens who can make a contribution in their neighborhoods.

Mrs. DRAKE. Thank you for that.

And I see I have used up my time. Thank you, Mr. Chairman.

Secretary WEST. I apologize for using it up.

Mrs. DRAKE. No, no. Thank you. That is very important, and we

appreciate your straightforwardness.

Dr. SNYDER. Our little clock seems to go straight from green light

to red light today, doesn’t it, without a warning sign?

Ms. Davis, for five minutes.

Ms. DAVIS. Thank you very much, Mr. Chairman.

And, again, thank you to all of you for your commitment to this

effort.

I wanted to follow up on the issue that we have just been discussing in terms of the different services and their evaluation. Do

you believe, and for any of you to respond, are we evaluating all

of the injuries that a service member brings?

And if that is a problem, and I think it might be—I want to talk

a little bit about traumatic brain injury (TBI) and post-traumatic

stress disorder—how do we get there?

Secretary WEST. I think it is a great question, and Congressman

Schwarz is waiting on it.

Ms. DAVIS. I am delighted to hear from the congressman.

Dr. SCHWARZ. Congresswoman Davis, nice to see you again.

The injuries that have resulted from this war are different of a

magnitude great enough that they have to be treated differently

than the chairman’s and my war, Mr. Kline’s war, and the traumatic brain injury, which we called closed head injury when I was

coming up through the resident ranks, probably is, of the signature

injuries of this war, the signature injury.

Most of the injuries are from blasts. It has been estimated that

80 percent of the casualties in this war in one way or another result from blast injuries. They could be soft tissue injuries and we

are doing a fabulous job of saving people who have wounds which,

in previous wars, would have been fatal within minutes.

The non-penetrating head injuries are the ones that I think are

the greatest conundrum and they all fall under the rubric of traumatic brain injury.

You have someone who loses cognitive abilities, loses memory,

loses ability in some ways to speak logically and coherently, is unVerDate 22-MAR-2001 13:34 Jul 16, 2008 Jkt 037326 PO 00000 Frm 00019 Fmt 6633 Sfmt 6633 C:\DOCS\110-64\37326.TXT HNS1 PsN: HNS1
16

able to find their way from point A to point B, families say something is wrong, we are not quite sure what it is, sleep incessantly.

In the case of one reserve brigadier general who the panel encountered, he was found to have an IQ that—and, by the way, in

the civilian world, he is a judge—was found to have an IQ that

would be considered below normal now.

Work is being done, and I have to single out Dr. Maria

Mouratidis at the National Naval Medical Center, on improving the

cognitive skills of people who have this diagnosis. The problem is

that the diagnosis is not made quickly enough and frequently the

diagnosis is not made at all.

And in the end, when, two or three decades from now, a reassessment is done of the signature injuries of this war, I believe that

the TBI, the traumatic brain injury and all of its sequella, lasting

years and years and years, will prove to be the most serious and

the most long lasting, have the most effect on the people who suffer

from it and, from the standpoint of the Congress and the healthcare providers, be the most expensive.

So if you are going to emphasize one, just one of the signature

injuries of this war, the concept promoted by Mr. Fisher and myself

and other members of this committee that we have a center of excellence established as soon as possible to deal with people with

TBI, that would be job one, and I hope that is something not only

that this committee and the Congress says should be considered,

I truly hope it is something that you mandate.

Ms. DAVIS. Thank you. I appreciate that, and I hope you would

include PTSD with that, as well, in terms of the kind of signature

injury that we don’t see readily apparent.

I think my concern and my question, also, though, is, how do we

make certain that the boards evaluate not just one injury but a

group of injuries, several injuries at one time?

Because traditionally, as I understand it—and please correct

me—that really is what they have done. And so we have missed

a lot of the injuries that people must be compensated for as they

leave the service and as they move on to the VA system.

So is this the kind of thing that we really have to address as we

address that transition with the VA system?

And I know my time is up.

Dr. SCHWARZ. Congresswoman, my response to that is that your

premise is correct.

Ms. DAVIS. Thank you.

Dr. SNYDER. Thank you.

Ms. Shea-Porter.

Ms. SHEA-PORTER. Thank you very much, Mr. Chair. And we certainly will miss you and look forward to a productive relationship

continuing. So congratulations.

My first question is addressed to Mr. West. I am concerned, as

all of us are here, about what has happened, but I picked up on

a particular statement that reserve component members face

unique challenges in the military health-care system.

And I have a particular interest in the national guard. They are

in my state, of course, and I have heard some conversation along

those lines and I wanted to ask you to please elaborate and address

17

some of those particular concerns and what your solutions would

be.

Secretary WEST. I think you may want to hear Secretary Marsh

on that. He has devoted a lot of time to that, if I might.

Ms. SHEA-PORTER. I actually was going to ask both, but, yes, feel

free, anybody. Thank you.

Do you want me to repeat it?

Secretary WEST. Your question is to elaborate on the problems

that the guard and reserves are facing——

Ms. SHEA-PORTER. Right.

Secretary WEST [continuing]. That we have alluded to in terms

of the care that they are receiving.

A couple things. One is that, in doing our review at Walter Reed,

we came across the fact that they are actually separately organized

in the rehabilitation process. That is, once they have finished their

clinical part, the immediate part and are held there for rehabilitation and for perhaps processing, the active duty are kept in something called the medical hold. The reserve components are part of

something called the holdover.

And so from the outset of their status there, they find themselves

segregated for reasons that are not clear to them. Now, although

every process like that starts with a reason, the fact is that the

more that we looked at it and the more we observed it, it seemed

far better to treat them all as one group.

There are different rules, and that is what Secretary Marsh was

referring to earlier, in terms of how they are treated when they return to their organizations.

So there is a great concern there and we have pointed to it in

our report and our belief is, for one thing, as Secretary Marsh said,

that it is simply something that everyone has to look at more closely. There is great concern in the reserve components.

Do you want to say anything further?

Secretary MARSH. I might comment that the support structures

for the active force and for reserve components are quite different.

When a unit is mobilized, say, at Fort Bragg, the support structure

centers on Fort Bragg, the dispensary, the post exchange (PX), and

all these things.

When a reserve or guard unit is activated, that network of support does not exist like you have on an active duty force. So it must

be implemented and you must develop a separate support system

for people who live in rural areas or who are far distant from other

communities.

Frequently, wives don’t know other wives in the reserve components, but they might in the active.

I think it is an area that we need to look to generally. I am not

certain that we have fully utilized the capabilities of our reserve

components, and I will give you an example in medical care.

We are beginning to see some problems on getting qualified physicians into the guard and reserves. It is beginning to show. If we

were to waive the requirement on the age above 50, and Joe can

speak to this, and not require——

Dr. SCHWARZ. I can speak to being above 50, for sure. [Laughter.]

18

Secretary MARSH [continuing]. And not require an eight-year

commitment, we could probably fill very quickly many of the vacancies that exist today in the Reserve community medical area.

Joe, do you want to comment on that?

Dr. SCHWARZ. Yes. There is an eight-year requirement now if

someone decides to return to the military or enter the military for

medical professionals. And the estimation is, and I believe it is

probably quite correct, that there are numbers of older medical professionals who would serve and willingly and with great skill, but

they are probably not of an age where eight years is practicable,

but perhaps three years or five years would be practicable.

And I believe that some of the positions, especially guard and reserve positions, where the individual could be at home, except for

deployments, would help fill some of those vacant slots for physicians, for nurses, for physicians assistants (PA), for other medical

professionals.

So I think changing that requirement to a shorter term of duty

would be a good thing and would allow a greater number of medical professionals to participate, especially in the guard and reserve.

Ms. SHEA-PORTER. Thank you all.

Major HOLLAND. Ma’am, one additional point is the Army has

taken and gone back to having one medical hold company, so both

the guard and reserve fall into it.

All I ask everyone to think of is those guard and reserve members are on active duty until the day they are discharged. They

need to be considered that way, evaluated that way and handled

that way, and their care needs to be the same.

There need not be a priority or a stair-step system, and if we can

do that, we would make lots of strides, ma’am.

Ms. SHEA-PORTER. Thank you.

Dr. SNYDER. Thank you, Ms. Shea-Porter.

I wanted to point out the Defense Bill that passed the House

that will go to conference with the Senate when they pass the bill

gives the Secretary of Defense permission to lower that eight-year

obligation to two years, but it is at the discretion of the secretary.

Ms. Sanchez.

Ms. SANCHEZ. Thank you, Mr. Chairman.

And thank you, gentlemen, for being before us today.

In reading the report, one of the issues that came up was the

challenges that were going on because of BRAC actions, A–76 competitions and funding constraints over at Walter Reed. And I think

that all the members of the subcommittee are concerned that Walter Reed not remain, as the report described it, in a state of limbo

until the new facility is completed.

And so my question is, how confident are you that Walter Reed

will be able to run at optimal levels while the facility is, in fact,

being closed down, until we get the new facility, et cetera?

And more importantly, and this comes from a visit I made myself, as you know, if we pay money, Members of Congress can go

over for some outpatient care there. I was over there talking to one

of the doctors, being seen by a doctor and talking to her. And she

was talking about movement and how doctors are leaving and how,

for her own personal career, it probably would be better if she took

a new position somewhere else. But she didn’t want to look like she

19

was jumping ship, because there was so much poor morale among

the troops right now—the troops, meaning the people who work at

Walter Reed—not just over what had happened, but, in particular,

because so many doctors and others are choosing to leave the facility.

So the second question is, how are we going to be able to retain

the best and the brightest to serve our service members during this

time, when, just on a personal basis, people have talked to me

about it?

Secretary MARSH. I could mention several things, but I am not

sure I have the whole answer, and Dr. Schwarz or others can contribute to that.

You mentioned the competition and A–76, because Walter Reed

could not control that. They were directed to do that.

When the BRAC came out and Walter Reed began to have problems on maintenance that related to the old hospital, a memo was

directed from the Department of the Army, as I recall, that you

could not request the appropriations to improve a facility that was

being closed by BRAC.

Now, I am sure that will be changed, because that is one of the

problems. I think the way that we are going to handle the Walter

Reed thing to achieve the goals that you are talking about is going

to require, one, a commitment to build a new hospital in a timely

way and currently fund the operation at Walter Reed at full tempo

up until you come to the time that you want to close its doors.

And I think others may want to add to that.

Mr. FISHER. I have never understood how you would sell a house

before you bought a new one, and we are talking about people leaving Walter Reed because there is no future. There is no date of a

new hospital. There is no reason, no reason at all, why the second

and a new hospital is not being started right this minute.

It has been three years since the BRAC Commission came out.

Where are the plans? Where is the date of starting the new hospital? I am a developer. When I am ready to build something, we

get started on it. We are talking—I have heard dates of 2012 before

the new hospital is built. I just don’t understand this.

The reason people are leaving, they have no future. If the date

was established, this hospital is being started, maybe then the people working in the hospital know that they will leave this hospital

and go to the new one. But to leave this thing up in the air for

so long, to me, is unconscionable.

Six-hundred-thousand Americans paid to have a center for the

Intrepid in San Antonio that DOD had promised to build for four

years. American people put together $50 million and, in 14 months,

built that center for the Intrepid in San Antonio.

There is no reason why the government can’t start this new hospital now. Maybe that would alleviate a lot of the problems of people leaving and people not knowing what is going on next.

I think that is Congress’s duty, to start this process now.

Ms. SANCHEZ. Anybody else have a comment on the panel?

Dr. SCHWARZ. Yes, I do.

Ms. SANCHEZ. I see that the light is red.

Dr. SCHWARZ. I have a very short comment, if I may, Mr. Chairman.

20

I agree with Mr. Fisher. Walter Reed Army Medical Center was

built 30 years ago. Thirty years in chronological age is not much;

30 years in medical advancement is an eon. A replacement hospital

needs to be built as soon as possible.

The concept of marrying Walter Reed with the National Naval

Medical Center in Bethesda, perhaps a consummation devoutly to

be wished, but I know that there are at least two and perhaps

three members on the panel who are very aware of the differences

in culture between the Army on one side and the Navy and the Marine Corps on the other. And I believe that is the reason that

things have not progressed as rapidly as they should. And I guess

there are several others of us down here who understand that difference, as well.

So they need a new hospital. They need the new hospital yesterday. And if the Army needs simply to build a hospital on its own

for whatever that hospital might cost, perhaps $2 billion, I would

remind all that we are spending $8 billion a month in Iraq and Afghanistan right now. It does not seem to be too high a price to pay

to get going on a new hospital for 25 percent of what we pay on

a monthly basis to carry on the military activities we are involved

in overseas now.

Build the hospital, build it now, and a lot of these problems will

be solved. Otherwise, the personnel problems will go on forever and

the facility itself will continue to superannuate to the point where

it is not anything any of us will be proud of.

There is no malign intent on the part of any member of the uniformed services, especially the Army. The staff, the physicians, the

nurses, and the ancillaries at Walter Reed are the best in the

world. The trauma care, as we have noted, is the best in the world.

These people are thorough professionals, but they need a facility

and I believe that that facility should be built as soon as possible.

And I think there are quite a few people on this side who would

support me on that, although the BRAC is the BRAC and, as all

of you know, the BRAC is a pretty difficult thing to get around.

I am sorry I took so long, Mr. Chairman——

Ms. SANCHEZ. Thank you, Mr. Chairman.

Dr. SCHWARZ [continuing]. But I wanted to say that.

Ms. SANCHEZ. Thank you, Mr. Chairman, for your indulgence.

Dr. SNYDER. Mr. Murphy, for five minutes.

Mr. MURPHY. Thank you, Mr. Chairman. And we are sorry to see

you go, as well.

Gentlemen, thank you for being part of the panel.

I have made personal visits to wounded soldiers at the Malone

House, and, as you know, the Malone House helps soldiers with

their mental, medical or psychological problems.

And when I was there, I always met with soldiers that had undergone serious surgeries. And one nice young solder in particular

had one of his legs amputated—one of those signature injuries, Mr.

West, Secretary West, that you mentioned in your testimony.

He was going back under the knife for an operation on one of his

eyes—again, injuries, sir, that resulted from his service in Iraq.

And although he was in good spirits, he imparted to me that he

was dissatisfied with the level of care he was receiving.

21

And soldiers like him, as you know, are the future of our country

and of our military.

And the question I have for the panel there is, how can this Congress prioritize the Independent Review Group’s recommendations

to have the greatest impact to improve our system for such service

members?

I would like your comments on that. Thank you.

General JUMPER. Well, I will start, and I think everybody has an

opinion on that, but I think that we have heard from distinguished

members of this panel today the importance of the traumatic brain

injury as a signature injury of this conflict.

And to be able to prioritize that properly, to be able to create a

center of excellence that can go back and research the history of

this, do the case studies on those that probably date back to the

Korean War or Vietnam War, to be able to distribute and identify

the cutting-edge diagnostics as they emerge, be able to distribute

those system-wide, and then be able to come up with the cuttingedge treatments and distribute those treatments system-wide

would be a great service to this nation, and also be able to reach

back to previous conflicts for those who we all know suffer from

these diseases from the past.

That, in my mind, would be the greatest service that we could

provide.

But second and close on its heels is to be able to attack this bureaucracy associated with the evaluation business. And Mr. Kline

pointed out that we do have advocates that the United States Army

have put with each of the injured members, and they are doing a

magnificent job. But it doesn’t keep the system from being adversarial, and it doesn’t keep that soldier from being impacted moralewise, seeing this system appear to turn against him or her as they

progress through the process.

So to be able to attack this process, to be able to do one physical

examination, the data of which is acknowledged and used by all,

to be able to have a code of identifying tables within the literature

that does the best it can to categorize the TBI and the PTSD injuries, to be able to proceed with the leadership at the policy level,

to, in good faith, wrestle these bureaucratic problems to the

ground, to have the Congress give them times and dates certain for

results that wrestle these problems to the ground would be, Mr.

Chairman, sir, would be a great contribution to this nation, I believe.

Secretary MARSH. Mr. Congressman, one of the things that came

up as we began this effort was a recognition that we were only

dealing with a piece of the pie, and the piece that we had was defined specifically to Walter Reed and, to a lesser extent, to Bethesda.

I was of the view then, and I am of the view now, that some of

the things that we are discussing that apply to Walter Reed apply

to other military hospitals in the United States, and I think the

Command Sergeant Major would confirm that.

The other thing that we realize, dealing here with some mammoth bureaucracies, we cannot solve this solely in the Department

of Defense. We are dealing in an inter-Cabinet thing.

22

If you are getting into A–76, you get into a whole different field.

You are getting into OMB. But we also know there is a consideration that relates to veterans and veterans affairs and the group

that is being chaired by former Senator Dole and also Mrs. Shalala.

So that is another shoe that has to drop.

But I am telling you this is a mammoth sort of task that you are

looking at. I think the Army is seeking to address a number of

things, the military hospitals, but you would do well to inquire

what the statuses are in Fort Bragg and Fort Gordon and Fort

Lewis and other places.

Secretary WEST. I don’t want to drag this out, Congressman and

Mr. Chairman, but I have to offer an alternative viewpoint. I think

the priorities are pretty clear.

One of the things that we are helped with is that some of the

things that provoked this investigation have now been moved out

on by Department of Defense and Department of the Army.

The question of facilities is very carefully being looked at. The

question of getting some people there, the brigade and the people

who can help our service members and their families get through

the process is being acted on.

But PTSD and TBI, Walter Reed, in its new format, and the bureaucratic process for physical disability evaluation are three big

issues that need a lot of attention right now.

Each one of them is a long-range effort and a long impact, but

we have to start it. And if you ask me where we would put priorities and where the emphasis seems to be, it is right there in our

report.

Mr. MURPHY. Thanks, gentlemen.

Thank you, Chairman.

Dr. SNYDER. Ms. Boyda for five minutes. Then we will go to Mr.

Wilson.

Mrs. BOYDA. Thank you, Mr. Chairman, and thank you so much

for the leadership. We will miss you on this committee, and looking

forward to the leadership of Mrs. Davis.

I just wanted to state one thing for the record. We kind of spoke

about it a little bit earlier, but I have a guard that was just injured

this weekend, and I would just like to go on the record as saying

that his wife would certainly appreciate the ability to choose where

he and his family go.

She is going to have to pay to get herself down to Fort Bliss, and

I would just like to go on the record as saying we certainly can do

better. Give them a choice. We don’t want them to feel like they

are being pushed out. Give them some control of their lives, and

it would mean a lot. And I heard you speak about that earlier.

But I would like to just address the whole A–76 process. And I

apologize that I was a little late, so if I have, in fact, missed this

discussion, I apologize for that. But the statement was made that

the A–76 directive was really placed on Walter Reed.

Could you describe what that is and just, again, the whole A–76

process as a whole and what it is meaning certainly——

Secretary MARSH. General Jumper has probably dealt with A–76

more than any of us.

Do you want to respond to that, General?

23

Mrs. BOYDA. Its ins, its outs, its goods, its bad, are we overseeing

it? What is happening?

General JUMPER. Well, there are varied and wide opinions on A–

76. And, of course, I tell you, as a guy who came out of uniform,

I am one of the biased ones.

I think that we have over-outsourced in many ways, and the direction to over-outsource was done with criteria that probably

didn’t always work to the best interest of the people in uniform.

At Walter Reed, again, the A–76 process required outsourcing

that put certain critical functions into the hands of—it took them

out of the hands of very experienced people that were used to working with a very old infrastructure at Walter Reed and put them

into the hands of lowest bidders that cut the services, cut the number of people attending the facilities in ways——

Mrs. BOYDA. In your mind, why do you think that was done?

General JUMPER. Because of savings. You saved money by

outsourcing those——

Mrs. BOYDA. Short-term savings anyway.

General JUMPER. Yes. Well, many of us would believe it is only

short-term savings. The process of A–76 believes it is long-term

savings. But to those of us who experience it, we believe that the

savings are only short-term, if at all, and certainly not long-term.

Secretary WEST. The A–76 process is never one that an organization chooses for itself. It is almost always told by a higher headquarters or a higher authority during the budget process or the

resourcing process, as part of putting together your plan for the future, go through the A–76 process, which is simply another way of

saying, ‘‘Compute all your functions.’’ That is, compute your cost as

a government function versus the cost of contracting it out.

Mrs. BOYDA. What do you think that the A–76 process does to

morale, in addition to not knowing where the building is going to

be on a given day or just the physical timing of the move? What

does the A–76 process do on top of that for morale?

Secretary WEST. In the several positions I have had in the Department of Defense and others elsewhere, I have never seen an organization or its people welcome the onset of the A–76 process.

Mrs. BOYDA. Do you think it affects morale negatively?

Secretary WEST. I am sorry?

Mrs. BOYDA. Do you think it affects morale negatively?

Secretary WEST. Oh, surely, surely.

Mrs. BOYDA. So it is not just that it is not welcomed; it has a

negative affect on morale.

As you might guess, I am a little concerned about A–76.

Secretary WEST. I don’t want to be unfair to those who conceived

of the process. But from the point of view of one who has actually

been part of organizations going through it, it proceeds from the assumption that there is a good chance that someone other than the

people we have recruited for the government in civilian positions

could do the job just as effectively and cheaper.

It proceeds from that assumption. That is not a good morale——

Mrs. BOYDA. Do you have any recommendations to this committee as we move forward?

24

I will say that the—who are the top medical people? Surgeon

generals of all three branches basically have suggested that A–76s

may not be having a positive impact, and I will put that politely.

Do you have any recommendations for this panel as it regards

A–76 and our health-care system?

Secretary WEST. That the medical centers and the health care in

the department, those institutions, be exempted from the process.

Mrs. BOYDA. Thank you.

Dr. SNYDER. Mr. Wilson.

Secretary MARSH. A–76 is quite old. A–76 was begun in the

1960’s, and it applies to many areas of government, and there is

a lot of controversy about it.

Dr. SNYDER. Mr. Wilson, for five minutes.

Mr. WILSON. Thank you, Mr. Chairman.

And thank you, Secretary West, for being here with Secretary

Marsh, your colleagues. We appreciate your service.

I am particular happy to see my fellow Washington and Lee

(W&L) University graduate, Secretary Marsh. You are certainly a

distinguished graduate, and those of us of W&L appreciate your

service and success.

Additionally, I want you to know how honored I was to serve

with Congressman Schwarz, who is sitting right next to you. What

a fine gentleman and a great patriot for our country.

As we look at this issue—and you all have really looked out for

the soldiers and sailors and Marines of our country, and I appreciate that very much—the Defense Health Board has recommended

that a specific individual be tasked with carrying out the recommendations of the Independent Review Group.

Would you support that recommendation? And who would you

recommend within the Department of Defense be tasked to carry

out the recommendations?

Secretary WEST. Our recommendation, of course, in our report

was that the important thing was that there be some entity,

whether it was an individual or a committee, responsible directly

to the Secretary of Defense, whose position it was or responsibility

it was to monitor compliance with our recommendations and action

taken.

The Secretary of Defense informed us in our exit interview with

him that he had designated a committee consisting of senior people

to meet each week and to carry out that function.

And so, from my point of view, we thought that he had acted immediately in response to our recommendations.

Your question is about an individual, and I am going to let any

of my colleagues who want to address that speak to it. I think that

he has acted in a way which we think is responsible.

Mr. FISHER. I had originally suggested that a, for want of a better word, czar be appointed to make sure that this is the second

or third committee that has come up with these suggestions. There

is a committee following us. That is the Presidential committee.

That we have had enough investigation. We need to get it implemented.

And whether it takes a czar or a committee or whatever it takes,

it should get started right away.

25

Mr. WILSON. And then, Secretary West, could the committee, in

fact, have the function of the czar?

Secretary WEST. That is certainly I think the intent of the Secretary of Defense, and it would, we hope, be the way it would work.

Mr. WILSON. Thank you very much.

And, additionally, Secretary Marsh and Secretary West, the

Army Medical Action Plan (AMAP) appears to be a systematic approach to addressing the problems regarding the care of covering

wounded combat veterans identified at Walter Reed.

What are your thoughts on this plan? And, in particular, do you

think successful implementation of the plan will significantly improve the quality of life for recovering service members and their

families?

Secretary MARSH. I think it will be helpful.

When this effort began several months ago, we learned that the

Army, about a year ago, had begun an inspector general’s (IG) report that looked at some of the same issues that we had. It was

a very comprehensive thing.

We received a briefing this morning, and the Army is taking

steps to address the issues that are raised in our report and, also,

the issues that were raised in its own IG report.

They have not completely addressed all of them. Some of them

go beyond their capabilities to remedy, for example, the evaluations

under the disability systems.

Incidentally, there is incompatibility in the evaluation systems in

the Army, inside the Army, and there are differences between the

Army and the Department of Defense and between the Department

of Defense and the Navy and the Department of Defense and the

Air Force.

So they are not going to resolve that in that regard. One, it is

beyond their capabilities. It is going to have to be done by law, in

my view.

But I think you are going to get a report here just very shortly

that gives you a summary of the actions taken under the IG report,

which is sometimes called the Army action plan.

Mr. WILSON. And, again, I would like to thank you. I want to

thank all of you.

I have the perspective of being a veteran myself, 31 years in the

Army Guard and Reserves, and I have four sons serving in the

military, including one who is a doctor in the Navy, three in the

Army National Guard.

Thank you very much for your service.

Dr. SNYDER. Gentlemen, you have teed us up well for the second

panel.

Members may have questions for the record. If they do, I hope

you will get those back to us in a timely fashion.

I also want to give members any chance, if they have a question

that they want to ask.

Mr. Kline, anything further?

Mr. KLINE. No.

Dr. SNYDER. Ms. Drake.

Mr. Wilson.

Ms. Davis.

Ms. Shea-Porter.

26

I wanted to hold up the report. The title, I think, is great, ‘‘Rebuilding the Trust,’’ and you have the Purple Heart on here.

I just want to make one point. We sometimes make mistakes referring to wounded warriors. And, obviously, everything in here applies to people who become ill or injured through non-combat

means. We care about them all.

As somebody who got the sickest I have ever been in my life was

when I was working in a refugee camp in Sudan, I appreciate the

kinds of things that can happen overseas.

I also appreciate the comment, a couple things that didn’t come

up in the discussion, you specifically are critical of the so-called efficiency wedges and the military-to-civilian conversion amongst

medical services, which this committee has been very concerned

about. And I appreciate your calling attention to that and, also,

your vocal commitment in the report to medical research.

Secretary MARSH. Mr. Chairman, in that regard, the funding

streams inside the Department of Defense on the medical budgets

was changed and no longer comes from the service secretaries of

the three services, but has been moved up into the Department of

Defense. And it, in my view, is not as effective or as efficient, and

it needs to be reviewed.

And I am very pleased to learn that you all are going to look at

that, because it is one of the sources, in our view, or certainly in

my view, of the problems that we have on financing.

Dr. SNYDER. And the surgeon generals have been very candid

about that.

Gentlemen, we appreciate you for being here, appreciate your

service, appreciate this report, which was put together very, very

quickly. I think you did a very thorough job.

We will be in recess for about three minutes while we are changing name tags, and anybody who wants to run to the restroom can.

Thank you. Thank you, gentlemen.

[Recess.]

Dr. SNYDER. Mr. Kline and I want you to realize we are talking

about Marine Corps three minutes, not congressional three minutes. [Laughter.]

So we are about ready to start here. I am going to go ahead.

I wanted to formally welcome you all and formally introduce you

all.

I don’t know if you were able to watch this or not, but Mr.

McHugh has been called to the floor to do an amendment on the

floor. That is why he is not here with us.

We are pleased to have with us on our second panel General

Richard Cody, vice chief of staff of the Department of the Army;

Major General Gale S. Pollock, acting surgeon general for the Department of the Army; Major General Eric Schoomaker, commander, North Atlantic Regional Medical Command and Walter

Reed Army Medical Center; Brigadier General Michael Tucker,

deputy commanding general, North Atlantic Regional Medical

Command and Walter Reed Army Medical Center; and Colonel Terrence McKenrick, commander of the Warrior Transition Brigade at

the Walter Reed Army Medical Center.

General Cody, you have an opening statement.

27

Does anyone else have an opening statement you want to

present? General Pollock.

General Cody, if you would begin.

STATEMENT OF GEN. RICHARD A. CODY, VICE CHIEF OF

STAFF, DEPARTMENT OF THE ARMY, U.S. ARMY

General CODY. Thank you, Chairman, distinguished members of

the subcommittee. I appreciate this opportunity to discuss with you

our continuing efforts to improve the outpatient care and the administrative support of our wounded soldiers and their families.

In February of this year, I made a commitment to our soldiers,

our families, the American people and to you that I would personally oversee the needed fixes to the care and support we provided

our wounded soldiers. We are here today as a group to provide you,

our soldiers, the American people an update on our progress to

date on that continued way forward.

In the last several months, we have done much to improve the

outpatient care conditions and support for our warriors-in-transition and their families both at Walter Reed Army Medical Center

and across our Army. In my written statement, I describe a number of the immediate fixes we have taken, but would like to highlight two of the most critical for you now.

First, to provide the caring, purpose-driven leadership our soldiers and families deserve, we have transformed and formed up 37

warrior transition units to replace the medical hold and medical

holdover companies. Established at locations with significant warriors-in-transition populations, we are working aggressively to man

these units with the right leaders in the right numbers with the

right training down to the squad level.

Second, we have established the transition triad, consisting of

the squad leader, nurse care manager and the primary care manager, all linked with each warrior-in-transition. This triad will

work closely together to ensure the medical, the administrative,

and the outpatient support requirements of our warriors-in-transition and their families, so that we ensure a positive, timely and

fair manner of medical care.

Of the initiatives we have implemented to date, I consider these

two to be the most important and most critical. They provide the

focused leadership and personalized care that our soldiers require

to expedite their rehabilitation and return to duty or timely and

fair disposition as they work through the physical disability evaluation process.

While we have done much already, there is still much to do. Our

way ahead is captured in the Army Medical Action Plan. Several

weeks ago, I sent out a Department of the Army operations order

to all of our subordinate commands and supporting agencies directing specific actions required to address 120 issues identified in our

action plan.

This order was received and acknowledged by our three-and fourstar commanders, our assistant chiefs of staff, and our hospital

commanders. The order specifies tasks, timelines and reporting requirements to ensure full implementation and enduring implementation of our Army Medical Action Plan and to sustain the momentum we have already gained.

28

Warrior-in-transition care is truly, at its heart, an issue of leadership, from squad leader all the way up to the chief of staff and

secretary of the Army. I assure you that nothing is more important

to the Army’s leadership than ensuring quality care for our soldiers

and families, and we are fully engaged to achieving that end.

Our acting secretary, Pete Geren, and I are principal participants

in the senior oversight committee, chaired by the Deputy Secretary

of Defense, that meets weekly to coordinate the Department of Defense efforts to improve medical care processes, disability processing and transition activities with the Department of Veteran Affairs.

Over the last several months, I have chaired several video teleconferences with our hospital commanders to receive direct feedback from them on the progress and challenges they are having out

there in our medical treatment facilities. These monthly video teleconferences have proven crucial to developing and disseminating

and implementing the Army Medical Action Plan and have been invaluable to focusing and synchronizing our efforts across the Army.

Our senior mission commanders, our two-star and three-star

commanders of our posts, camps and stations participated during

the most recent teleconference and provided their respective insights as to how we are doing in taking care of their soldiers.

I can’t emphasize enough how important the care of our soldiers

and our families are to this Army, an all-volunteer force that is

making incredible sacrifices every day during this time of war.

Our nation could not ask our soldiers and their families to make

these sacrifices and not ensure that their medical care and overall

quality of life is at least equal to the quality of their service and

their sacrifice. We cannot ask our soldiers to ensure the rigors of

combat and then endure an under-resourced or bureaucratic system when they come home.

This Army is many things, but ultimately it is about people and

it is about our soldiers. The entire Army leadership is committed

to getting this right for them and their families.

And I look forward to your questions.

[The prepared statement of General Cody can be found in the

Appendix on page 76.]

Dr. SNYDER. General Pollock, we will go to you.

And then, General Schoomaker, you have an opening statement

also.

General Pollock, for as long as you need.

STATEMENT OF MAJ. GEN. GALE S. POLLOCK, ACTING

SURGEON GENERAL, DEPARTMENT OF THE ARMY, U.S. ARMY

General POLLOCK. Mr. Chairman and distinguished members of

the subcommittee, thank you for the opportunity to update you on

the Walter Reed Army Medical Center and the noteworthy achievements of the Army Medical Action Plan.

In the last four months, the Army and the Army Medical Department have taken significant actions improving the management

and care of soldiers in an outpatient status. We are committed to

getting this right and providing a level of care and support to our

warriors and their families equal to the quality of their service.

29

As you have heard, the Vice Chief of Staff, General Cody, the G–

1, Lieutenant General Rochelle, and the commander-Installation

Management Command, Lieutenant General Wilson, have been

personally invested in finding solutions.

Shortly after publication of the media reports, General Cody

reached out to the Armor School at Fort Knox and tapped Brigadier General Mike Tucker to be our bureaucracy buster and to

serve as the deputy commanding general of North Atlantic Regional Medical Command.

We have put Mike in charge of the Army Medical Action Plan,

the AMAP, and he has been diligently pursuing a comprehensive

plan to improve outpatient management at Walter Reed and across

our Army.

At the same time, Medical Command (MEDCOM) established a

tiger team composed of ten subject-matter experts, led by Colonel

Ben DeKoning, and charged them to determine if any of our other

medical facilities were experiencing issues similar to those at Walter Reed.

This multidisciplinary team spent a month on the road visiting

11 different installations, inspecting soldier welfare, infrastructure

quality, medical administrative processes, and soldier and family

information sharing.

The team identified some concerns similar to those at Walter

Reed, but also found best practices that could be shared across the

Army Medical Command. The tiger team’s findings and recommendations became one of nine different source documents used

by the AMAP team to develop a detailed and comprehensive action

plan.

In its 90 days of existence, the AMAP team conducted an initial

analysis, developed lines of operations, codified the requirements,

conducted personal reconnaissance and assessments, hosted a synchronization conference, and established a bevy of quick wins,

short-range goals, and long-term goals.

Although the team has ‘‘medical’’ in its title, its composition and

focus is much broader. Permanent team members came from Manpower and Reserve Affairs, the Installation Management Command, the Army G–1, the Army G–3, and Medical Command.

Other participants include the Army Corps of Engineers, the

TRICARE Management Activity, Veterans Affairs, and other Federal agencies.

The team has already provided several updates to Acting Secretary Geren and received clear senior Army direction and leadership. Everyone is working toward the same goal, and we are all

working with urgency.

The AMAP succeeded in meeting all of its quick wins, many of

which I detail in my written testimony. I would like to highlight

and elaborate on just two of them now.

We have been very focused on family support. As we analyze

each aspect of the soldier support, we ask ourselves, ‘‘But what

about the family?’’

First, we heard concerns about how loved ones were supported

upon arrival at the airport. In response to those concerns, we implemented a program of family escorts whose mission is to greet

the families at the airport, transport them to the hospital, and

30

bring them to the soldier family assistance center. There they meet

with counselors or chaplains and relax a bit before they go to the

ward to see their loved one for the first time.

It sounds like a simple thing, but to pull it off required some serious bureaucracy-busting. It is absolutely the right thing to do,

and the families deserve this special treatment.

Another quick win that seems rather simple but that we expect

to be of enormous benefit to our families is the trained ombudsmen

we have assigned to each facility.

Although all of our facilities have had patient representatives for

years, they were seen by some of the stakeholders as inadequate.

We evaluated and agreed it was time for a transformation.

We combined the ombudsman with a patient representative, developing an empowered patient advocacy office with a direct line to

the hospital commander and to me. They no longer sit in their offices waiting for a distressed person to find them. They are required to get out and meet every warrior-in-transition and

proactively engage family members. They are further charged as

local bureaucracy busters to implement immediate fixes and work

every problem through to resolution.

We will maintain a central database of their case work so we can

spot trends early and take responsive action. Patient advocacy will

not be a buzzword in the Army Medical Command. It is a required

mindset and an ever-present attitude. We are here for our patients.

I want to ensure the Congress that the Army Medical Department (AMED) places high priority on caring for these warriors-intransition and their families. I am proud of the AMED’s efforts

over the last four months, and I am convinced that, in addition to

our quick wins, we are setting the stage for long-term solutions

that will significantly enhance the rehabilitative care and support

of our warriors and their families.

Thank you for allowing me to be present at the hearing, and

thank you for your continued interest and support of the warriors

and families that we in the Army Medical Department are honored

to serve.

I look forward to your questions.

[The prepared statement of General Pollock can be found in the

Appendix on page 81.]

Dr. SNYDER. Thank you, General Pollock.

And this committee likes having Schoomakers around. So, General Schoomaker, go ahead.

STATEMENT OF MAJ. GEN. ERIC B. SCHOOMAKER, COMMANDER, NORTH ATLANTIC REGIONAL MEDICAL COMMAND

AND WALTER REED ARMY MEDICAL CENTER, U.S. ARMY

General SCHOOMAKER. Thank you, sir.

Mr. Chairman, distinguished members of the subcommittee,

thank you for this opportunity to address the committee. I am

speaking today as the commanding general of the North Atlantic

Regional Medical Command (NARMC), commander of eight hospitals and eight clinics in the North Atlantic, to include our premier medical center in the North Atlantic, Walter Reed Army Medical Center.

31

Approximately three months ago, my command sergeant major

and I stepped into what you have heard described as a perfect

storm that had affected Walter Reed and really all of Army medicine in the Army. My arrival really was the one part of a very aggressive plan on the part of the Army and the Army Medical Department to track that storm and to wrestle it to the ground.

Since that time, we have been unremitting with the incredible

support of the Army, the Department of Defense and this Congress

to solve those problems. We have used Walter Reed and its campus

to harvest problems really and to seek across the Army solutions

and best practices and, where those weren’t available, to create

new solutions with the leadership and assistance, of course, of my

deputy commanding general, Mike Tucker, our bureaucracy buster

that you have heard described by General Pollock.

Rather than to enumerate all of what is written in my statement,

I will just highlight a few things that we have worked on.

First of all, almost immediately we moved all of the patients that

were in Building 18 out of Building 18. No patients have been put

back in Building 18. I dare say we might not have any other patients, soldiers or civilians in Building 18 until the campus is

BRAC’ed and we turn the facility over.

We have roofed the Building 18 so that our equity is conserved,

but we have elected not to use that as a domiciliary or administrative building.

Second of all, as you have heard General Pollock describe, we

have a plan of receiving families at the airport. So just as we receive their warrior, sons, daughters, husbands, wives, grandchildren, through the Air Force’s assistance at Andrews, we receive

them and bring them to Walter Reed.

We have a program of sending letters to each of the units that

these warriors have left back behind. There is a hole left, literally

and figuratively, in that warfighting unit and those commanders

and first sergeants. And the squad leaders and squad members lose

track of where these soldiers are, and they need some sense that

the system is working for them and that their teammate, their

comrade has not been lost.

And so Colonel Terry McKenrick and his staff in the Warrior

Transition Brigade have already started with the outpatient group,

and we are moving toward the inpatient population, as well, to immediately alert the unit to where their soldier is.

We have created the Warrior Transition Brigade. This is the

commander of the first Warrior Transition Brigade at Walter Reed,

Colonel Terry McKenrick, a combat veteran. And he has done a superb job with his command sergeant major, Jeff Hartless, in standing up that brigade and really breaking down all the boundaries

between med hold, med holdover and building that triad that you

have heard described by the vice and the acting surgeon general.

We have many other things—ombudsmen, patient advocacy, the

creation of a soldier and family assistance center in the hospital—

that will be duplicated across the Army.

Let me focus this on one soldier, though, that some of you have

heard about before, a soldier that was featured in an article on the

sixth of April, when he wrote about the problems that he had. And

I raise him because we have used soldiers like him and others to

32

go back and ask the question today: If we had what we have going

now, would we have the problems or would they have encountered

the problems that they encountered then?

This soldier was a mobilized national guardsman from Mississippi, a great kid, slow-talking, plain-speaking Mississippian

who joined the Army because he wanted to do something meaningful with his life, became a military police (MP), was deployed.

On one of his trips on the main supply route (MSR) into Baghdad, he was hit by an improvised explosive device (IED). It took the

legs off his driver. He was in the turret as a gunner. He was

knocked back. It broke his leg, the upper thigh. He also had a laceration of one of the major arteries in an arm, and he had a traumatic brain injury, a mild form of traumatic brain injury.

He complained about the problems, not with his care—his care

was excellent, and, as many of our patients, and you have heard

from families and service members alike, the care he received in

the hospital was excellent. He got a rod put in his leg. He got a

repair to his arm.

But what he had problems with is when he transitioned to the

outpatient arena in a facility on a campus that has no primary

care, no robust care for folks like that.

And we now have the Warrior Transition Brigade, with a squad

leader, primary care manager and nurse case manager.

He had problems with a wheelchair. He had a mechanical wheelchair, with a broken leg and a bum arm, and we gave him a mechanical wheelchair. I am embarrassed. I was humiliated, talking

to this soldier with my sergeant major, about how we could have

done something like that. But we didn’t have squad leaders who

could look out for the soldiers. We didn’t have a case manager who

would have identified a big hole in our plan for that soldier.

He complained about the fact that he had mild traumatic brain

injury, and so he was putting Post-It notes all over his room in the

Malone House, a great place to live. And he was well-supported,

but he didn’t have a mother with him. His mom, a nurse, was down

in Mississippi taking care of a husband who was dying of Lou

Gehrig’s disease. So he was alone in a room, with mild traumatic

brain injury.

We now have a squad leader and a case manager and primary

care manager who tracks our soldiers and who is going to be able

to keep up with their problems, and a primary care manager who

is going to be trained in managing mild traumatic brain injury. So

we are not going to have problems unrecognized and untreated.

And he had problems with the personnel system. How could he

get promoted? How could he get an invitational travel for his mom

to come and visit when she could? Again, we have a soldier and

family assistance center in the hospital that handles all of those

issues, a one-stop shop that is focused on the soldier.

So I like to believe that we have solved his problems. And, frankly, Colonel McKenrick and his people have identified problems that

we never knew existed.

A soldier who has a large number of boxes and baggage that he

has to get back home, who is going to pay for his own shipment

of goods back home? His squad leader jumps on it, figures out a

way to get the Army to pick that up appropriately, and the soldier

33

is on the plane and his boxes aren’t, and you don’t hear about it,

and we don’t have a disgruntled soldier and family on our hands.

You know, 107 years ago today, an Army major physician named

Walter Reed started his experiments in Cuba, the 26th of June,

1900, to find the cause and transmission of Yellow Fever. His studies, which are landmark studies, changed the face of America and

changed the face of global health.

His name is associated with military health care of the highest

order and caring for soldiers and the world population. We feel

very strongly that we are restoring his name to the place it should

be in history and that we are here to restore the confidence of the

American people, the Army, and you in what we are doing at Walter Reed.

Thanks, sir, for the opportunity to speak today.

[The prepared statement of General Schoomaker can be found in

the Appendix on page 91.]

Dr. SNYDER. Thank you all for being here.

General Cody, we will start with you, but I would like to just

briefly go to each one of your team there. You five people are remarkable folks. You have risen to high levels of leadership within

the Army. But like all good people in the military, somebody is

going to replace you at some point and you will be moving on.

And one of the concerns we have is what is being built into this

system, that, one or two or three years from now, your successors

won’t somehow be lured off to other topics and that the concerns

that you are dealing with, very energetically dealing with, may not

be the same focus of those that come after you.

What are you all and what are your successors going to be following to be sure that we don’t repeat some of the problems that

you all are correcting?

If we could start with you, General Cody, then I would just like

to hear from each of the four people.

General CODY. Thank you, Chairman. That is a great question

and one that, when I started this, you know, my expertise is not

in this area, but I learn pretty quick.

When we looked at this, that was the first thing that the Secretary and I discussed, as well as when I brought Eric Schoomaker

in and Gale Pollock. We all sat down.

The one question—we knew how to fix it very fast, some of these

things, but our real concern was, how do we make this stick and

how do we make it enduring? Because we believe that, one, it is

the right thing to do, but more importantly, we are going to be with

this all-volunteer force—I believe we are going to be in a prolonged

struggle for some time.

That is why we did an executive order and an operations order.

I can’t remember when we have ever sent out a headquarters Department of the Army operations order. It has been a long time. I

will go back and find out when. In fact, we can give you one for

the record.

But in doing that, and it was signed by a four-star, this thing

becomes a requirement for all our two-star generals, our three-star,

our four-star generals, the Department of the Army staff, and it is

enduring and it lays out the plan.

34

The second piece of it—and so as the G–1 changes out, he still

has to comply with this. As the new vice chief comes in or a new

commanding general at Eisenhower or some other place, this thing,

with 120 of the tasks and purpose, is very directive in nature.

The second piece—and you know this oh-so-well—if you don’t put

money against it, it doesn’t become enduring. And so, as we laid

this out, some of the money clearly up front has been done with

global war on terror (GWOT) supplemental dollars. But in the

2009–2013 Program Objective Memo (POM), we are putting in an

average—and I have to look on my cards so I get it right for the

record—an average of $370 million each year in the 2009–2013

POM.

And this will cover the things at different installations that we

build up for the warrior transition units, the operations tempo

(OPTEMPO) dollars required, the operations & maintenance Army

(OMA) dollars required, to cover the salaries of the behavioral people that we are contracting out for, as well as to take care of the

operations of these warrior-in-transition units and the additional

piece that the Army is providing for our hospitals and our garrisons.

In part of that is $168 million right now that we need to do in

military construction to become Americans with Disabilities Act

(ADA)-compliant for the warrior-in-transition barracks, as well as

some other construction that we need to put in.

So that has been our way, Chairman, to make sure that this becomes enduring.

The last thing I will say is the warrior-in-transition units have

been documented in the Army’s personnel structure. And so we

have a brigade at Walter Reed. Most of the other warrior-in-transition units are battalion level and then in the smaller posts, camps

and stations, they are company level. But they are now in our personnel documents and in our Army unit documentation. And so,

that is another way of doing it to make sure it is enduring.

Dr. SNYDER. Does anyone else have any comment on that issue?

General Tucker or General Pollock?

General POLLOCK. Yes, please.

Dr. SNYDER. General Pollock.

General POLLOCK. I think that it is very, very important to the

Army Medical Department to get this right and to sustain it because of the concerns that we have for setting the bar for the nation, particularly in rehabilitative care.

Because what we are dealing with now is something that the rest

of the Nation has never needed to. And should we have to deal

with any kind of large terrorist events in the United States, the

same struggles that we had at Walter Reed could be repeated anywhere in the country. So if we have figured out the best way to

manage these men and women and their families, we will be able

to serve as a resource for the nation.

The other reason that I believe that we will sustain the focus on

this is the morale of the Army Medical Department was very badly

affected by all of this media presentation and the awareness that

we had let a single soldier down.

We can’t recruit and retain if we are not proud of what we do.

So it is absolutely essential that we recover from this so that we

35

can continue to do what we have an obligation to do in support of

the warfighter.

So there is no question, in my mind, that the professionals that

I work with in the Army Medical Department want to have this

corrected for the long term.

Dr. SNYDER. Any comment, General Tucker?

General TUCKER. Sir, I will just say that at my level in the Army

Medical Action Plan, I do a lot of fixing out there in terms of people

who have been subjected to the former system. And every time we

fix and we do that very quickly, we automatically go into, was that

a problem of policy, was it a problem of regulation or law, because

we need to fix that so we don’t have this gap that someone else

could fall into.

So I think that is part of the bridging strategy, as well, sir, to

sustain.

Dr. SNYDER. General Schoomaker.

Colonel McKenrick.

General SCHOOMAKER. I think Colonel McKenrick would like to

describe some of the things that we are doing in the way of developing doctrine that is going to be a part of the Army and enduring

legacy of this work.

Dr. SNYDER. Go ahead, Colonel.

Colonel MCKENRICK. Sir, one of the initial charters from General

Cody was for us to not only stand up this new organization and brigade here at Walter Reed, which would be the pilot across the

Army, but also to write the doctrine, what we do, what our mission

is, the tasks that we have to accomplish on a daily basis for the

squad leader, the case manager, and then to describe in detail how

we do that, put those systems, those procedures in a document.

We have just finished that. Today we are hosting a warrior transition unit conference for 150 warrior transition unit commanders.

First sergeants, battalion commanders, command sergeants major

from across the Army are here at Walter Reed, and we are running

them through two days of training on those systems and procedures, talking to them about PTSD, TBI, much of the training that

we did for our own cadre over the last three months.

Now, those are the kind of things make this system enduring.

The TDA, the table of distribution and allowances, the manning

document that General Cody referred to, for us, is an enduring document. It requires that we have four companies’ worth of troops on

the document. We are only manned and authorized for manning for

three of those companies. That gives us the flexibility to increase

capacity for our cadre if that is required. And, of course, our goal

is that, before I leave command, to be able to deactivate, to be able

to take that down to two companies.

But that table of distribution and allowances, that doctrine, those

are the enduring systems that we have in place for Walter Reed

and for across the Army.

Dr. SNYDER. Mr. Kline, for five minutes.

Mr. KLINE. Thank you, Mr. Chairman.

Thank you, gentlemen and lady, for being here today.

Speaking to the morale of the personnel at Walter Reed, that

was immediately raised to me as a concern when the Building 18

issue came up. And I really hated that that happened, because noVerDate 22-MAR-2001 13:34 Jul 16, 2008 Jkt 037326 PO 00000 Frm 00039 Fmt 6633 Sfmt 6633 C:\DOCS\110-64\37326.TXT HNS1 PsN: HNS1
36

where in this process has anyone really questioned the extraordinary professionalism and care that those professionals, doctors

and nurses and medics and technicians have provided to the soldiers at Walter Reed, and not only the soldiers, the active-duty soldiers, but some of my close friends. I am at the age now where a

lot of my retiree friends are going to Walter Reed for care and getting outstanding care.

And so I think it is important that we remind ourselves and

those professionals at Walter Reed that they really are world-class

and some would say the best in the world.

The issue has been around transition, evaluation boards, outpatient and all of those sorts of things. And so I have a question,

and I think it is going to be for Colonel McKenrick maybe more,

because I am a little bit confused.

I am very anxious that we do this right, but I have listened to

the testimony and I have heard words like triad, soldier and family

transition office, trained, ombudsmen, patient representatives, advocacy office, a care manager, a Warrior Transition Brigade with

subordinate warrior transition units. And I am trying to decide or

understand what fits where.

What, Colonel, or to anybody who wants to answer, what is the

relation of all of this stuff that I just listed? It all sounds important

and sounds like it is taking care of soldiers, but is it all coordinated? Is it all you, Colonel? What is that?

Colonel MCKENRICK. Sir, I will take the first stab at that, and

what I don’t answer I am sure someone else will help me out with.

It is a coordinated effort, and it starts with that triad of warrior

support: the squad leader, the case manager, the primary care physician. Those three individuals form a network that take care of

that warrior, their family, any of the needs that they have.

In addition to those are a variety of other systems at Walter

Reed, around the Army.

Mr. KLINE. Excuse me. Hang onto that thought.

They do not all work for the Warrior Transition Brigade, though,

right? You have a physician, he is doing something, and you have—

who is in charge?

Colonel MCKENRICK. Sir, I am in charge, but in my brigade,

down in my company, I will have a company commander. In his

company, he will have 12 case managers taking care of his 200

warriors. He will have 18 squad leaders and 6 platoon sergeants

all taking care of those warriors. And then he will also have a primary care physician that is part of our warrior care clinic.

So you have got that teamwork down at the company level, and

that will be throughout the Army, where you have the primary

care physician, the doctor, working with the nurse case manager,

working with the squad leader, all there to make sure that this soldier, whatever problems they have, they get to their appointments,

the care plan is set, everybody understands the warrior, the family

member understands that care plan, have a say in it, a vote in it,

and we help them through the process.

Mr. KLINE. That sounds good. Do they all work for one person?

Colonel MCKENRICK. Sir, at the company level, those case managers work for the company commander. The squad leaders——

37

Mr. KLINE. And the physician and the nurses, they work for

somebody else.

Colonel MCKENRICK. Sir, they are all in my brigade. They all

work for me. Ultimately, they work for me. But down at the company level, that doctor is working for that company commander. All

those warriors in that company, that doctor is there to take care

of them.

Mr. KLINE. Super. And so the advocacy for the patient, for the

wounded warrior, comes through you.

Colonel MCKENRICK. Yes, sir.

Mr. KLINE. If the wounded warrior now enters this morass that

we discussed with the previous panel of evaluation boards, are you

the advocate or your organization the advocate?

What was described in the last panel and which we have heard

a lot about and I think all of you are very familiar with is you have

an adversarial relationship between the soldier and the evaluators

in this board process. And we don’t want that soldier, Marine, airman, sailor to be out there sort of adrift and feel like the system

is working against him.

So it has been my belief that we ought to have a Warrior Transition Brigade, or the Marines call it a wounded warrior regiment,

or somebody who understands that soldier and is the advocate and

who the soldier knows is their advocate. So when they run up

against a problem, they are turning to somebody.

Is that you?

Colonel MCKENRICK. Yes, sir, that is us. That is our brigade.

When the warrior first comes in the hospital and is an inpatient,

that squad leader and case manager go over and introduce themselves. Now, they have a social worker and they have doctors and

nurses taking care of them in the hospital, but our cadre come over

and introduce themselves.

When they become an outpatient, that squad leader is interacting daily with that warrior and their family. The case manager is

meeting them at least weekly to review their care plan. The doctor

is seeing them for all their needs, referring them to specialists.

When that warrior is going through rehab treatment, that squad

leader is going up there with them to their appointments, motivating them through their rehab.

When that warrior goes to the review board, their medical evaluation board or their physical evaluation board, that squad leader

goes there with them and talks to them, understands their issues

and concerns. And that squad leader’s job is to answer all their

questions; if they can’t answer them, to go find the answer and

bring that back to them.

The same with the family, to help them understand all the

issues, understand all the questions, and be able to answer everything.

General SCHOOMAKER. I would say, sir, that you have identified

one of the problems we have had all along, which is these are fundamentally, in the private sector, what you would call, or the academic sector, what you would call multidisciplinary teams, and we

would call them combined arms teams in our business.

But we are trying to exercise unity of command and control

whenever possible to ensure that the soldier, warrior and his famVerDate 22-MAR-2001 13:34 Jul 16, 2008 Jkt 037326 PO 00000 Frm 00041 Fmt 6633 Sfmt 6633 C:\DOCS\110-64\37326.TXT HNS1 PsN: HNS1
38

ily, his or her family, are under the care of an accountable commander.

And when those teams are multiple in number that have to

interact with an individual patient—I mean, you are going to have

physicians and occupational therapists and physical therapists, you

are going to have a psychiatrist, psychologist—those department

chiefs who supervise those individual practitioners all fall under

the hospital commander, and that hospital commander falls under

me.

So ultimately there is unity of command that is going to pull all

these together. And what we focus upon is what the individual

warrior-in-transition requires.

Mr. KLINE. Thank you.

Thank you, Mr. Chairman.

Dr. SNYDER. Ms. Drake, for five minutes.

Mrs. DRAKE. Thank you, Mr. Chairman.

First of all, thank you all for being here, and it is quite impressive what you have just described.

And I have got two questions, but, first, I want to comment. Kind

of maybe a model is what we hear in Special Ops with Navy

SEALS, how they assign someone to stay with that person for their

team member. And yours is kind of a little different process, but

probably along the same thoughts.

But from listening to what you have just described to Congressman Kline, my first question would be, do we have the resources

and the manpower to do what you are talking about? Do you need

more from us? Do you need more from DOD? And how we are going

to do all of this?

And then, second, for you, General Cody, is there built into all

of this a feedback mechanism so someone at your level, at the fourstar level, would know if there is a problem, that our soldiers

would be willing to go up that chain of command somehow and let

you know there is a problem?

Because typically we see our military members don’t want to

complain, it is not part of who they are. And so I want to make

sure there is a feedback mechanism, how that would work not only

for the military member, but also for their families, because often

they are the ones that see that something is going on and they

don’t know how to get that information to you.

So the two questions on the feedback and on do we have the resources and the manpower to do what you have just described.

General CODY. Thank you for those questions, because I think it

is important for us to discuss them.

First, on the resources, this Congress and Office of the Secretary

of Defense (OSD) has allowed the Army now to, after the temporary growth of 30,000, to make it a permanent growth of 65,000

to the active-duty force.

I am taking some of that 65,000 and redirecting it. We were taking at a high prior to it and over 2,000 personnel spaces. The other

piece of the resourcing—and that is just for these warrior-in-transition units and I believe they are enduring.

You heard Colonel McKenrick say that we have got them on the

tables of distribution and allowances, and that means we can resource to it. When we don’t have to resource to it based upon deVerDate 22-MAR-2001 13:34 Jul 16, 2008 Jkt 037326 PO 00000 Frm 00042 Fmt 6633 Sfmt 6633 C:\DOCS\110-64\37326.TXT HNS1 PsN: HNS1
39

mand at different places, we can ratchet it back. But we always

have the authorization document, which means that we put on the

personnel system that requirement. So we have enough resources

now with the 65,000 Army to be able to do that.

The resources in terms of the operational maintenance dollars

and the Military Personnel (MILPER) dollars we are doing with

GWOT dollars this year and next year and I am putting it into the

budget as we build the 2009–2013 program. And I believe that,

one, with the help of Congress and OSD, we will be able to put that

much money in. It is about $368 million to $370 million a year to

be able to run at the level we are operating at right now, with

about 5,000 warriors-in-transition across our Army on any given

day.

So I believe that we have got the right resources right now, and

I am watching it closely.

Now, the feedback mechanism is one that we have established

with the executive order that we sent out from the Department of

the Army, with the tasks that I have given to the Department of

the Army IG to go back and to look at everything that the panel

before you went out and looked at, as well as what we are executing here.

They have scheduled looks. The medical community have their

scheduled looks. But at the same time, we have put in these soldier

and family hotlines, 1–800 number, and we get—those command

24/7, being manned, and that is part of the resourcing that we did.

And so we are getting feedback there.

We also are training ombudsmen so that they can bring forward

those issues to us.

But I firmly believe that the best feedback we are going to get

is the investment we are making in the training of the squad leaders, platoon sergeants and these company commanders and first

sergeants who are part of that triad of care with the case manager,

and that is where we are going to get the feedback.

And I am convinced that with the right training that we are putting in right now, the selection process of who we are putting in

these warrior-in-transition units to take care of these soldiers, that

is where we are going to get most of our feedback from.

Mrs. DRAKE. Thank you very much.

Thank you, Mr. Chairman. I yield back.

Dr. SNYDER. Ms. Davis.

Ms. DAVIS. Thank you, Mr. Chairman.

And thank you all very much for tackling what are some very

difficult issues, and we appreciate that.

I wanted to go a little further along with the combat support

arms personnel that you are working with. And my first question

really was, when I had a better understanding of how this triad

was coming together, is there something that is not being done, because these folks are being recruited and actively involved in this

way?

What roles were they performing before and how do you recruit

them? Some criticism might be that, in that position, they might

not be as sympathetic perhaps as someone might be. And how does

the culture that they bring with them from the military, how does

that interface with the hospital culture?

40

General POLLOCK. I will take that for starters, because we tasked

from across the Army Medical Department to bring in nurse case

managers to Walter Reed, which did cause us to abruptly take

nurses out of other facilities. So we have been doing local hires

there, and we are looking at how we need to assign.

So the fact that we brought medical/surgical (MED/SURG)

nurses in from other facilities, they were accustomed to dealing

with patients and their families. They know how to coordinate all

of those pieces.

But it is a challenge for us because we do have a shortage of

nurses in the Army nurse corps, and so when you need to move

them, you have second-and third-order effects on other places.

We are actively recruiting, but with the national nursing shortage, we aren’t always able to rapidly fill.

Ms. DAVIS. I appreciate that, and that is a great concern, because

we know that that is true in the general sector, as well.

How is that working?

Colonel MCKENRICK. Ma’am, I will add to the portion that deals

with our cadre. They have come in to be the squad leaders and platoon sergeants. Many of them are combat veterans. Most of them

have led in combat. They are used to taking care of soldiers, taking

care of their fellow comrades. They are honored to be selected for

this mission to take care of our fallen comrades.

They have all been through training that we conducted when

they first came on board that taught them how to deal with TBI

and PTSD and the medications that the warriors are on.

They are used to training their soldiers to high standards of performance in preparation for combat. They have changed that focus

for this mission to take care at the highest standards of care for

their warriors and their family members.

So it is the same energy, the same high level of professionalism

and competence, but directed in a different way toward taking care

of those warriors and all their needs.

Ms. DAVIS. And they are tapped to do this. Is there a call for volunteers, essentially, among the group of people that would be eligible?

Colonel MCKENRICK. I don’t think that most of our cadre were—

they were assigned this duty, but if you had asked them if they

could volunteer for this duty, they would have. It is an honorable

mission.

Like I said, most of them have been deployed and they enjoy the

opportunity to provide energy and effort into taking care of those

who desperately need their help.

General SCHOOMAKER. Let me put a very resounding exclamation

point on what Colonel McKenrick is saying.

Physicians and nurses and administrators in the hospital business do not have a corner on the market of caring for soldiers. It

starts with the young non-commissioned officer (NCO) who is caring for his or her soldiers and the officer corps that cares for them,

as well.

And I am very impressed with what this Warrior Transition Brigade has brought to us and how they have applied their NCO and

soldier-leading skills to this task. It is part of the warrior ethos

41

that we not leave a fallen comrade, and that is very clear in Walter

Reed today.

In fact, this might be the best place to insert this. It derives from

what Congressman Kline said, as well. You list all the people who

now are lined up to give support to these warriors-in-transition. I

have now the concern that we have too many folks, all, in many

respects, beginning to take responsibility and accountability for

things across all these disciplines.

I would make the very strong plea that we not be micromanaged

on the individual ratios of folks, so that we have some latitude to

take experiences and take lessons learned from this new enterprise

and apply them logically.

Ms. DAVIS. I know you certainly recognize the perfect storm that

our last panel talked about. Just very quickly, and you can perhaps

answer this at another time, do you think that we are truly prepared for that next perfect storm as we see large deployments coming back, perhaps not with physical injuries so much but certainly

with mental health issues and TBI? Do we have that transition in

place?

General CODY. I think we do from a leadership aspect. The medical piece, I think that there is work to be done research-wise on

PTSD and TBI. And we are aggressively moving forward, and with

the help of Congress, with the inject of the money for TBI research

and PTSD, it is very helpful.

We are going out and chain-teaching right now in the whole

Army, starting in July, how to look at PTSD and TBI. It was started with our AMED and with our other experts. We have got it vetted now.

And, again, reinforcing what General Schoomaker said, this is

about first sergeants and company commanders teaching their

leadership and their soldiers what to look for in terms of the

stressors of combat, how to take care of each other, how to recognize whether you have the symptoms of PTSD or TBI, and educating our force.

We are also going to take it to the family members.

So if we don’t do that, I think there is a real part of the perfect

storm that we would have to catch up on very quickly. So we are

moving out on that in July.

The further piece about will we have enough case managers and

enough behavioral clinicians and some of the other people that are

my doctors on my left and right are worried about hiring, because

there is a national shortage of them, I think it is something that

we are all going to have to work toward.

And I would defer to General Pollock and General Schoomaker

to talk to you about that piece.

General SCHOOMAKER. Well, I would just say real quickly I think

that one of—I can’t answer your question, because I don’t have that

crystal ball. I will tell you, as General Pollock has alluded to and

General Tucker and the Vice, that we are putting in place processes that will be there, that will be enduring and that are addressing the right questions and the right needs once they do arise.

One important one that we haven’t talked about, but the first

panel did, was our interagency handoffs between the DOD and the

VA, for example. We have a very large capacity in this nation to

42

respond to health threats and health requirements. And I think

one thing that we are beginning to do far better than we have ever

done in my career in the Army is to begin this discussion in battle

handoff with the VA and with other elements of the private sector,

for example, in rehabilitative medicine.

Those are the things that we need to do, and do far better than

we have done historically, and I think those processes are being established.

Dr. SNYDER. Ms. Shea-Porter.

Ms. SHEA-PORTER. Thank you very much.

Major General Pollock, I would like to start with you, please. I

remember in March you came before us and had a discussion about

efficiency wedges, and I would appreciate if you would give us an

update, the impact that these were having and what you see as

problems that are fixable versus we are stuck in for the while.

General POLLOCK. Thank you.

Congress did come back and support us. So the Department of

Defense received $200 million to refund the efficiency wedge, for

which I am very grateful, because in fiscal year 2008, my efficiency

wedge was $142 million, which is equivalent to a large facility like

Fort Hood.

So in the short term, because Congress has basically funded

what we hadn’t had funded, we are okay in the short term. But it

is something that we need to stay attuned to as we move forward.

So thank you very much for that support.

Ms. SHEA-PORTER. Thank you.

But could you tell us what will happen, what you anticipate? Because we are going to continue to see more soldiers, as you know,

coming and requiring these services and more problems inside the

personnel system. What do you forecast for us, if you want to just

tell us what we need to know in four years, in six years?

General POLLOCK. I think one of our shortage areas that will be

a challenge for us to fill will be behavioral health.

The good news, when we look at behavioral health, though, is we

know so much more now than we did immediately after Vietnam.

Now, we know that there are certain symptoms that are very, very

normal for people to display after being in the stress of combat,

being stressed by a traumatic event, where they potentially could

have lost their lives or they saw others lose their lives. Those

symptoms are very normal for us as human beings and the majority of us will work through them, but we almost need permission

to know that the thoughts and the emotions that we are having are

normal.

Then, as we give people permission to have those experiences, to

admit those experiences, it increases the likelihood that they will

work through the symptoms and it will not develop into a fullblown disorder like we have seen so many people from Vietnam

suffer.

So we are very hopeful that with the changes in therapy, with

a recognition of symptoms, we will be able to prevent that onslaught of all of these disabled people that we keep hearing about,

because we think that we know enough now that we are going to

be able to reduce a significant amount of that.

43

We won’t prevent it all, because we don’t all have the resiliency

and the coping mechanisms that we need sometimes to get through

things, but I think that, with what we know, we are going to really

make a lot of progress in that.

And then, again, as I mentioned before, there are certain areas

that we will step out and lead the nation. And I think as we start

to destroy the stigma that is associated with asking for and receiving behavioral health, we are going to make inroads into the concerns for depression, which are now predicted to be the leading

cause of illness and lost time by 2010 for our nation.

Ms. SHEA-PORTER. Thank you very much.

And, Major General Schoomaker, could you please tell me, what

are the records like at this point and the communication records

between the VA and the active-duty military, DOD?

My understanding is that they still have some problems, soldiers

accessing their records and the different people involved in the case

being able to have instant access to records. How are we doing

there?

General SCHOOMAKER. Well, I mean, for the movement of patients into the four polytrauma centers for the VA—in Tampa, in

Richmond, in Palo Alto and in Minneapolis—that is going extremely well. In fact, I think the latest is to try to move very large

digital records of scans and the like. But routine records I think

has been moving now fairly easily.

There has been a project in place to move bidirectional flow of

digital information from the VA into the DOD’s electronic health

record. We have a system called Armed Forces Health Longitudinal

Technology Application (AHLTA), they have a system called Vista,

and there is a bidirectional flow.

I believe by the end of summer, ma’am, is that correct?

General POLLOCK. The TMA, the TRICARE Management Activity, is telling us that by the first of October, all of our facilities will

have access to the bidirectional health information exchange.

Ms. SHEA-PORTER. Thank you very much. I am happy to hear

that.

Dr. SNYDER. Mr. Wilson.

Mr. WILSON. Thank you, Mr. Chairman.

And I would like to thank all of you for your service, Generals

and Colonel, here today.

The reason I stayed in the National Guard of South Carolina for

31 years, and the Army Reserves too, is because the people that I

served with I felt were the most competent, capable and patriotic

people I know.

And so I just want to thank you for your service and I know your

passion and commitment for our wounded warriors and for their

families.

I have the perspective, I have visited the field hospital in Baghdad. I have been to Landstuhl, I have been to Bethesda, I have

been to Walter Reed. The people that you have working with you

I believe are just extraordinarily capable. And with your leadership, the changes that needed to be made after identifying Building

18 I think can be made.

I also have the perspective and appreciation for what you are

doing because I have three sons in the Army National Guard who

44

could be in your care, and I have faith that in your care they would

do well.

I also have the perspective of another son who is a Uniformed

Services University of Health Sciences (USUHS) graduate, who is

currently a doctor in the Navy. And so I learn firsthand from him

of the commitment and dedication of the military medical professionals.

General Cody, could you explain how the Army will evaluate the

success or failure of the Army Medical Action Plan?

General CODY. As I said earlier, Congressman, one of the things

that we have set in place with the executive order that went out,

we also put in an inspection program with the Department of the

Army IG, as well as internal to each one of the military medical

treatment facilities. They have their own internal inspections. All

of this is reportable back up to the Department of the Army.

And what we are going to do right now, because we just put it

out—and it is a five-page program. In January of 2008 is when we

hit phase five. In stride with that, the teams will go back out to

look at each one of the medical treatment facilities.

I am personally going out and looking at 18 of the largest ones.

I start here next week. I have had General Tucker out. And I carry

with me the action plan. And then each place—and I am hesitant

to say which ones I am going to, because three of them are surprises, and they will sit down and tell me where they are.

And so we have a pretty aggressive feedback and inspection program. Clearly, we have to change the inspection program of the Department of the Army IG, as well as General Pollock’s leadership

in the AMED, they have to change their inspection, because we

have 120 items that we are looking across the board at.

So that is how we are tackling it, and I feel pretty confident that

we will get it right.

Mr. WILSON. And, General Tucker, I appreciate that General Pollock has identified you as the bureaucracy buster. I can’t imagine

a more difficult job. And indeed I know it was with great intent the

Med hold units, but it didn’t seem to work. And so I am very hopeful that your efforts, according to the Army Medical Action Plan,

that you have been appointed by General Cody, that has been identified as the action officer.

And in this position, do you feel that you have the necessary resources and manpower to get the job done successfully? Are there

changes to the Army or DOD policies or legislative authority that

may help you succeed in your mission?

General TUCKER. Sir, without question, I have all those things.

I have been given enormous authority by the Army leadership.

And I can tell you that in my travels—I have gone to eight different installations, and I have briefed all over the Pentagon—I

foresee no pushback from any person at all. They welcome all these

changes, as dynamic as they are. We are bending some pretty thick

metal here in the Army.

I think it is just testimony to the warrior transition company

itself, the baseline organization.

Just to give you a comparison, sir, before, this organization was

manned with nine members in its cadre. Today that is 39. So that

45

gives you an appreciation that a 75 percent increase in leader-toled ratio.

And when the Army commits to something, we put boots on the

ground. And, sir, this is putting boots on the ground in a big way

across our entire Army, and I think it is going to serve us well.

Mr. WILSON. As I conclude, again, I want to thank you for your

service and as a Member of Congress, as a parent, as a fellow veteran, just thank you for what you have done and what you will be

doing in the future for our wounded warriors.

Thank you. God bless you.

General TUCKER. Thank you, sir.

General CODY. Thank you, sir. And, by the way, you know, at

least three of your sons got it right. And we are just as proud of

Hunter, who just joined Reserve Office Training Corps (ROTC). So

we look forward to getting him in our ranks.

Dr. SNYDER. I have a 13-month-old son, but he has not expressed

any interest yet, General Cody. [Laughter.]

General CODY. I still may be around, so I might be able to influence him. [Laughter.]

Dr. SNYDER. General Clark lives just down the street from us, so

he has been trying to indoctrinate him in West Point. [Laughter.]

I don’t know if other members will have many questions, but we

are going to go ahead and start a second round.

A quick question, Colonel McKenrick, for you, before I go back

to General Cody. Your unit is an integrated unit of both reserve

component and active component and both guard and reserve.

Have you had any issues dealing with the fact that you have got

a bunch of people that are working under different personnel policies and promotion policies? Has that been an issue for you or has

that all gone very smoothly?

Colonel MCKENRICK. Sir, that has been a challenge for us. We

recognized early on the need, when we integrated those, to make

sure that we had expertise in each one of our units, each one of

our warrior transition companies.

Dr. SNYDER. Personnel expertise?

Colonel MCKENRICK. Yes, sir. Personnel, promotions policies, pay

policies, all those issues that are different between the different

components of the service.

So we currently have one expert that we have got working in a

cell that we are going to establish at brigade, put down in amongst

those companies. We have got, at Human Resources Command

(HRC), some paperwork to pull in a second person. And we are

working an initiative to get a third, so that we have three personnel that are national guard-reserve experts that focus on the very

difficult orders process that deals with national guard and reservists and the pay and promotions and other personnel issues.

So it is a challenge for us that we currently have one person. We

need to get two more, and we are working that aggressively.

Dr. SNYDER. General Cody, I am not a big one for rehashing old

history, but I wanted to ask a lessons-learned question, if I might,

because I know when you first heard about this, you were very concerned about it.

I guess when I first read The Washington Post story, I first heard

about all the details that were in the story, I thought back. If I was

46

Ike Skelton, I would be able to tell you the name of the general,

but it was one of Ulysses Grant’s predecessors, in his capacity, who

was quite an old man at the time, but they would find him in the

middle of the night, when all the troops were sleeping, going tent

to tent, opening flaps, making sure people actually were on dry

ground, that they had their clothes dried out. He was kind of oldtimey, ‘‘I am going to take care of my troops, even if they don’t

want to be taken care of’’ kind of soldier.

And it seemed to me that—my question is in terms of lessons

learned. It seemed to me that somebody wasn’t doing that, that

somebody should have been going, at a high level of rank, door to

door, room to room, talking to people, looking in the showers and

that kind of thing.

Has this created any apprehension amongst you in other areas

other than medical that maybe there is not that kind of attitude

about leadership? I mean, do we have people out there sticking

their head in the boiler room, sticking their head in the air conditioning rooms at all these different facilities?

What have been your thoughts about that? Because I know you

were very concerned when you first heard about this in terms of

the leadership.

General CODY. Clearly, my biggest angst was the fact that this

should not have happened. It was a failure of leadership, and, as

you know, we relieved a lot of people and we moved people out, and

we quickly—my assessment up front was we didn’t have people

going to each one of those rooms.

I went through each one of those rooms at Building 18, but, quite

frankly, there should have been lieutenant colonels and majors and

captains and sergeant majors and other people checking those

things out.

We have asked that question, is this indicative of an Army that

is stretched pretty thin by repetitive combat tours and everything

else? What I am seeing outside of that in our combat units is not

the same. We have got very, very good, engaged leadership.

The decision that we made four years ago that company, battalion and brigade and division commanders and their sergeant majors and first sergeants would train a unit up during the reset period, build the team, deploy with that team to combat and stay in

command positions and bring them home was a pretty smart thing

that we did, unlike what we did during Vietnam, where you could

have three company commanders in one tour or three battalion

commanders in one tour.

And so when the units come back, you have got a well-rested

first sergeant—well, maybe not first sergeant, but a well-rested

new company commander getting ready to take command, a battalion commander and a brigade commander. And the handoff between those commanders and the lessons learned are being passed

very, very aggressively.

Plus, our two-star commanders I have great trust and confidence

in, and our two-star sergeant majors. They all know that they have

to pay very, very close attention and walk around into the barracks, walk around into the motor pools, because they only have 12

months to reset that outfit, assess their leaders, build the team, get

the training done, and then they are going right into combat.

47

So that is happening.

The failure at Walter Reed at Building 18 was just an unfortunate failure of people being—I don’t want to say out of sight, out

of mind, but they were across the street.

We did not resource the AMED at Walter Reed with the ratios

that you just heard Mike Tucker talk about. They were forced to

take it out of clinics. They were taking medical NCOs and other

people. So they were doing double jobs, and, quite frankly, it

caught up to us. They went from 300 to 400 to 500 to 600 outpatients. But some leader should have caught it, and it is unfortunate.

But the net result of all of this is we have revamped everything,

and I feel very, very confident that the young men and women that

we have asked to go, over 2,000 of them that we will build into

these warrior transition units, the care that our soldiers and the

families get is going to be wonderful. And it is going to be what

you and I would want for our son or daughter, and America will

be proud of it.

It is unfortunate that it took Building 18 for us to get there, but

I see something good coming out of this. And so I am committed,

as all the other people here.

But more importantly, the question you asked, are our commanders below us cognizant, and the answer is yes. And I feel pretty

good about it, but we will continue to check.

Dr. SNYDER. Mr. Kline.

Mr. KLINE. Thank you, Mr. Chairman.

Colonel McKenrick, I want to echo some of the thoughts and

comments that the chairman made, having to do with personnel

issues. That seems to be at the heart of the problem. What are the

policies? Not only for guard and reserve and active, but you have

to somebody who really knows that. So I would encourage the

Army and you to work hard to make sure you have got people with

the requisite skills.

A quick question for you: Who signs your Officer Evaluation Report (OER)?

Colonel MCKENRICK. Sir, I work for General Tucker as the deputy commanding general for North Atlantic Regional Medical Command (NARMC), and my senior rater is General Schoomaker.

Mr. KLINE. Okay, great, good idea. Thanks. It is amazing. That

was the right answer to the question.

I want to go back to something that I raised very briefly with the

earlier panel, and realized I was probably talking to the wrong people, but there was a finding in their report that says, ‘‘Walter Reed

Army Medical Center and National Naval Medical Center staff

members, especially those in the nursing field, are showing signs

of compassion fatigue.’’

And so I want to ask you probably, General Pollock, General

Schoomaker, and perhaps Colonel Horoho, hiding in the back there,

if you agree with that, and if so, what you are doing about it.

General POLLOCK. I will change hats here and put on the chief

of the Army nurse corps hat.

And, yes, they are absolutely struggling. Unfortunately, the

Army has not made mission for the Army nurse corps since 1999,

and each year our junior officers are fewer and fewer. As a result,

48

we are asking them, as the junior officers, to do more and more

work.

And, unfortunately, when there is a civilian nursing shortage

and you either can’t fill your general schedule (GS) positions or the

contractors don’t come to work, and the civilians have the option

of refusing over time, who do you turn to to provide care? It is the

military nurse.

They are also the same nurses that deploy. So we put them in

a combat environment for a year, and then we come back and we

work them perhaps harder than they were working in a combat

theater.

Mr. KLINE. So, if I can interrupt, this isn’t just a matter, as the

recommendation and the findings say, a formal study of stress, immediate action, provide stress reduction programs for all personnel,

that is maybe a decent idea, but that is not at the heart of the

problem.

You have got a resource and personnel problem, is that right?

General POLLOCK. Correct, sir. And Colonel Horoho has done a

fabulous job working with some compassion fatigue and stress

management initiatives at Walter Reed, but the cause of the problem is the nursing shortage and our inability right now to bring

those nurses into the military.

Mr. KLINE. Well, as I have said before, we are doing our part in

our family. My niece is an Army nurse down in San Antonio right

now. My wife is a retired Army nurse. I try to keep this information from her, because she is going to have this desire to run back

and put the uniform back on again. So don’t even go there. [Laughter.]

General POLLOCK. Well, we would welcome that, sir.

Mr. KLINE. I am afraid that would be the case. So we will keep

this little secret.

General POLLOCK. Because if we could each attract one, sir, we

wouldn’t have a nursing shortage.

General SCHOOMAKER. Sir, if I could make one comment.

Mr. KLINE. Yes, General?

General SCHOOMAKER. Because like General Pollock, I served as

the chief of the Army Medical Corps until last October for four

years. And I have thought about that phrase and that notion that

we are suffering from compassion fatigue for some time, and I have

asked people to help me understand better what that means. Because, frankly, most people, as you know from your wife, go into

medicine and nursing knowing that they are going to see a lot of

human misery and they are going to see suffering.

Frankly, we also get reports from people who have even deployed

to the theater of operation that this is some of the most rewarding

work they have ever performed in uniform, and they seek opportunities to go out again and take care of these soldiers.

So what exactly are we talking about when we talk about compassion fatigue?

I think what I hear most people talk about is the fatigue not of

taking care of the most severely injured and most challenging patients, it is the fatigue of a system that doesn’t allow us to transfer

records to the VA very successfully, a system that puts a physician

or a nurse in a position of being an adversary of a patient they are

49

trying to take care of. Because why? The patient is frustrated with

a physical disability and evaluation system that the physician or

the nurse has no control over.

Mr. KLINE. So you don’t see a lack of compassion as the——

General SCHOOMAKER. Absolutely.

Mr. KLINE. What I found striking, I guess that is what had me

going down this road, is I was just struck that they said there is

compassion fatigue. I can understand where fatigue would wear on

you and perhaps you would be a little bit sharper in your response

or something, but I was having difficulty understanding how they

concluded that this was compassion fatigue.

General SCHOOMAKER. I think it is bureaucracy fatigue.

General CODY. Absolutely. That is why we took on the bureaucracy first. I echo what General Schoomaker said. I have gone out

and talked to these doctors at the caches that had second tours or

third tours. I have talked to them up on the intensive care units

(ICU), the nurses.

I agree with General Pollock that we have a nurse shortage. We

need to fix it. But everywhere I go, it is not one of not wanting to

take care of and not wanting to do the best in terms of compassionate care of our soldiers. The frustration is with our bureaucracy, our system, and, in some cases, our personnel assignments,

and, in some cases, it is the OPTEMPO.

But when you put a nurse or when you put a doctor with a patient or a family, you don’t see that. What frustrates them has

been the bureaucracy and that is, quite frankly, what we have

tackled.

Mr. KLINE. Thank you.

Colonel Horoho, I didn’t mean to single you out back there, but

congratulations on the command, as well. Did you have something?

Colonel HOROHO. Thank you, sir, very much.

All of our clinicians, I would say, remain extremely compassionate when they are providing care. And they are providing care

24/7 to all of our warriors and their beneficiaries. We as a command have worked very, very hard.

We just got approval to be able to put in a retention bonus so

that we can retain those quality nurses that have been providing

care for the last several years at Walter Reed.

We have also been working very aggressively with the intercardiac health promotion program, to work with a stress-reduction

program, to provide not only for our nurses but all of our healthcare providers, because it is not just taking care of our warriors,

but there are multiple stresses in people’s daily lives. So we want

to keep them all very, very healthy.

We have also gotten approval to be able to fund the 100 unfilled

positions that we had, so that we can recruit and be much more

competitive as we are competing with all the hospitals in the

Washington, D.C. area.

Mr. KLINE. Thank you.

And thank you for your indulgence, Mr. Chairman. I do think

that is something that we as a Congress and we as a committee

need to continue to look at, those items like retention bonuses and

things to fill that shortage, because we have heard it continually

in this vein.

50

I yield back.

Dr. SNYDER. Mr. Kildee tells me it was General Winfield Scott.

It was a Civil War general that I knew you all wanted to know

that I couldn’t remember.

Ms. Davis.

Ms. DAVIS. Thank you, Mr. Chairman.

And I certainly look forward to working with all of you.

What is a fair amount of time for us to try and go back and

evaluate the system that has now been put in place?

General CODY. I think, ma’am, I will take it first.

We are in phase two of our five-phase plan. I think you ought

to ask us back probably October-November timeframe, and then we

ought to be called back probably in February, right after the State

of the Union and other things get out of the way. We will be pretty

much closure on execution of phase five. Those are the timelines.

So I think somewhere in the fall, and then bring us back in here

right after the first of the year.

Ms. DAVIS. Thank you.

General CODY. Because we are going to continue to go out and

measure. There will be some changes. If we have any drastic

changes, we go out there and find something that we had not been

able—or we didn’t anticipate, clearly, we will transmit that to you

all. But I think those two timeframes.

Mike, what do you think?

General TUCKER. Yes, sir, I agree 100 percent. We have got a

good glide path. We are being resourced as we should be to facilitate and set the conditions for this plan to be successful and, like

General Cody said, along those timelines October and then again

in February. February, we see ourselves as wheels up, air speed

and altitude, gaining momentum.

General POLLOCK. The other piece that I will add to that is each

of the tasks that we have identified for the AMAP is actually listed

on a scoreboard for me so that I can constantly monitor it. So once

a week, they do an update for me that identifies whether anything

has changed. So if there is a change, say, an amber has gone to

green, then I get a little thumbs-up next to it so I know that it is

a recent change.

But we are monitoring that very carefully, because I want to

make sure that because we fix this piece, that one doesn’t then

break. So we have oversight of the entire process.

So I am comfortable saying that we can move forward.

Ms. DAVIS. Thank you.

While you are all here, I know we are trying to get a handle on

the evaluation systems so that people are fairly compensated for

their injuries, for their disabilities, as they transition.

And I know, General, that you have asked the judge advocates

to help with some of that transition. Is that a large enough effort

that we would be able to see some suggestions, I guess, coming out

of that?

What I am trying to determine is, is this a system that really

needs a whole overhaul? Is it built on the idea that somehow people are going to try and fraud the system, as opposed to seeking

reasonable compensation from it? And can we learn from the judge

advocates, if they are working?

51

Is there a way out there, is there a mechanism that we can begin

to perhaps have good information and move forward with this over

the next, I would hope, two years?

General CODY. I think, one, we understand now where the friction points are. We are talking about the physical disability evaluation system.

Before the war started, ma’am, we averaged about 6,000 cases a

year. I think we are averaging now about 12,000, which tells you

that we need to—we should have been a little bit quicker in responding to that case load, that plus the amount of wounded that

we have had in this war.

We have gone back and looked at the MEB and the PEB process.

We have identified the liaison officer (LNO) as the clutching mechanism and a crucial part of that for the soldier, and we are training

those people.

We also looked at extensively the legislative changes that we

needed to pass through Congress and say we and the OSD—now,

I am part of the steering committee at OSD that meets once a week

with the Veterans Administration, led by Secretary Gordon England and the deputy of the VA. We have put five or six now recommended changes that will help eliminate that friction point and,

to your point, the issue of having a soldier almost have to ask for

something that we should give them as a country anyways.

And right now, I think some of the laws are such that, with

minor changes, we could eliminate that friction point, and the

Physical Disability Evaluation System (PDES) and the movement

through adjudication would be much, much smoother.

But we have created a situation in some cases, especially with

our national guard soldiers and our reserve soldiers, where, quite

frankly, with a law change, this will all go away.

Ms. DAVIS. I look forward to working with you on that. Thank

you very much.

Thank you, Mr. Chairman.

Dr. SNYDER. Mr. Wilson.

Mr. WILSON. Thank you, Mr. Chairman.

General Schoomaker, the Independent Review Group reported a

finding that the philosophical and operational differences between

Walter Reed Army Medical Center and the National Naval Medical

Center are hampering the efforts to transition to the Walter Reed

National Military Medical Center, as required by the BRAC decision.

It is further reported that the leadership and personnel time devoted to planning the integration of clinical services have detracted

from the time required to manage the medical center.

How are you addressing these issues today? What are your views

on the IRG’s recommendation for a general or flag officer to be

placed in charge of the transition team?

General SCHOOMAKER. Well, sir, first of all, I would have to concur with the group that there are within the national capital area,

where you are talking about two medical centers operating in a

somewhat coordinated fashion, but in two different locations, in

two different somewhat distinct cultures, I would have to agree

that that is occurring today.

52

But I want to make clear that I am not trying to throw stones

at the Navy here. The Navy has a different culture about how and

a different process by which they manage severely injured Marines,

largely Marines. They do it in a decentralized fashion. They do not

keep them at the National Naval Medical Center Bethesda. They

try to get them back to Camp Lejeune or Camp Pendleton, close

to their units and close to civilian or the VA system, and they are

much more rapid in moving that way.

On the other hand, the Army, with a larger burden of these severely injured soldiers, especially amputees and more severely

brain injured soldiers, tends to keep them at Walter Reed.

We have created, for all intents and purposes, what we lost after

Vietnam, which is a rehabilitative medicine capability. We have

moved toward a civilian model of acute inpatient medicine and ambulatory care and no intermediate rehab service.

We have now built, for all intents and purposes, de facto, a

stepped-down rehab center, called the Malone House. It was never

designed to be that, but that is what it effectively does for families

and soldiers.

And we keep them together because we in the Army have adopted a very aggressive ethos of maintaining and retaining as many

of those soldiers as possible. We are now returning 20 percent of

our amputees to active duty. That is about five times higher than

we have historically. We now have soldiers fighting—we have at

least one soldier fighting with a prosthesis in Afghanistan today.

That is a very strong part of our ethos and our ambition.

Frankly, I think the future Warrior Transition Brigades and

companies and battalions will contain as a part of their cadre soldiers who are severely injured and are fully recovered and returned

to duty.

So what we are trying to do is move these two cultures together

in a way that involves also the VA system, so that we more rapidly

and proactively identify who is going to return to duty and we

ought to keep on campus and keep in active rehabilitative medicine

programs and research, and who ought to be transitioned more

rapidly to the VA system and to home care, and that has got to be

a part of that blending.

As far as the overarching command and control, I think our vice

has worked out with the vice chief of staff of the Navy a method

by which that transition will take place.

Mr. WILSON. And, indeed, I am glad you brought up about assisting persons to return to duty.

Last week, I had the extraordinary opportunity—a hero of mine

is Major David Roselle, and so I had the great privilege and opportunity to host them for a tour of the Capitol. What a wonderful

young fellow he is and his wife, Kim, and their children, two little

guys, Jackson and Forrest. What a role model that he has been. It

was just chilling to see, again, the quality of the young people serving in the military of the United States.

General Cody, as a former member of the national guard, I was

interested as you pointed out that the wounded warriors, say, who

return to a base, as General Schoomaker mentioned, the Marines

returning to their bases—and I appreciate that there is not being

a difference between serving guard members and active duty.

53

But what type of coordination is there of Guard members who return home with their adjutant general, their state adjutant general? Are they kept informed of their release, of their return to

home state? How is that handled?

General CODY. First off, they stay on active duty. Clearly, their

unit, as I think General Schoomaker may have said, or Colonel

McKenrick, when a soldier arrives into a warrior training unit,

they have an aggressive program to notify the unit that your warrior is here.

In the case of national guard units, the The Adjutant General

(TAG) is notified. But that soldier is still on active duty as he goes

through that care. And then when you talk about transitioning

back either in a still active-duty status while he is rehabilitating,

he could go to a civilian health-care organization. At that time, the

handoff, he still has that triad of care of a squad leader who is assigned and a case manager and his unit is notified.

Now, if his unit is deployed, like with the Minnesota Guard right

now, they have their own rear detachment that takes care of that.

So it is a little bit different, but the concept is the same.

But the most important thing is we don’t discharge them from

active duty until we are assured that we have got that young soldier on the right path, either returned to full duty; if he has to be

medically retired, he is so or she is so. But we make sure of that

handoff, or go through a handoff to the veterans hospital.

So it is a little different, but the safety nets are still there.

And I would ask General Tucker, he just went through this going

out there, he could probably give you a couple anecdotes of how it

is working.

General TUCKER. Sir, we have LNOs from the national guard at

our medical treatment facilities, and they immediately hook up

arm-in-arm with these warriors as they come back. And so they are

with them as one of their national guard brothers to help them

through that process and link them back to their unit and all their

needs and specific requirements that they have, sir.

Mr. WILSON. Again, thank you for what you are doing for our

troops and their families.

Dr. SNYDER. I had two final questions I wanted to ask.

General Tucker, you mentioned earlier this afternoon that when

you have a soldier that has a specific problem, that you get together with the soldier, your folks do, and get the problem resolved

fairly quickly.

In the course of doing that, do you run across things that you

think, ‘‘You know, that really ought to be a statutory change. I

need to let somebody know in the Armed Services Committee that

we have got a problem with statute?’’ Is that something that you

all have your feelers out for?

Because we are certainly aware that we can be part of the problem.

General TUCKER. Sir, absolutely. The Army has provided me—

when I said they give me pretty good latitude, they allow me to

build a team. So I have a team of about 22 personnel that work

up here at Skyline up at Falls Church. And, sir, I have expertise

in there from all the branches of the Army and some of the levels

within the VA.

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And so when we see those things, we quickly begin to crack the

nut as to, at what level does this problem reside? Can we fix it

within the MEDCOM, or is it an Army problem, or is it a DOD

problem or a VA problem or legislative problem?

And we have got a pretty good battle drill that we get things

channeled into the right venues, sir, so that they get addressed

rapidly.

Dr. SNYDER. I hope all of you will feel free to let us know if you

think that there are things that we need to do differently.

My last question, General Pollock, we have had complaints at

some point recently from M.D. types that are saying that there is

variation from specialty to specialty in the length of deployments

overseas, and it is creating some heartburn amongst folks, that

they feel that they are not being treated fairly.

Is that an issue that you are familiar with? Is that an

accurate——

General POLLOCK. Yes, it is, sir. It is an area I am familiar with,

and it is an area that I am working with the Army now because

the deployment strain on the Medical Department, because we are

not as large as we need to be, in support of a long war, in support

of a growing Army. The Army G–3 and the Army G–1 are working

with me on both deployment issues and the size of the force.

Dr. SNYDER. But the specific issue that certain specialties of physicians are treated differently because of their—you have need

for——

General POLLOCK. Yes, sir. We currently have a group of 13 specialties that do a 6-month deployment, and that had to do with how

small and how intense the demand would be on that specialty.

We would not have been able to provide them what is now called

an adequate dwell time at all. So by decreasing the deployment period compared to the rest of the group, we were able to do a better

job at retaining them so that it didn’t get worse.

But we are looking at some modifications so that there would be

more equity across the system.

Thank you.

Dr. SNYDER. Mr. Kline, anything further?

Mr. Wilson, anything further?

Yes, General Cody, did you have a final comment?

General CODY. Chairman, to get to your point that you asked

General Tucker, Congress has been very, very good here in the last

year, two years, assisting us with any type of legislation. And Mike

Tucker and General Pollock and General Schoomaker and the rest

of the people working this have gotten with our legislative people

and gotten with OSD, and we are putting some of those things forward.

I would like to comment, though, that there are significant medical provisions in H.R. 1585. And I have scanned through it, I have

had my staff look at it, and we think this is absolutely the right

direction to go on many of the items in H.R. 1585.

However, there are some things in there that would cause more

bureaucracy for us. I will just be honest with you.

One of them is prescribing ratios. You have heard Colonel

McKenrick today and you have heard General Tucker talk about,

listen, we know how to do this, and it would not be helpful if you

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prescribe ratios, and it may become bureaucratic as we wrestle

through 37 warrior transition units to get them up to speed. Now

you make it law, and that could be problematic for us.

So I would ask your indulgence, if we could help by commenting

on how that particular section should be written.

Another one that may cause us problems is congressional notification. The phrase is in there for congressional notification. We

clearly, as an Army, want to let every one of the elected officials

know exactly when a wounded warrior is wounded, where he or she

is going to be taken care of. But, again, making it law and making

it very prescriptive may require us to have another bureaucracy,

and I worry about some of the specificity there.

And so I would ask your indulgence as we comment back on H.R.

1585. The rest of it is fine, and there is a lot of great things in

there about the efficiency wedges and pre-and post-deployment cognitive assessments, and all those things are all moving in the right

direction. But I just worry sometimes about being too prescriptive

and it becomes law.

Dr. SNYDER. I share your concerns. We in Congress, with good

intention, can certainly create problems. We are very much aware

of that.

On the other hand, with regard to those two issues, if you and

I had had a conversation a year ago about how do you think the

ratios are at Walter Reed, you would have told me you thought

they were about right, and it clearly turned out that they were not

right.

And so what you are seeing is, when we drafted that, and I had

a role in drafting that legislation——

General CODY. Unfortunately, I would have said two years ago

I don’t know, I will have to get back to you, because I didn’t know,

which is another problem.

Dr. SNYDER. I think things clearly are moving in the right direction.

The issue of notification came about. That has been a frustration

for Congress. And we had this discussion, both at the member and

staff level, at length, because if the notification issue language had

been different under law, so that we would actually know in a

timely fashion when someone from our district ends up at one of

these facilities or has a severe wound, I don’t think we would be

dealing with the kind of problems we had at Walter Reed.

Now, why do I say that? Because just like General Tucker resolves problems when he runs into them, that is what our congressional offices do. Maybe we don’t do it, but our staffs do. We get

a call.

If we had a notification that this person was wounded and is at

this facility, our staff would check on him, we would be in touch

with him, give us a call. And every congressional office in the country now has that frequently occur, where they get phone calls.

I have had it—you make a courtesy call when someone has lost

a loved one overseas, and it is almost pro forma to say, ‘‘If we can

do anything, give us a call,’’ and the next day they call back and

say, without ever anticipating that they would need to get hold of

them.

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So that is why that language was put in there, that we think we

can be a part of the solution, that when we get a call from somebody, when we hear about somebody, if we can have us or a staff

member go by and put a business card on their hospital table that

says, ‘‘If you have got any problems, if your family has got any

problems, give us a call.’’

And at the time, they may think, ‘‘Well, that congressman is the

last person I am going to call,’’ until something happens that frustrates them. And that is the kind of calls we get, and then we

would be calling you, and then you would have known there was

a problem, General Cody.

And because what was happening, the staff was going over there,

and every soldier they ran into with a problem, they were taking

care of the problem. The issue was there were people that were

lost, that had just left the campus that weren’t running into staff

members in the hallways, and we didn’t know they were having

problems.

So that was the purpose of that language. It may not be the most

artfully written, but that is the intent of it, is that we would be

part of kind of having the feelers out there for where there are

problems.

But I appreciate your comment.

General CODY. We want everybody on the team, Chairman, and,

again, every one of these are helpful and we understand the purity

of the intent. I would just say because we are going to make it law,

I think we could have a good discussion to make sure that we get

it right.

Dr. SNYDER. I share your concerns, and that was one of the questions I asked General Jumper earlier, from his perspective on being

both sides of this thing. We are always willing to pass laws, but

we all want to do stuff that is helpful and not become part of the

problem down the line.

We appreciate you all. And if I picked up future Chairwoman

Davis’s intent, we will probably see you somewhere around the October timeframe.

Thank you.

We are in recess.

[Whereupon, at 4:11 p.m., the subcommittee was adjourned.]

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DOCUMENTS SUBMITTED FOR THE RECORD

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QUESTIONS AND ANSWERS SUBMITTED FOR THE

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QUESTIONS SUBMITTED BY MR. MCHUGH

Mr. MCHUGH. The AMAP includes the requirement for a command and control

structure along with primary care managers, nurse case managers and squad leaders for Warrior Transition Units with thirty-five or more soldiers. Given the present

number of warriors in transition throughout the Army: How many of each of these

required personnel will be needed to staff all of the Warrior Transition Units that

will be established by the Army?

General CODY, General POLLOCK and General SCHOOMAKER. Given the projection

of approximately 8,000 Warriors in Transition (WTs), the Army estimates a requirement for 2,408 personnel (1,498 military and 910 civilians) to staff the Warrior

Transition Units, to include 40 primary care managers, 345 nurse case managers,

and 680 squad leaders.

Mr. MCHUGH. What are the planning factors for determining the number of personnel needed?

General CODY, General POLLOCK and General SCHOOMAKER. The following Armyapproved staffing ratios were used to determine the personnel requirements for each

Warrior Transition Unit.

• 1 company for every 200 Warriors in Transition (WTs)

• 1 company commander and first sergeant for every company

• 1 executive officer for each company of at least 150 WTs

• 1 platoon sergeant for every 36 WTs

• 1 squad leader for every 12 WTs

• 1 nurse case manager for every 18 WTs (medical centers)

• 1 nurse case manager for every 36 WTs (community hospitals or health centers)

• 1 human resource sergeant for every 200 WTs

• 3 human resource specialists for every 200 WTs

• 1 finance sergeant for every 200 WTs

• 1 supply sergeant for every 200 WTs

• 1 supply specialist for every 200 WTs

• 1 patient administration sergeant/specialist for every 200 WTs

• 1 medical evaluation board physician for every 200 Soldiers in the MEB

process

• 1 primary care manager for every 200 WTs

• 1 social worker (family therapist qualified) for every 100 WTs (1 for every

50 at Walter Reed and Brooke Army Medical Centers)

• 1 training specialist for every 200 WTs

• 1 occupational therapist for every WT brigade or battalion

• 1 occupational therapy technician/recreation specialist for every 200 WTs

• 1 physical evaluation board liaison officer for every 30 Soldiers in the MEB/

PEB process

• Ombudsmen are ‘‘earned’’ as follows:

Æ >35 WTs-200 WTs = 1 Ombudsman

Æ 201 WTs-400 WTs = 2 Ombudsman

Æ 401 WTs-600 WTs = 3 Ombudsman

Mr. MCHUGH. How will the Army obtain the personnel?

General CODY, General POLLOCK and General SCHOOMAKER. Department of the

Army Execution Order (EXORD) 118–07, Healing Warriors, dated June 2, 2007, directs the establishment of Warrior Transition Units (WTUs), to include primary care

managers, nurse case managers, squad leaders, and command and support staff at

35 locations worldwide. The EXORD also calls for 55 ombudsmen at these locations,

as well as 130 physical evaluation board liaison officers. This represents a total reVerDate 22-MAR-2001 13:34 Jul 16, 2008 Jkt 037326 PO 00000 Frm 00123 Fmt 6601 Sfmt 6621 C:\DOCS\110-64\37326.TXT HNS1 PsN: HNS1
120

quirement of 2,408 personnel. A significant planning factor in enabling the Army

Medical Department to attain 50% strength in all WTUs by September 3, 2007, is

the availability of mobilized Reserve Component personnel assigned to Medical

Readiness Processing Units (also referred to as Medical Holdover Units) as a result

of consolidation of these units and Medical Hold Units into WTUs. Additionally, positions will be filled from the available population of qualified personnel (those Soldiers already serving in Medical Holdover and Medical Hold units) to attain 90%

strength in WTUs by January 1, 2008. The Army intends to source these positions

for the long term with the planned increases in Army end strength.

Mr. MCHUGH. Will the increased requirement for these individuals affect future

military to civilian conversions and if so, how?

General CODY, General POLLOCK and General SCHOOMAKER. Staffing Warrior

Transition Units will result in increased military requirements but many of them

are non-medical. An in depth review of military medical positions identified for conversion is on-going to determine the feasibility and advisability of continued conversions.

Mr. MCHUGH. The House version of the National Defense Authorization Act for

Fiscal Year 2008 mandates ratios for case managers, service member advocates and

PEBLO personnel to service members undergoing outpatient treatment. How many

additional personnel would the Army require for the Warrior Transition units if the

conference report includes the ratios in the House version?

General CODY, General POLLOCK and General SCHOOMAKER. The House version

of the National Defense Authorization Act for Fiscal Year 2008, HR 1585 would set

the ratio of case managers to Wounded Warriors at 1:17. The Army Medical Action

Plan (AMAP) calls for nurse case managers at a ratio of 1:18 Warriors in Transition

(WTs) at Army Medical Centers where the acuity of care required is high and to

1:36 at those Army treatment centers where the acuity is much lower. HR 1585

calls for service member advocates at a ratio of 1:30 WTs. The AMAP establishes

that ratio at 1 ombudsman for every 200 WTs. The House version would establish

the ratio for PEBLOs at 1:20, while the AMAP sets this ratio at 1:30. The difference

in requirements between these two approaches is presented in Table 1 below.

TABLE 1

Position HR 1585

Requirement

AMAP

Requirement Delta

Case Manager/Nurse Case

Manager 500 345 155

PEBLO 195 130 65

Advocate/Ombudsman 240 55 185

TOTAL 935 530 405

Table 1 summarizes these differences which are based on a current WT population of 3,903 undergoing a Medical Evaluation Board (MEB) to calculate the

PEBLO requirement, 7,189 WTs currently in WTUs to determine the ombudsman

requirement, and a projected total capacity of approximately 8,000 WTs to project

the case manager/nurse case manager requirements.

It should be noted that these numbers do not include the command and support

positions required to staff all WTUs. The U.S. Army Medical Command established

the number of medical unit personnel required according to the Army Medical Action Plan at 2408. It should be noted that this does not include the requirement to

staff Community Based Health Care Organizations (CBHCOs) with nurse case managers (48) or other required CBHCO personnel.

Æ