MATURATION OF THE COMBAT HEALTHCARE

SUPPORT SYSTEM IN IRAQ

October – December 2008

Perspective 1

MG Russell J. Czerw

Task Force 62 Medical Brigade Combat Healthcare Support System 5

in the Mature Iraq Theater of Operations

COL Patrick D. Sargent, MS, USA

Healthcare System Planning Along the Combat Theater Maturity Continuum: 11

Transitioning an Expeditionary Medical Force to an Integrated Healthcare System

COL David P. Budinger, MS, USA

A Systematic Approach to Combat Healthcare Improvement: 19

Task Force 62 Medical Brigade Combat Healthcare Support System Model

MAJ Alan K. Ueoka, MS, USA

Medical Civil-Military Operations: The Deployed Medical Brigade’s Role in 25

Counterinsurgency Operations

LTC Jeffrey Bryan, USA; CPT Danelle Miyamoto, MS, USA; LTC Vincent Holman, MS, USA

Transition of the Detainee Healthcare System to a Correctional Model: 29

An Interagency Approach

LTC Vincent Holman, MS, USA

Employment of a Joint Medical Task Force in a Counterinsurgency Operational Environment 35

COL Scott Avery, MS, USA; LTC Vincent Holman, MS, USA

The Complexity of Moving Patients in Today’s Maturing 41

Counterinsurgency Environment: Who, When, and How

LTC Michael C. Richardson, MS, USA

Clinical Quality Management in a Mature Combat Environment 51

COL Susz Clark, AN, USA; MSG(P) Richard Brewer, USA

Medical Capability Team: The Clinical Microsystem for 57

Combat Healthcare Delivery in Counterinsurgency Operations

COL Susz Clark, AN, USA; MAJ Jon K. Van Steenvort, MS, USA

The Deployed Electronic Medical Record 63

MAJ Leslie E. Smith, MS, USA

Medical Equipment Standardization in a Maturing Combat Theater 68

LTC Bruce Syvinski, MS, USA; CPT Jason Hughes, MS, USA

Applied Ethics in a Combat Theater of Operations 71

MAJ Frederick C. Jackson, MS, USA

Health Facilities Planning: Determining Infrastructure Requirements 79

for Form and Function from Clinical and Operational Capabilities

MAJ Don Chapman, MS, USA; LTC Kristen L. Palaschak, AN, USA

Expanding a Professional Dental Care System: Experiences of Task Force 261 88

Multifunctional Medical Battalion During Operation Iraqi Freedom 07-09

LTC(P) Frank L. Christopher, MC, USA; et al
LTG Eric B. Schoomaker

The Surgeon General

Commander, US Army Medical Command

MG Russell J. Czerw

Commanding General

US Army Medical Department Center and

School

0911102

GEORGE W. CASEY, JR

General, United States Army

Chief of Staff

DISTRIBUTION: Special

Administrative Assistant to the

Secretary of the Army

By Order of the Secretary of the Army:

Official:

JOYCE E. MORROW

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October – December 2008 The Army Medical Department Center & School PB 8-08-10/11/12
October – December 2008 1

A few months ago, the staff of the Army Medical

Department Journal and I were contacted by the 62nd

Medical Brigade, then deployed to Iraq as Task Force

62 Medical Brigade (TF62 MED), who presented a

proposal of significant relevance and value, not only

for current combat operations, but also for training and

planning in the long term. TF62 MED offered a

collection of manuscripts dealing with the various

aspects of their experiences, initiatives, and lessons

learned in Iraq, all written while the authors were in

theater. Therefore, the information is of immediate

relevance, reflecting the situation as it exists in Iraq

right now, rather than discussions of experiences of a

totally different environment. We are very pleased to

present those articles in this edition of the AMEDD

Journal, and strongly recommend that the information

they contain be studied by all commands and

organizations involved in military medicine, at all

levels. There are implications for planning, training,

and management, as well as areas that should be

addressed doctrinally, because, in all likelihood, Iraq

and Afghanistan represent the operational combat

environments of the foreseeable future.

Upon arrival in theater, the leadership of TF62 MED

quickly recognized that the environment within which

they would be required to provide healthcare support

had dramatically changed from that encountered by

previous medical support units. Obviously, during high

intensity combat operations, the medical support

resources are focused on providing those services most

necessary in the tactical environment to save the lives

of wounded and injured Warriors. However, TF62

MED found itself in a totally different situation, a

mature theater of operations within which casualties

from direct combat have been significantly reduced.

However, even more complex challenges were

developing as the US military operates in a

counterinsurgency environment, while assisting the

Iraqis to develop the capability to assume their own

security responsibilities. The role of healthcare support

had to be reevaluated and tailored to become a

valuable factor in the overall mission of Coalition

forces as it exists today.

COL Patrick Sargent, the Commander of TF62 MED,

was the driving force behind the development and

implementation of a plan to provide the highest level

of medical support to the multinational force

throughout Iraq, including Coalition and Iraqi security

forces, while assisting the Iraqi government in the

creation of a public healthcare structure. His opening

article describes the philosophy and approach that

established the overall structure for this ambitious,

extensive, and complex adjustment of the existing

medical capabilities. Subsequent articles detail various

aspects of the resulting healthcare support system,

providing a clear perspective on the extent of the effort

involved, the details and considerations that were

addressed, and the simple, dedicated hard work that

the professionals across the units of TF62 MED

performed in transforming COL Sargent’s vision into

reality.

COL David Budinger follows with a detailed, carefully

developed description of the many, often disparate

elements that must be considered for the provision of

healthcare support as a combat theater matures. In

simple terms, that maturity is the evolution from

widespread, noncontiguous hostilities into an environment involving fixed bases, functioning infrastructure, and obligations to the host nation as it

struggles to recover into a functioning nation-state.

COL Budinger’s article consolidates the major

elements involved in evolving healthcare support in

concert with the changing conditions and situational

factors as some measure of stability and order are

established in increasingly large areas of the combat

theater. It is an eye-opening, thought-provoking article

which should be of great interest to doctrine developers and strategic planners.

MAJ Alan Ueoka presents the formal planning process

for TF62 MED’s combat healthcare support system

Perspective

Major General Russell J. Czerw
2 www.cs.amedd.army.mil/references_publications.aspx

Perspective

(CHSS) in his carefully crafted article. He leads the

reader through the systematic approach that the planners used to identify the parameters of the effort, the

categorization of those parameters, the organization of

the approach to address the parameters, and the

considerations of resources and philosophical underpinnings that will support implementation of the plans.

The result is an omnibus map depicting the elements

of the CHSS, the interdependencies of those elements,

and the flow of effort to successfully reach the overall

objectives. MAJ Ueoka describes how TF62 MED

successful converted theory and ideas into action over

a wide area, in a very short period of time.

Vital to a successful counterinsurgency strategy are

civil-military operations (CMO), as the support (or

lack of opposition) by the local national population

denies the enemy concealment, support, and freedom

of movement. LTC Jeff Bryan and his coauthors have

contributed an article which clearly and succinctly

describes the key role that military medicine plays in a

successful CMO strategy. In addition to shelter, food,

water, and a measure of security, medical care is

extremely important to the local population, most of

whom may have had little in the way of medical care

prior to hostilities. TF62 MED established a proactive,

vibrant program of medical CMO, integrated with

medical assets of other Coalition forces and the Iraqi

government. This article is must reading for those

planning and organizing the CHSS for all future

deployments into Iraq.

Detainees are an unavoidable byproduct of combat or

security operations. Also unavoidable is the fact that

healthcare for those detainees in Iraq is, and has been,

the responsibility of the US military medical support

assets. As the responsibilities for security are assumed

by the Iraqis, the question of how to transition the

healthcare responsibility to the host nation remains a

complex issue. LTC Vincent Holman proposes an

approach by which the detainee healthcare system

currently in place should be transitioned into a system

appropriate for a national correctional custody

structure. His well conceived article proposes drawing

upon the expertise of the US Department of Prisons,

and the National Commission on Correctional

Healthcare for development of such a model. Further,

he recommends the incorporation of more training into

detainee healthcare in the curriculum of the AMEDD

Center & School.

COL Scott Avery and LTC Vince Holman describe the

real-world complexities and details, as well as both the

obvious and subtle considerations that TF62 MED had

to factor into the development and execution of their

plan to establish a standardized structure for force

healthcare across the Iraq theater of operations. Their

article provides insight into the scope of planning that

was required when TF62 MED’s leaders decided to

change the medical support landscape in keeping with

the evolving realities of the military, political, and

infrastructure environments. The analysis of the situation, definition of the requirements, identification of

resources, development of the plan, and successful

implementation are testimony to the professionalism,

skills, dedication, and leadership of the medical

professionals who ensure that they are there, wherever

and whenever our Warriors need them.

Effective management of resources is a constant

concern for every healthcare delivery organization. It

is especially acute for those that are required to

function thousands of miles from the sources of

manpower, supply, and assistance. LTC Michael

Richardson was the TF62 MED Medical Regulating

Officer (MRO) who, as he states in his excellent

article, “...gets the right patient to the right place, at

the right time, by the right means.” Indeed, emergency

dispatchers in US metropolitan areas have performed a

similar function for years, routing critical care patients

to available facilities based on proximity, capability,

and space availability. The MRO in Iraq has to

perform that function for an entire country, while

making additional judgments as to the patient’s

status—does the patient meet the criteria for treatment

by US/Coalition military resources according to the

medical rules of eligibility, or must an adequate Iraqi

medical facility be located? LTC Richardson’s article

provides insight to the complexity of the medical

regulatory function, which, interestingly, has become

more complicated as the theater of operations matures.

One of TF62 MED’s top goals was the establishment

of theater-wide, standards-based healthcare delivery.

Crucial to achieving that goal was the implementation

of a system to measure and ensure the quality of

healthcare services, assess the shortfalls, and define

the actions necessary to meet the standards. COL Susz

Clark and MSG(P) Richard Brewer have provided a

carefully organized and detailed description of the

TF62 MED program to create such a quality

management system throughout the Iraq theater. Their
October – December 2008 3

THE ARMY MEDICAL DEPARTMENT JOURNAL

article explains the considerations involved across

each aspect of clinical care, the metrics required, and

the steps necessary to support the control system. The

results ensured that a Warrior in Iraq receives the same

quality of care, no matter when or where in-theater it is

needed.

COL Clark also collaborated with MAJ Jon Van

Steenvort in an article proposing the development and

implementation of a modular medical organizational

structure. This concept, centered around what they

term the medical capability team (MCT), is in line

with the combat unit structure to which the Army has

moved in adapting to the realities of modern, external

threats to the United States. The goal is the availability

of teams of medical professionals with specifically

focused capabilities, allowing medical support to be

more easily task-organized in keeping with the force

structure that requires their services. The article is a

well-developed, thoroughly researched presentation of

the advantages and effectiveness of the MCT concept.

Their proposal will add additional insight to the

current, ongoing discussions among those charged

with planning the future doctrine and force structure of

Army medicine.

The beginning of Operations Iraqi Freedom and

Enduring Freedom in 2003 brought with it the first

attempt to fully deploy electronic medical record

(EMR) capability into a large scale, extended

operational environment. Much time and money had

been spent on developing an electronic capability since

1991. Indeed, over the years the AMEDD Journal has

published a number of articles discussing various

aspects of EMR development and implementation, as

well as the pros and cons of the systems that AMEDD

professionals have used in delivering healthcare

services. MAJ Leslie Smith adds an article reflecting

the very recent experience of healthcare providers in

the Iraq theater. His article provides an informative

overview of the evolution of health information

systems, and gives an excellent look at the numerous

problems and obstacles that developers face in

attempting to create a single, all-encompassing master

system that solves the myriad of disparate

requirements for medical information gathering,

storage, movement, and retrieval. MAJ Smith clearly

demonstrates how this seemingly straightforward

requirement is in fact one of the most complex data

management puzzles faced by system developers. The

need is profound, but a satisfactory solution still eludes

us. Fortunately, the extensively documented experiences from real-world operational theaters—rather

than theoretical suppositions and canned field exercise

reports—are now on the record for use by system

planners and designers. Hopefully, combat deployments in the near future will have an integrated,

simplified, reliable system of medical documentation

to support their operations.

Another aspect of the effective management of

resources so critical to ensuring healthcare delivery

throughout any theater of operations is the availability

of functioning equipment with all the supplies

necessary for its use. As described in the article by

LTC Bruce Syvinski and CPT Jason Hughes, upon

arrival in Iraq, TF62 MED immediately initiated a task

force medical equipment validation and standardization review board which imposed standardized

equipment criteria across all task force units.

Equipment requirements were validated, and, most

importantly, the task force logistics managers had

complete knowledge of what equipment was where,

and the maintenance and supply requirements of each.

This article is a textbook on the criteria, protocols, and

procedures which create a cost-effective, responsive,

and supportable system to ensure that functional medical equipment is available where and when needed.

Early in the deployment period, the leadership of TF62

MED recognized the seemingly increasing occurrences

of a problem that, unfortunately, has always been

present within military organizations, no matter the era

or the nation. Personal misconduct in violation of the

ethics and values that the US military strives to instill

in our personnel is always a challenge, which,

regrettably, can occur without regard to age,

experience, or rank. In response to alarming statistics,

the Task Force Commander directed the creation of a

training package to unambiguously address the

problem areas, reemphasizing the Army’s expectations

as well as the consequences of failure. MAJ Frederick

Jackson has written an excellent article describing the

process by which TF62 MED’s Applied Ethical

Framework training package was developed.

Especially revealing is his discussion of the research

that was done in an effort to discover the underlying

reasons for the various types of misconduct. Armed

with that information, they created a training module

for each category of misconduct, addressing the factors

that contributed to the problem, but also explicitly

restating the regulatory framework within which our
4 www.cs.amedd.army.mil/references_publications.aspx

conduct as professional Warriors must be structured.

The scope of the resulting training package is indeed

impressive. However, the effectiveness of this effort

was undoubtedly enhanced by the real-world context

in which it was created and delivered. This is another

example of perfectly targeted, situational training,

rather than garrison classroom lectures, lists, theory,

and tests. MAJ Jackson’s clear, detailed, well

organized article should be on every leaders’ reading

list, especially those tasked with leading our Soldiers

through extended deployments in distant theaters.

Perhaps nothing is more indicative of the maturation of

the military situation in a theater of operations than the

improvement in the medical facilities that support our

Soldiers. Every combat campaign begins with

expeditionary medical support; quickly established,

mobile, focused on trauma patient stabilization and

evacuation. As the situation stabilizes, mobility

requirements diminish, and the scope of necessary

medical services increase. Correspondingly, the need

for upgraded facilities arises to accommodate the

evolving medical support requirements. MAJ Donald

Chapman and LTC Kristen Palaschak have contributed

an article detailing the process by which such upgrades

are being accomplished in the Iraq theater of

operations. Their article highlights the starting point,

the creation of the clinical concept of operations, the

defining document upon which the plans for the new

or upgraded facility are based. As such, the concept of

operations must capture information from many areas,

some of which have little to do with actual healthcare

delivery. The article uses a case study about

replacement of the medical facility at Contingency

Operations Base Speicher to illustrate the process. This

is an interesting presentation of a process that is both

logical and unique, because the Iraq theater of

operations is itself an environment that has little

precedent in modern US military experience.

The ready availability of dental care for deployed

Warriors during combat operations has long been

recognized as a significant force multiplier.

Understandably, as combat operations begin and

expand throughout a theater, specialty and complex

dental care are not usually available in close

proximity, mandating evacuation to a facility in

another geographic area. However, in an exact parallel

to the changes in medical care and facilities that are

necessary in a maturing theater of operations, so too

will theater dental care evolve into a primarily fixed

facility model, with increased scope of care capability.

Such an evolution requires detailed planning and

implementation management, employing most of the

considerations and steps addressed throughout other

articles in this issue with regard to the overall combat

healthcare support system. LTC(P) Frank Christopher

and his coauthors have written a comprehensive,

detailed article that describes the work done by the

Task Force 261 Multifunctional Medical Battalion in

establishing a theater-wide dental care delivery

structure in the current environment of Iraq. They

examined the geographic dispersion of the

requirements, evaluated the variability in the provider

specialties that occur in the rotations of dental support

units, and projected the facilities, both existing and

required, that would be necessary to provide the level

of dental care which should be available to our

deployed Warriors. The result is a flexible, integrated

dental care support system that maximizes resources,

including provider, equipment, and facility, to contend

with the changes in both patient requirements and

dental personnel. The article by LTC(P) Christopher et

al also discusses the dental care afforded detainees, a

complex problem because in most cases the detainee

must be brought to the clinic to receive that care. Also,

our dental professionals are heavily involved with

dental civil-military operations, including programs in

the communities and a close working relationship with

Iraqi dental resources and government agencies.

TF261 established a series of continuing dental

education events for Iraqi dental professionals to assist

with development of their knowledge and skills as they

continue to develop a self-supporting capability to

provide dental care to their population. This article is

another case study of how our medical and dental

professionals call upon their education, training,

initiative, and leadership to recognize, attack, and

solve the complex problems they face in providing

excellent quality healthcare to our Warriors, no matter

the locations or conditions in which they must serve.

Perspective
October – December 2008 5

EVOLUTION OF THE COMBAT HEALTHCARE SUPPORT

SYSTEM

Porter writes, “Positions built on systems of activities

are far more sustainable than those built on individual

activities.”1 Historically, the medical task force has

focused almost exclusively on delivering robust and

accessible medical care and force health protection

support since operations began in Iraq 5 years ago.

Immediately upon assuming the mission, I noted the

medical task force was charged to deliver 3 essential

medical tasks:

1. Combat health support, which we call worldclass Warrior healthcare, to US and coalition

forces.

2. Protect the health of US and coalition forces.

3. Enhance government of Iraq credibility by

supporting self-reliant Iraqi public health

systems.

To accomplish these tasks my staff and I fused

traditional military campaign planning with a businessoriented strategic planning process. The result was a

hybrid method focused on operating a health system

providing medical support to a multinational corps

decisively engaged in a counterinsurgency operation.

We developed and published a medical campaign plan

that provided our medical force with an in-depth

understanding of how I visualized the operational

environment, describing how we would provide

medical support to the corps Warriors. The medical

task force had the responsibility for providing medical

care to 170,000 US and coalition forces, 150,000

contractors, Iraq Army and Iraqi Security Forces (ISF),

local nationals, and 28,000 detainees. Our beneficiary

population exceeded 300,000 people ranging in age

from infants to the elderly. Our patients’ medical

conditions required care ranging from trauma care for

children with burn and blast injuries to hospice care

for elderly detainees with terminal illnesses. We

quickly realized that in order to effectively command

and control our medical resources caring for the vast

number of Soldiers and civilians across a diversity of

medical conditions, we had to break away from the

traditional echeloned tactical paradigm of medical care

delivery. We needed to build a combat health support

system (CHSS) that possessed tactical agility capable

of meeting the complexity of the counterinsurgency,

while establishing the best features of a well-managed,

US quality healthcare system.

For this reason, we designed a CHSS comprised of 3

subsystems: a Warrior healthcare system, force health

protection system, and medical civil-military

operations system. These systems complement and

synergize each other in accomplishing the collective

mission as well as their specified tasks. Our CHSS

model, illustrated in Figure 1, has the look and feel of

Task Force 62 Medical Brigade Combat

Healthcare Support System in the Mature

Iraq Theater of Operations

COL Patrick D. Sargent, MS, USA

ABSTRACT

Leading a deployed combat healthcare system is a very complex task and requires a command and control structure that

is a unique blend of technical and tactical expertise to efficaciously deliver world-class medical care to America’s sons

and daughters. The medical task force in Iraq has successfully managed the transformation of the medical footprint from

a tactically arrayed set of disparate medical units to a nascent integrated healthcare system with many features similar to

the best healthcare systems in the United States. The American public demands, and Soldiers, Marines, Sailors, Airmen,

and Coast Guardsmen deserve US quality medical care, whether they are being treated at a military medical center in

the US, or a US medical facility in Iraq. This article presents an overview of the 62nd Medical Brigade’s development

of the combat healthcare support system during its tenure leading the US medical task force in Iraq.
6 www.cs.amedd.army.mil/references_publications.aspx

a balanced scorecard,2however, it is not a balanced

scorecard in the purist sense. Although we have

designated traditional ends/outcomes, ways/delivery

systems, and means/applications and enablers and

programs, the only objectives we cite are in the ends

portion of the model. The primary purpose of the

CHSS model is to provide an operational framework

for the delivery and management of quality healthcare

throughout our healthcare system. The CHSS model

allowed me to clearly communicate the strategic,

operational, and tactical efforts of our medical task

force with task force members, customers, and

stakeholders. Ultimately, the CHSS model focused our

organizational energy and engineered well-disciplined

systems to execute our medical campaign plan.

The Warrior healthcare system, force health

protection, and medical civil-military operations

Task Force 62 Medical Brigade Combat Healthcare Support System

in the Mature Iraq Theater of Operations

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Pro

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Resources

Force & Human Resource

Management Fiscal Stewardship Medical IM/IT MHS Acquisition, Research/Dev elopment,Inf rastructure

Customer and Stakeholder Perspective

Optimize Return to Duty &

Conserv e Combat Power

Maximize Well Present f or

Duty & Reduce DNBI

Improv ed Health Status,

Public Conf idence, Increased

Capability and Capacity

Warrior Healthcare

System

Force Health Protection

Systems

Medical Civil-Military

Operations

Hospitalization, Surgery ,

Diagnostic & Specialty Care Prev entiv e Medicine Systems Detainee Healthcare System

Primary & Dental Care

Sy stems Veterinary Care Sy stems Pro-MEET, Cooperativ eMedical Engagements

Trauma & Chronic Care

CPGs

Mental Health Care and

Building Resiliency

Facilitate Improv ed Access to

Iraqi Health Serv ices

Medical Regulation and

Clinical Integration

Facilitate Timely Iraqi Patient Transf ers/

Discharges f rom US to Iraqi Facilities

Internal Processes and Systems

Learning and Growth

Clinical Quality Management Electronic Clinical

Documentation Dev elop Adaptiv e Leaders Continuing Education &Training

Organizational Assessment Comprehensiv e Risk

Management

Logistics & Maintenance

Management

Health Facilities Planning &

Management

Moral Compass,

Ethical System Framework

Agile Joint/Multinational C2

Structure & Methods

Efficiency , Eff ectiv eness, Outcome

Measurement & Accountability Systems

Family Leadership Ambassadorship Growth

Protect the Health of

US & Coalition Forces

Enhance GOI Credibility by

Supporting Self-reliant Iraqi

Public Health Systems

Provide World-Class

Warrior Healthcare to US

& Coalition Forces

Figure 1. The Task Force 62 Medical Brigade model for development and execution of the Combat Healthcare Support

System. The model was conceived and designed to optimize healthcare support in the mature combat theater while

operating in a counterinsurgency environment.
October – December 2008 7

THE ARMY MEDICAL DEPARTMENT JOURNAL

subsystems are each directly in support of our 3 core

missions: providing world-class Warrior healthcare to

US and coalition forces; protect the health of US &

coalition forces; and enhance the credibility of the

government of Iraq by supporting self-reliant Iraqi

public health systems. Each system has component

delivery systems, or ways, with their own defined

objectives and measures of effectiveness (MOE) that

allow us to define success and objectively measure our

progress. The development and use of MOEs are

critical to help discipline our principal management

focus and energy on those elements of our

organizational performance most important to our

patients and stakeholders. As you can imagine, as a

medical brigade, all of our MOEs either directly or

indirectly supported the care or protection of the

coalition forces and detainees or supported the

Government of Iraq’s care for their citizens’ health.

Visually and practically, the foundation of the

brigade’s CHSS model is our value system. Our moral

compass and ethical framework incorporate the Army

values and Warrior ethos. Task Force 62 Medical

Brigade’s values are the embodiment of the

Constitution and the American flag, which is why I

coined the acronym: F.L.A.G. for Family, Leadership,

Ambassadorship, and Growth.

These simple tenets, presented in Figure 2, have

sustained us through some tough times and allowed us

to successfully serve as ambassadors for the Army

Medical Department and our great Nation.

WARRIOR HEALTHCARE SYSTEM

Physicians are the clinical leaders of care in the

healthcare organization.3 As the medical task force

commander, I fundamentally value the physician’s role

in the medical task force. Over the course of this

deployment, it became increasingly clear to me that

delivering quality medical care required a

multidisciplinary team approach and weaving together

the talents of the various healthcare professionals.

Reflecting on the increasingly mature operational

environment we instituted interdisciplinary patient

safety, risk management, and clinical quality

management programs across the medical task force in

Iraq to enhance the communication and teamwork

between our various professionals and support staff to

improve patient safety. After instituting these

programs, we witnessed quantitative and qualitative

improvements in our patient safety and clinical quality

management programs inside the medical treatment

facilities.

We widely implemented and provided recurring input

to the joint theater trauma system’s trauma clinical

practice guidelines (CPGs), and we implemented

several chronic care CPGs. These guidelines were a

starting point in standardizing the delivery of medical

care, but they did not unnecessarily restrict our

physicians from practicing medicine using their

clinical judgment. They retained the professional

autonomy to not use the CPG if their clinical judgment

led them to a better plan of care. The joint theater

trauma registry and deployed combat casualty care

research team played an integral role in the success of

the task force’s medical mission. Their efforts were

instrumental in our ability to contribute to the military

healthcare system’s efforts to use our trauma-rich

environment to advance evidenced-based medicine.

The brigade instituted a Quality-Healthcare Assessment Visit (Q-HAV) Program modeled in the spirit of

the Joint Commission’s* patient tracer methodology.

This allowed our combat support hospitals to receive

an objective assessment of their hospital and enabled

the Q-HAV Team to observe and disseminate the best

practices of each organization throughout the medical

task force. This was a paradigm shift away from the

traditional, checklist-based organizational assessment

programs focused on reviewing policies and standard

operating procedures.

Over the past 15 months, we have sustained a 98%

survivability rate for trauma patients who arrive at our

7 hospitals. Throughout our deployment, during and

after “the surge,” we have seen a precipitous decline in

casualties and trauma and have used this time of

improved security to improve the integration of the

electronic medical record, radiology and lab services,

primary and specialty care, and clinical integration.

Focusing on improving the Iraq theater’s radiology

infrastructure by working with Defense Health

Information Management System, we upgraded the

Medweb®(667 Folsom St, San Francisco, CA)

capacity allowing radiographs taken at level II clinics

to be read by a radiologist at a level III hospital.

*Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Blvd, Oakbrook Terrace, Illinois.
8 www.cs.amedd.army.mil/references_publications.aspx

Given the US, Coalition, and ISF

successes over the past 15 months

which significantly improved the

security situation, we have seen a

precipitous decline in the number of

casualties, prompting us to reevaluate

the distribution and content of our

medical footprint. As the combat force

in Iraq shrinks, combat unit

commanders are challenged to

maximize their well-present for duty

strength as the mission has not subsided.

In support of their needs, my objective

is to reduce the number of Soldiers

requiring evacuation out of theater for

specialty care, and reduce turnaround

time to get Soldiers back to their units.

We are presently developing a specialty

care referral clinic, first focusing on

gastroenterology, and planning to

expand to screen and treat patients

within the specialties that have the

highest rate of evacuation out of theater.

Lastly, we are leveraging the decline in

trauma patients to refine our outpatient

business practices to improve timely

access to care and optimizing the

utilization of our providers.

FORCE HEALTH PROTECTION

The medical task force has achieved the lowest

disease-nonbattle injury rate in the history of land

warfare. This is largely a result of the preventive

medicine and veterinary medicine teams that are

dispersed across the battlefield, conducting applicable

inspections in their respective areas and coaching

Soldiers and leaders about keeping the force healthy. I

have been extremely impressed with the level of

professionalism displayed by these teams, which

generally consist of junior enlisted Soldiers and junior

officers. These Soldiers epitomize the concept of the

“strategic corporal” and are great ambassadors for the

Army Medical Department.

The veterinarians have played a crucial role in

reducing the feral animal population around our

forward operating bases and contingency operating

bases. The Corps Commander established a force

protection dog program that allows units to acquire a

dog for the express purpose of security. Therefore,

when registered, these dogs are eligible for the same

care provided to our military working dogs. The

veterinarian medicine teams have sustained a very

impressive survivability rate for military working dogs

under their care.

We have made tremendous progress in the

accessibility and quality of behavioral health (BH)

services in Iraq as well. The task force has achieved a

99.3% return-to-duty rate for all Soldiers treated by

our BH personnel. These dedicated professionals

conduct prevention, consultation, and restoration care

inside the division and brigade areas of operations,

largely by moving in and around the operational areas

with the supported units. The primary cause of

operational stressors is the Soldier’s inability to cope

with issues on the “home front.” Our BH personnel

focus their preventive and restoration services on the

skills required to sufficiently cope with stressors from

home: anger management, relationship building, and

communication. Generally, after a 3-day visit to our

restoration centers, Soldiers return to duty more

capable of dealing with their stressors.

Task Force 62 Medical Brigade Combat Healthcare Support System

in the Mature Iraq Theater of Operations

Figure 2. Reproduction of the in-theater poster displaying the tenets of

the F.L.A.G. institutional philosophy developed by the TF62 Medical

Brigade as the foundation for the combat healthcare support system.

I will never leave a fallen comrade

We not only fight for the Constitution and our Democracy,

We fight for each other.

Families take care of each other and treat one another

with dignity and respect.

You enlist Soldiers, Sailors, Airmen, and Marines, but

reenlist Families.

I will never accept defeat

No one is more professional than I.

Lead from the front with personal and organizational

integrity.

Leadership is a TEAM sport-counsel, coach, and mentor.

I will always place the

mission first

Duty, Honor, Country!

Your character must honor our nation, your service, unit

and Family.

Ethical conduct and medical diplomacy are force

multipliers.

I will never quit

Know your job, do your best, and develop your abilities to

the utmost.

Always seek to improve your physical and spiritual fitness.

We are a learning organization and must maintain a

perpetual quest for knowledge.

S O HE L P M E G O D !

Family, Leadership,

Ambassadorship, and

Growth

“Your life is not important except for

the impact it has on anoth er life”

Jackie Robinson
October – December 2008 9

THE ARMY MEDICAL DEPARTMENT JOURNAL

As a result of the Mental Health Advisory Team’s

recommendation that the brigade become more

involved in the suicide prevention aspects of mental

healthcare, we developed suicide risk management

teams in several of the brigades. These teams consist

of the commander, chaplain, and a behavioral

healthcare advocate. This innovative approach to

providing behavioral healthcare demonstrated the

commands’ concern for their Soldiers who have

behavioral healthcare needs. We conducted an

informal survey that revealed Soldiers wanted their

command involved more in their care; thus, this

program provides us the opportunity to connect the

Soldier and command while respecting the Soldiers’

desire for privacy. Our combat stress control units treat

over 6,400 patients monthly, and each encounter is

captured electronically using the combat and

operational stress control workload and activity

reporting system (COSC-WARS). Electronic

documentation of the COSC-WARS has proven

beneficial and affords primary care doctors the ability

to evaluate our Soldiers in a holistic manner. The

behavioral healthcare personnel provide “stealth

mental health” circulating with Soldiers, and are truly

combat multipliers.

MEDICAL CIVIL-MILITARY OPERATIONS

Detainee healthcare is the medical task force’s most

strategically important mission. The task force has the

responsibility for providing care to over 28,000

detainees. The quality of medical care the detainees

receive is identical to that provided to US and coalition

forces. The delivery of medical care to detainees is

uniquely challenging due to the physical layout of the

detention facilities and the security requirements. The

majority of medical care provided to detainees is done

at the wire fence of the compounds, hence the term

“wire medicine.” The medic is the primary person

conducting triage at the wire using an algorithm

directed model of care. For medical conditions beyond

the scope of the medic, detainees are moved to the

compound treatment area where they are seen by a

primary care provider. Each compound is covered by a

nurse case manager to ensure the detailed plan of care

is implemented for the detainee patients.

A major challenge in the detainee population is the

documentation of care; however, we have recently

implemented the Battlefield Medical Information

System-Tactical (BMIST) as the primary means of

documenting the medical screening within the detainee

population at the wire. This ensures there is not a

break in the communication and delivery of care. For

security reasons, the detainees are routinely moved

between compounds, creating a significant challenge

to manage their medical care requirements. Thus the

electronic medical record assists in ensuring continuity

of care as well.

Detainee nurse case management ensures quality and

standardization across the detainee healthcare

continuum. Nurse case managers have also effectively

assisted in the management of chronic conditions.

Diabetic detainees have more favorable management

of their conditions, as measured by hemoglobin A1C,

than other diabetics in similar disease management

programs.

Professional meetings, engagement, education, and

training, and cooperative medical engagements have

afforded the medical task force the ability to directly

influence the strategic lines of operations within the

Multi-National Force and Corps. As the security

situation began to improve, our medical, dental, and

veterinary teams were highly sought after by combat

unit commanders to provide cooperative medical

engagements (CMEs) with their Iraqi counterparts.

Throughout our deployment, we have supported CMEs

in support of provincial reconstruction teams, Iraqi

military training teams, and coalition brigade combat

teams. Our task force’s involvement enabled these

organizations to build rapport with local Provincial

leaders and citizens. Through the cooperative medical

engagement we have leveraged our assets to employ

medical diplomacy across the battlefield. Our

veterinary officers have provided the Iraq veterinarians

with training on artificial insemination, rabies

surveillance, and food procurement guidelines. As the

security improves, so does the Iraqi economy. Our

veterinarians have assisted Iraqis with inspecting soda

bottling and canning plants prior to being awarded

contracts to sell soda to coalition forces.

At the request of the Iraqi Minister of Health and the

Multinational Force-Iraq Surgeon, the task force

recently developed health professions training courses

focused on physicians, nurses, and healthcare

administrators. The program will enable our healthcare

professionals to train Iraqi healthcare personnel

managing a hospital in the context of a larger

healthcare system. The program spans the range of
10 www.cs.amedd.army.mil/references_publications.aspx

lectures, one/two-day seminars to providing didactic

and practical training with multidisciplinary teams of

healthcare professionals in the US military treatment

facilities.

Local nationals filled a disproportionately large share

of the US hospital beds in the medical task force at the

beginning of our tour. Therefore, we addressed this

program with the following goals in mind: reduce the

Iraqis’ dependency on our medical treatment facilities

and increase their confidence in the Iraqi healthcare

system. A secondary reason for the number of Iraqis

entering our medical treatment facilities was the US

and coalition forces misunderstanding of the medical

rules of eligibility (MROE). Adherence to the MROE

is a significant challenge, but vitally important to

ensure our limited medical resources are readily

available for the care of US and coalition forces.

Improvement in these areas have led to a significant

reduction in the proportion and overall number of US

hospital beds occupied by Iraqi patients.

The Medical Task Force has the responsibility for over

180 case management liaison officers, bicultural

bilingual advisors and Iraqi advisor task force

personnel. These are Iraqi-Americans or highly skilled

former military personnel that are expressly focused

on providing the Corps with medical information, or

atmospherics, describing the status of medical care and

facilities throughout Iraq. Their reporting has shaped

the Corps’ focus and guided the force’s efforts to assist

in building the quality and capacity of Iraq’s medical

systems.

CONCLUSION

The medical infrastructure within the Iraq theater of

operations has matured over the course of the past 15

months. The CHSS model has sufficiently allowed me

to develop and maintain a precise understanding of my

medical warfighting functions. The CHSS translated

data into useable information that allowed me to make

informed decisions on the effectiveness of our internal

processes and systems. Moreover, the CHSS provided

a structured way of defining and measuring medical

quality in a tactical environment, specifically, our 3

core missions of providing world-class Warrior

healthcare to US and Coalition Forces; protecting the

health of the US and Coalition Forces, and enhancing

the Government of Iraq’s credibility by supporting

self-reliant public health systems.

REFERENCES

1. Porter ME. Competitive Strategy: Techniques for

Analyzing Industries and Competitors. New York,

NY: The Free Press; 1980.

2. Balanced Scoreboard Institute. What is the balanced

scoreboard?. Available at: http://www.balancedscore

card.org/BSCResources/AbouttheBalancedScorecard/

tabid/55/Default.aspx. Accessed October 6, 2008.

3. Griffith JR, White KR. The Well-Managed

Healthcare Organization. 6th ed. Chicago, IL: Health

Administration Press; 2006:203.

AUTHOR

At the time this article was written, COL Sargent was

the Commander, 62nd Medical Brigade, deployed to the

Iraq theater as Task Force 62 Medical Brigade.

Task Force 62 Medical Brigade Combat Healthcare Support System

in the Mature Iraq Theater of Operations

Crest of the 62nd Medical Brigade
October – December 2008 11

The subject of a piece of mosaic art cannot be seen

when viewing it from too close of a vantage point.

Likewise in history and life, we often miss the

significance of what is happening when we are in the

middle of major changes. It is only by stepping back

and gaining perspective that we are able to discern

where we have been and gain wisdom about how to

proceed. The war in Iraq has been a crucible for

countless advances in science, technology,

counterinsurgency tactics, and medical practice. Many

of the advances were designed prior to application,

while others were created through practical

improvisation, and still other advances resulted from

facing life-or-death crises. Some of the changes were

immediate and revolutionary while others were

incremental and evolutionary. These advances are

interwoven with the passage of time, and together

result in combat theater maturation. Though space

constraints necessitate some oversimplification, this

article introduces both conditions which should prompt

analysis and decision-making, and several dimensions

of a healthcare system which develop as a combat

theater matures.

The maturation of the Iraq theater of operations is

celebrated by Soldiers returning to Iraq for their

second or third deployments because of the tangible

improvements in security and creature comforts.

Theater maturity affects command and control,

communications, logistics physical plant facilities,

utilities, security, force protection technology, national

and provincial government, and healthcare. Medical

practice advances in the US military health system in

Iraq are very obvious in the historic low rates of both

death due to wounds and loss of manpower due to

disease and nonbattle injury.

Germany and Korea today provide excellent examples

of the end state of US military health systems in a

mature theater of operations. The US military

treatment facilities in both of these theaters are part of

sophisticated, integrated healthcare systems well

adapted to their environments. Combat healthcare

organizations must be effective, whatever the cost.

Healthcare organizations in mature theaters must be

effective and efficient in managing the care of their

supported populations. At some point in history the

deployable hospitals operating out of tents in Germany

and Korea were replaced by temporary buildings.

These hospitals eventually moved into permanently

constructed facilities. Likewise, the medical services

provided within these facilities were adjusted over

time, shifting from a battle injury and trauma focus

during combat operations to a disease and nonbattle

injury focus which today places first emphasis on

primary care, a specialty care network, and community

hospitals. It is impossible to separate technological

advances from chronologic maturation in historic or

modern theaters of operations as technology

improvement and time are interwoven. Historians can

comb the records to find the environmental and

technological conditions and the operational factors

which resulted in the establishment of the first

permanent facilities in Germany and Korea. These

changes in conditions and factors were, in effect,

decision points.

Until very recently, mainstream campaign planning in

the US Army largely neglected detailed planning for

stability or counterinsurgency operations in the theater

after major offensive or defensive operations have

ended. The operational campaign planning curriculum

in our professional military education institutions

historically involved planning and wargaming the

major muscle movements of reception, staging,

onward movement and integration, combat operations

in detail through the actions on the objective, and then

the instructors would declare the end of the exercise

Healthcare System Planning Along the

Combat Theater Maturity Continuum:

Transitioning an Expeditionary Medical

Force to an Integrated Healthcare System

COL David P. Budinger, MS, USA
12 www.cs.amedd.army.mil/references_publications.aspx

(ENDEX). Each of these elements involved

preparation of very detailed plans which included

major decision branches, sequels, and decision points

for the combatant commander and sustainment force

leaders. Planning for healthcare support followed this

paradigm as well. Healthcare planning exercises

traditionally declared ENDEX after the combat

objectives were achieved without regard to the

enduring requirements and changes 6 months, 12

months, or 36 months after major combat operations

ended. The US military’s more than 5-year

engagement in Iraq has prompted the development of

revolutionary doctrine changes for operations in

general, and counterinsurgency operations in

particular.

Learning from the practical experiences of the

maturing Iraq theater of operations, we are in the

optimal position to step back and gain the necessary

perspective to assess our progress and then guide our

strategic decisions about the future design and

establishment of health services and facilities in a

maturing theater of operations. This article is an initial

attempt to create a construct for developing a military

health system throughout the lifecycle of a theater of

operations. The following paragraphs describe several

decision points and dimensions of the healthcare

systems which should be considered in planning across

the strategic timeline which I call the “theater maturity

continuum.” Figure 1 is an oversimplified depiction of

select maturation milestones for the US military health

system in Iraq along a rough timeline to help illustrate

this concept.

DECISION POINTS FOR MILITARY HEALTHCARE SYSTEM

MATURATION

Establishing firm decision points for adding,

removing, or changing the medical support resources

in a theater of operations can be more difficult than

establishing decision points for combat operations.

There are rarely distinct times, locations, or events to

prompt actions or decision-making. There are,

however, environmental, organizational, political, and

physical factors for the healthcare leader to consider

which may prompt his decisions to deliberately

advance, reduce, or change clinical processes,

organizational and support structures, or physical

plants. Many of these are common factors which

healthcare leaders in noncombat theater settings

consider as well. They may be either externally or

internally generated. Below are listed several potential

decision points or variables:

 Changes in the operational security, threat level or

enemy composition and activities

 Geographic or operational changes in supported

units or populations

 Higher command orders to establish, discontinue,

or modify a particular level of support or clinical

service

 Requests or demand from supported customers or

units

 Monthly analysis of injury patterns, disease

prevalence, and evacuations out of theater for

specialty consultation, to higher levels of care, or

for rehabilitative services

 Analysis of diagnoses or causes for lost duty time

 Healthcare professional observations and

recommendations

 Acquisition or loss of essential equipment or other

technology

 Acquisition or loss of physicians or support staff

manpower with a particular skill set

 Rates of shipment of lab specimens or

transmission of radiographic images out of theater

 Advances in medical practice and medical

technology

 Increases or decreases in funding, changes in

funding methodologies, or invalidation of

assumptions or projections in business cases, or

economic breakeven points

 Findings and recommendations from consultants,

audits, external agencies, or investigations

 Changes in supply content, vendors, or distribution

systems

 Changes in routine personnel transportation

circuits, strategic or tactical MEDEVAC asset

density or flight patterns

 Public sentiment (both US and local national)

about longevity of the mission

 Changes in public, media, or political sensitivity

about specific diseases, conditions, or technology

Healthcare System Planning Along the Combat Theater Maturity Continuum:

How an Expeditionary Medical Force Transitions to an Integrated Healthcare System
October – December 2008 13

THE ARMY MEDICAL DEPARTMENT JOURNAL

 Requirements to support host-nation stability

directly or indirectly through cooperative medical

engagements, educational programs, medical

diplomacy, or humanitarian assistance

DIMENSIONS OF HEALTHCARE SYSTEMS WHICH VARY

WITH THEATER MATURATION

According to Army Field Manual 3-0:

Campaign capability is the ability to sustain operations

as long as necessary to conclude operations

successfully...It is an ability to conduct sustained

operations for as long as necessary, adapting to

unpredictable and often profound changes in the

operational environment as the campaign unfolds.

Army forces are organized, trained and equipped for

endurance.1

Relatively few dimensions of the US military

healthcare system remain static as a theater of

operations matures. History reveals countless

examples of military hospitals and medical companies

moving with or shadowing the advance of combat

forces during expeditionary campaigns. As the

campaign extends in duration and mission variables

change, medical system leaders must consider several

physical, manning, and operational elements in order

to adapt the health system to the new environment.

Many of these dimensions are briefly described below:

Hospital and Clinic Physical Plants: The most visible

dimension of military health system maturation is in

the physical plants of hospitals and clinics. In an

expeditionary phase of a campaign the tents and

expandable trailers (ISO shelters) of the deployable

medical system (DEPMEDS) are an appropriate

hospital physical plant, given that they are relatively

mobile and can be modularly customized to fit mission

requirements and environmental constraints. These

systems are not, however, optimal for use in extended

campaigns when the hospital will be employed in a

static location for several years. The Army’s Health

Facility Planning Agency provides the medical leader

with expert consultants to assist in analyzing the

requirements, designing, contracting, and building

hardened facilities for long duration campaigns. It is

not uncommon to design medical facilities for use

between one and 10 years integrating a combination of

existing permanent buildings, plywood structures,

DEPMEDS ISO shelters, or multisection trailers on the

new hospital site. Security threats may necessitate the

addition of concrete t-walls and mortar-protective

overhead shelters or entirely hardened structures in

order to meet force protection requirements. The

facilities intended for use longer than 5 to 10 years are

much more expensive and incorporate more elaborate

utilities, medical gas, communication, and life-safety

systems.

Command and Control/Governance: During the expeditionary phase, the medical brigades or medical

commands are focused on a more volatile and dynamic

supported combat force. Their priority efforts are

primarily wrapping the medical force’s capabilities

around the operational force’s requirements. As the

theater matures, the hospitals and clinics establish

many of the functional committee structures that are

found in medical facilities in the United States to assist

with the management of the hospital. The medical

command and control (C2) or governance structure in

the medical brigade must be significantly expanded in

order to conduct health system management functions

as the theater matures. The theater medical C2

headquarters has a traditional battle staff, but requires

augmentation personnel to man the clinical operations

section, including theater surgical, behavioral health,

and preventive medicine consultants. Recognizing the

need to transform the tactically postured medical force

into a health system, the medical task force in Iraq

added a healthcare administrator to help incorporate

strategic management systems and further integrate the

health system using modern business tools and

methods. In the most mature theaters, the medical C2

structure functionally transforms into a regional

medical command-type configuration as seen in the

United States and Europe.

Healthcare Continuum: The expeditionary medical

system uses the traditional echelons of combat

healthcare, which generally include primary and acute

care supported by very limited medical technology and

manning from the maneuver battalion’s level I

battalion aid stations. The area support medical

companies of the brigade combat teams and

multifunctional medical battalions operate level II

facilities which possess slightly expanded diagnostic

and patient holding capabilities. In settings where

tactical risk increases and evacuation distances or

weather conditions will likely impede the use of rotary

wing medical evacuation (MEDEVAC), it is common

to add a forward surgical team to these level II
14 www.cs.amedd.army.mil/references_publications.aspx

Healthcare System Planning Along the Combat Theater Maturity Continuum:

How an Expeditionary Medical Force Transitions to an Integrated Healthcare System

Figure 1: Selected U

S

military health system advances across the continuum of combat theater maturity in Iraq.

*Table of Organization and Equipment: Defines the structure and equipment for a military organization or unit†Table of Distribution and Allowances: Prescribes the organizational structure, personnel and equipment authorizations, and requirements of a military

unit to perform a specific mission for which there is no appropriate table of organization and equipment.

‡Com

mand and control

Tactical focus Move and shift with supported force Enduring bases with outposts Fixed bases and com

munities

Clinical focus Trauma and primary care,

very limited specialty care

Early integration of hub-and-spokesystem: primary care, robustemergency/trauma care and limitedspecialty care centers and circuitriders

Integrated health system

with

focus on primary and traumacare, population and demandbased specialty care, someappointed care

Primary, definitive specialty, traumacare with com

munity hospitals;

population health focus; appointedcare

Evacuation policy Requiring 7 days or longer, accom

modating more time for recovery and rehabilitation; also Theater

Temporary Holding Detachments

Overseas Army com

munity hospital

standards

Facilities Deployable medical shelters and hybrids, semipermanent and use

of seized permanent structures

Semipermanent construction Permanent construction to US

standards

Equipment Modified TO

&E* equipment replaced with durable US equipment

with augmentation

Theater-provided US standardequipment

US standard

Medicaldocumentation

Paper and limited electronicmedical records

Standardized use of electronic medical record

Supply system

Modified TO

&E* standard w/enhancements. Regional hubs augmented by com

mercial suppliers Prime vendor

Utilities Organic power and water base prime or city power and water/sewage system Base/city utilitiesFunding Requirements-based Possibly budgeted Workload-adjusted budgetQuality, patientsafety, andperformanceimprovement

Unit-based quality andpatient safety efforts

Com

mand-wide quality management standards, striving towards US/JC

standards where practical; use external visits and patient/system tracermethodology

Joint Com

mission accredited

On base EM

S Tactical medical evacuation. Base emergency services. 911

System

Integrated 911 System

with security, fire, and ambulance

Unit manning

Organic modified TO

&E* manning, augmented modified TO

&E*

manning document

Augmented MTOE and/orManning Document/TD

A† with

civilians and contractors

TD

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contractors; Joint manning

C

2‡/

governance TO

&E* Medical Brigade or Medical Com

mand/Medical Support Com

mand Regional medical com

mand

Campaign phase Expeditionary Enduring Campaign with Improving Security Stable environment

20

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06 20

07-20

09 20

09-Unknown Fully mature

C

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October – December 2008 15

THE ARMY MEDICAL DEPARTMENT JOURNAL

facilities to provide trauma and resuscitative surgery.

As the combat theater matures, the levels I and II

facilities function as troop medical clinics which also

provide emergency medical treatment capability on an

area support basis. In the more mature theater the

combat support hospital (CSH) adds more

sophisticated diagnostic, surgical, and specialty care

capabilities. Today it is normal for the mature combat

support hospital to have fluoroscopy, a 16-slice CT

(computerized tomography) scanner, and a greater

variety of laboratory capabilities. The clinical

workload in the CSH in the mature theater shifts from

being dominated by trauma to an outpatient care focus.

Over time, the supported combatant commanders place

increased emphasis on preserving their well-present

for duty strength and desire to have their Soldiers

returned to duty more quickly. This is often

attributable to reductions in combat troop strength and

difficulty obtaining replacement Soldiers. In response

to these expectations, the medical leader should

consider adding women’s health, gastroenterology,

cardiology, and neurology services. It is also prudent

to consider pediatric services too, if the organization is

expected to perform humanitarian assistance support

or care for the local national population in the theater.

When planning health services in the mature theater, it

is important to consider the high density of US

contractors who use the health system. The health

screening process for contractors is much less rigorous

than for Soldiers, thus these patients are generally

older and have more chronic health conditions. In the

more mature theater, it is appropriate for the medical

leader to encourage the establishment of contractor

operated healthcare facilities on the major bases if the

deployed healthcare system desires to reduce

contractor dependency on the US military hospitals.

Clinical Integration and Medical Regulation and Evacuation Resources: In order to get patients in the expeditionary theater to the right level of care in a timely

fashion, unit provided casualty evacuation vehicles or

ground ambulances and MEDEVAC helicopters

evacuate patients, in accordance with doctrine, to the

closest facility with the appropriate level of care. As

the theater matures and the relative proportion of

routine outpatient care or “rule-out” consultations and

referrals increase, the health system leader must

establish a specialty consultant system to enable

telephonic or email consultations, and, if appropriate,

patient referrals. It is also appropriate to work with the

MEDEVAC system leaders to establish routine

MEDEVAC ring routes to fly on regular days of the

week. The high density of specialists and

subspecialists in the medical corps relative to the need

for professional filler system* general medical officers

(GMOs) in level I and II facilities results in a several

specialists and subspecialists filling GMO roles in the

mature theater. Though this is not an optimal way to

meet the deployed force’s primary care needs, this

substitution practice does yield the secondary benefit

of having a rich array of specialists available in theater

for consultation. The medical leader in the mature

theater should closely monitor the assignment of these

specialists, and place some of them in clinic locations

near transportation hubs in order to capitalize on their

ability to serve in dual roles, using their specialty skills

when they are not performing their GMO functions. In

the mature theater it is appropriate to regularly monitor

evacuations and diagnoses by medical specialty to

guide decisions on establishing dedicated specialty

care clinics either at the hospitals or on the major

transportation cross-roads at airport-based health

clinics.

On-base Emergency Medical Service or 911 Phone

System: Once the expeditionary force is positioned on

longer term bases, it is appropriate for the medical

leader to establish an on-base emergency medical

service or 911 phone system in order to speed

ambulance responsiveness and access to prehospital

care. Four years after the establishment of a major base

in Bosnia, a Soldier suffered cardiac arrest at the gym

one mile away from the combat support hospital. The

Soldier’s buddies and the gym staff did not have

access to a 911 phone system, so they called for help

using their unit’s MEDEVAC request procedures. It

*The professional filler system (PROFIS) predesignates qualified Active Duty health professionals serving in Table of

Distribution and Allowance†units to fill Active Duty and early deploying and forward deployed units of Forces

Command, Western Command, and the medical commands outside of the continental United States upon mobilization

or upon the execution of a contingency operation.2

†Prescribes the organizational structure, personnel and equipment authorizations, and requirements of a military unit to

perform a specific mission for which there is no appropriate table of organization and equipment (the document which

defines the structure and equipment for a military organization or unit).
16 www.cs.amedd.army.mil/references_publications.aspx

took almost 20 minutes for the ambulance to arrive at

the gym. The Soldier died and the medical leaders

quickly established a 911 telephone number for the

base in just 2 weeks.

Quality Management and Performance Improvement:

Medical units in the less mature theaters traditionally

establish their own quality standards and operate

within the scope of privileges of the assigned

healthcare providers. In these theaters, there are not

consistent efforts to assess or document competencies

or scopes of practice for the nursing staff or medics.

Basic combat skills call for Soldiers to constantly

improve their foxhole. The medical force should be no

different in constantly improving the quality and

reliability of the health system. As the theater matures,

it is important for the medical leader to progressively

adopt US healthcare quality standards to the degree to

which it is practicable in the more austere

environment. It is not until much later in the

maturation continuum that the healthcare facilities

would even consider Joint Commission* accreditation.

Leaders should, however, instill quality management

standards, patient safety, and performance

improvement systems that embrace US quality

standards as that is what Soldiers, commanders, and

the Soldiers’ loved ones expect and deserve. Over

time, more media, elected officials, coalition nation

leaders, claims attorneys and external agencies take

interest, not just in survival rates and casualty figures

in the deployed healthcare organization, but they also

demand information to document the quality of care

delivered, particularly in high visibility cases or after

untoward outcomes. Adoption of as many Joint

Commission standards and principles as practical

safeguards both the patients and the medical force’s

interests. Though it happens, in the mature theater it is

never proper for members of the healthcare team to

say “this is combat; we don’t do that quality

improvement BS here.” The medical task force

headquarters in the mature theater establishes an

inspection program which should include regular

assessments of the hospitals and medical companies

adherence to standards ranging from the provision of

care, to documentation and communication, to the

environment of care. The high rate of turnover in the

mature theater necessitates a high frequency of quality

and safety-oriented staff assistance visits. Leaders and

quality management staff members in the mature

medical treatment facilities and medical task force

headquarters use the same patient and system tracer

methodology commonly used in US healthcare

facilities in order to assess and improve clinical and

support system quality.

Manning: As the theater of operations matures, the

medical force adds the appropriate staff commensurate

with increased care specialization, technology of

equipment, and sophistication of the physical plant.

Medical leaders should consider employing full time

contract facility maintenance, utilities, and

housekeeping staff once the hospital or clinic is in a

permanent location. Several lower density or

frequently deployed specialties become over-used or

depleted during longer term operations in the mature

theater. It is wise to consider permitting US

government civilian employees or contractors to

perform select functions in the more permanent

healthcare facilities. It is important to work all of the

details of both civilian personnel management,

including management-employee relations, and

contracting officer and contracting officer

representative roles and requirements well in advance

of bringing civilians or contractors into the healthcare

facilities. Additionally, as the business accountability

and finance requirements in the medical treatment

facilities and the medical C2 headquarters increase,

leaders should consider which of these functions must

be done in theater and which could be performed

remotely by a contractor or other agency in the

continental United States (CONUS) in direct support

of the deployed medical task force.

Equipment and Standardization: Standard medical

equipment sets for the CSHs and the medical

companies are rarely adequate for the expeditionary

medical force because they tend to lack several items

of diagnostic and surgical equipment which providers

rely upon in their practice. Most expeditionary medical

units deploy with augmentation equipment they have

specially procured in order to meet their providers’

basic requirements. The longer the medical force stays

in the theater, and the more broadly the healthcare

facilities’ scope of care expands in order to

accommodate specialty care providers’ needs, the

greater the demand for traditional medical equipment

found in community hospitals and medical centers in

*Joint Commission on Accreditation of Healthcare

Organizations, One Renaissance Blvd, Oakbrook Terrace,

Illinois 60181

Healthcare System Planning Along the Combat Theater Maturity Continuum:

How an Expeditionary Medical Force Transitions to an Integrated Healthcare System
October – December 2008 17

THE ARMY MEDICAL DEPARTMENT JOURNAL

CONUS. As hospitals move into more permanent

facilities, they replace their deployable hospital beds

with commercial beds. They also add more

sophisticated refrigerators with alarm systems, c-arms,

various scopes, monitors, and commercial sterilizers in

order to meet the clinical quality and durability

requirements of the staff. Rather than permit

unchecked acquisition of a wide variety of equipment

from a plethora of manufacturers for the various

facilities across a theater, the medical task force in the

mature theater establishes a medical equipment

standardization board to consider and procure the

commonly accepted advanced equipment which can be

shared between facilities, and maintained with a

common set of repair and calibration equipment. These

multidisciplinary equipment standardization boards

function similarly to a capital equipment program and

budget advisory council in CONUS military treatment

facilities (MTFs). Reducing the variety of models

within a common type of medical equipment allows

the clinical engineering staff to maintain a common set

of repair skills, manuals, parts, and spare medical

devices to provide to facilities when their equipment is

out for repair. Given that the intermediate maturity

health systems do not have a dedicated capital

equipment budget, the MTFs’ equipment is funded on

a requirements basis using a letter of justification and

an operational needs statement which passes through

service component command channels for approval at

the military service secretary’s office. The Army’s

Office of The Surgeon General and the US Central

Command recently established a Joint Medical

Technology Assessment Review Team to serve as an

objective office to guide and validate the acquisition of

high cost and advanced technology medical equipment

requirements for the maturing theaters of Iraq and

Afghanistan.

Communication and Documentation of Care: Although

documentation of healthcare is beneficial in managing

the health of a patient, and for communication between

members of the healthcare team, it is not commonly

among the highest of priorities in the expeditionary

medical force. As the theater matures and the

healthcare organizations assume a more predictable

pattern of operations, the medical record becomes

more important to the healthcare team. The more

mature healthcare systems establish standards

requiring providers to document their care using the

electronic medical record (EMR). The hardened

facilities and more reliable utilities provide a more

stable environment improving the reliability of

information systems and the electronic medical record.

The EMR follows the patient as he is evacuated

through the healthcare system out of theater to military

or Veterans Affairs healthcare facilities in CONUS,

and provides a longitudinal record for reference

throughout his life. The MTFs in the more mature

theater also use the electronic medical record to

perform medical record reviews to assist with quality

management functions. They also typically have a

robust set of secure and nonsecure telephones and

dedicated bandwidth on the mature bases’ networks,

and they use enhanced VSAT (very small aperture

terminal) satellite systems. As is the case in CONUS,

healthcare providers are generally dissatisfied with the

slow speed of the EMR system, but in many cases the

mature healthcare facilities acquire voice recognition

software to mitigate their frustration by assisting with

the dictation of clinical notes.

Business and Accounting Functions: Theater medical

rules of eligibility often require the US healthcare

facilities in the theater of operations to provide care to

all categories of patients who present at their facilities

in order to preserve life, limb, or eyesight. Deployed

MTFs do not have any organic capability to perform

any medical record coding, third party insurance

billing or collecting, or accounting for contractor or

noncoalition force healthcare. Additionally, the

deployed medical facilities and headquarters, even in

the semimature theaters such as Iraq in 2008, 5 years

after the invasion, lack the resource management

staffs, manpower, and workload accounting staffs to

perform basic workload accounting and analysis

functions. At some point farther along the theater

maturity continuum, these business and accounting

functions should be added. As stated earlier, many of

these functions may be performed remotely from

CONUS in support of the deployed MTFs. The

funding of deployed MTFs is normally requirementsbased and thus not subject to the typical constraints of

a fixed or workload-adjusted budgeting system. As the

theater matures even further and budgeting systems

evolve, the deployed medical task force should

consider establishing resource management or

business offices.

CONCLUSION

The maturation of the Iraq theater of operations over

the first 5 years demonstrates that leaders deliberately
18 www.cs.amedd.army.mil/references_publications.aspx

and successfully improved quality, integration, and

accessibility of the healthcare system. As the adage

goes, Soldiers do well those things their commander

checks. This has proven true in assessing the

remarkable improvements in the content of care as

well as the medical support systems. When planning

and executing future campaigns, it is imperative that

we deliberately design and implement mechanisms to

catalyze the maturation and ensure quality

performance of the important healthcare and support

functions based on the conditions in the operational

environment. As the medical force enjoys the benefit

of more time, leaders must establish and monitor

decision points, analyze the environment, develop

plans, and then professionally manage this maturation

in order to strategically improve healthcare. It is too

easy to stand still, analyzing and observing, waiting for

the rate of change to slow before acting. Leaders must

not view the deployed US healthcare system as a series

of one-year deployments, but instead purposefully

guide development, striving to achieve US quality

standards, constantly improving health system

integration, and developing facilities with

technologically appropriate equipment, all while

leading a well-trained, adaptive, and competent staff.

In conclusion, when considering the length of time it

takes for a theater to mature, it is helpful to look at one

Army hospital in Seoul, Korea, which passed a major

milestone 58 years after it supported expeditionary

operations in the Korean War. It has benefitted from

many generations of improvements, but it has

continuously wrapped its services around the

operational needs of the supported units and met the

needs of its individual patients. The former 121st

Evacuation Hospital made one of its final advances

along the maturity continuum as it was given the

permanent name as the Brian Allgood Army

Community Hospital in June 2008, in honor of this

outstanding officer who sacrificed his life while

leading the maturation of the healthcare systems in

Iraq on January 20, 2007.

REFERENCES

1. Field Manual 3-0: Operations. Washington, DC: US

Dept of the Army; February 2008:chap1,p1-16.

2. Medical Corps Professional Development Guide.

Fort Sam Houston, TX: US Army Medical

Department Center and School; March 2002:27.

AUTHOR

At the time this article was written, COL Budinger was

the Deputy Commanding Officer, Task Force 62 Medical Brigade, Baghdad, Iraq.

Healthcare System Planning Along the Combat Theater Maturity Continuum:

How an Expeditionary Medical Force Transitions to an Integrated Healthcare System

COL SCOTT JOINS THE AMEDD JOURNAL EDITORIAL REVIEW BOARD

The AMEDD Journal welcomes COL Dana P. Scott, VC, USA as a

member of the Editorial Review Board. COL Scott is the Deputy

Chief, US Army Veterinary Corps, AMEDD Center & School, Fort

Sam Houston, Texas.

COL Scott joins the board replacing COL Marc E. Mattix, VC, USA.

COL Mattix has been a member of the Board since October 2007.

We thank COL Mattix for his dedication to the high standards and

professional quality of this publication, and his support to our

mission. We wish him well in his return to the big skies and wide

prairies of Montana.

The Editors
October – December 2008 19

Positions built on systems of activities are far more

sustainable than those built on individual activities.

Michael Porter1

INTRODUCTION

The medical task force’s system of organizational

strategy and change management lies within the

combat healthcare support system (CHSS). The CHSS

is a customized offshoot from traditional balanced

scorecards2in that the task force does not state the

operational objectives on the strategy map, but simply

shows the strategic macro-objectives. There are subsystems and select initiatives which support the

accomplishment of these objectives. The CHSS

modified strategy map shows the interdependencies

and synergy of various subsystems in support of Task

Force 62 Medical Brigade’s strategic objectives (listed

on page 20).

The medical task force for Operation Iraqi Freedom

completed 5 years of support to Multi-National

Forces-Iraq combat operations in early 2008. The task

force headquarters has engaged in every aspect of

command and control (C2) for each of the medical

functions in Iraq with distinct requirements from

predeployment planning, planning for future

requirements to reception, staging, onward-movement

and integration to mission execution, sustainment, and

redeployment.

The medical task force in Iraq has C2 responsibility

for 46 medical units. These units consist of 4 hospitals,

4 headquarters elements, and 38 companies and

detachments that provide healthcare to US and

Coalition forces, select contractors, and detainee

populations throughout the Iraqi area of responsibility.

Although there have been numerous rotations and a

fresh look at the delivery of healthcare each year, there

were very few signs of health systems integration

beyond trauma management. The commander and

senior leaders of the Task Force 62 Medical Brigade

(TF62 MED) identified a requirement for integration

and standardization of processes and systems, and an

increased emphasis on task force-wide performance

improvement. The vehicle to implement a strategy was

modeled after the balanced scorecard.2 This method

enables the commander and senior leaders to illustrate

a customized strategy map demonstrating task force

strategies and the ability to communicate them across

the organization, as well as to identify key internal

processes that drive strategic health service support

successes. Ultimately, the medical task force

commander is responsible for implementing

Department of Defense (DoD) healthcare policy.

Examples of this are the documentation of care in the

electronic medical record, treatment of mild traumatic

brain injury and post traumatic stress disorder, and the

implementation of recommendations after the Mental

Health Assessment Team (MHAT) V* study.3

The TF62 MED CHSS strategy map, presented as

Figure 1 on page 6, provides a graphical depiction of

functions and relationships between all medical units,

as well as different medical warfighting functions. All

the medical warfighting functions are synthesized into

an integrated healthcare delivery system in order to

A Systematic Approach to Combat

Healthcare Improvement: Task Force 62

Medical Brigade Combat Healthcare Support

System Model

MAJ Alan Ueoka, MS, USA

*MHAT V is the fifth of a series of mental health advisory teams sent by the Army Surgeon General to the theaters of

operations (Iraq and Afghanistan) to assess the mental and behavioral health of deployed Soldiers; the quality of mental

and behavioral healthcare; access to this care; and to make recommendations for changes to improve the mental health

and mental health services to our men and women who are deployed into combat environments.
20 www.cs.amedd.army.mil/references_publications.aspx

*Chain-teach is a method of unit training in which designated unit members first receive the training, after which it is

their responsibility to train another level of personnel, who in turn will continue training others. The training continues

in a pyramid fashion until all personnel requiring such training have received it.

provide effective battlefield healthcare. The model is

only a blueprint for how we build—it is not the

building.

The combat healthcare delivery system uses a strategy

map, adopted from Kaplan and Norton’s ongoing

studies on strategic management.4 The medical task

force further divided our mission into 3 achievable

ends:

1. Provide World-Class Warrior Healthcare to US

and Coalition Forces. The intent is to optimize

Warrior return-to-duty and conserve combat

power. This focuses on medical treatment of

both battle injury and disease and nonbattle

injury (DNBI), and care for the injured and ill.

The dedication to human life has led to an

almost 98% return-to-duty rate for every service

member arriving at our treatment facilities.

2. Protect the Health of US and Coalition Forces.

The intent is to maximize present-for-duty and

reduce DNBI. This focuses on proactive,

systematic surveillance and prevention of threats

to service member health. Currently, there is a

DNBI rate of only 2.5%, which is the lowest in

the history of warfare.

3. Enhance Government of Iraq Credibility by Supporting Self-Reliant Iraqi Public Health Systems.

The intent is the promotion of medical

diplomacy and the enhancement of the

Government of Iraq’s (GoI) credibility. Focuses

on efforts and systems to support the GoI’s

ability to effectively defend itself, and ensure

basic services for the Iraqi people.

These ends drive the task force’s efforts toward

achieving unilateral improvement in focused areas

through weekly review and management of

measurable tasks. These ends are listed at the top of

the strategy map. As an integrated healthcare delivery

system, the medical brigade task force headquarters

has been absolutely critical to the establishment of

documented process and improved healthcare systems

and subsystems. In rapidly changing and fluid

environments like counterinsurgency operations, units

find their sustainable solutions through injecting their

units with the culture of process improvement and

continual learning and growth. The vehicle to

implement a strategy was modeled after the balanced

scorecard2and strategy map. This method enabled the

task force commander and senior leaders to show the

task force how to create a customized strategy map

that allows the task force to:

 Clarify task force strategies and communicate

them across the organization.

 Identify the key internal processes that drive

strategic health service support success in the Iraq

theater of operations.

 Align the DoD’s investment in people, technology,

and organizational capital for the greatest impact

in combat casualty care.

 Expose gaps in the military health system

strategies and take early corrective action.

IMPLEMENTING THE COMBAT HEALTHCARE SUPPORT

SYSTEM STRATEGY MAP

TF62 MED systematically implemented and

rigorously executed a strategy map known as the TF62

MED CHSS throughout the task force to the lowest

unit levels. The task force began the implementation of

the strategy map through a chain-teaching* program,

directed through a fragmentary order and requiring all

units to comply with the top-down driven vision of the

system. Performance improvement and patient safety

are the task force’s main effort ensuring that desired

outcomes are realized and systematic fixes are

established. Leaders ensure every member of their

section or unit are able to describe how they fit into the

CHSS model and support the 3 major purposes of the

medical task force. All members of the task force are

also charged to describe a specific systematic

performance improvement initiative on which they are

working.

DESCRIPTION OF THE STRATEGY MAP

The TF62 MED combat healthcare support system or

modified strategy map portrays the key elements that

make up the organization and how they fit together in

the overall strategy. The modified strategy map

considers perspectives of the stakeholders (military

A Systematic Approach to Combat Healthcare Improvement:

Task Force 62 Medical Brigade Combat Healthcare Support System Model
October – December 2008 21

THE ARMY MEDICAL DEPARTMENT JOURNAL

health system) and customers (patients and casualties).

The depth of the model is based upon objectives and

resources.

Objectives

All CHSS objectives and measures of effectiveness are

developed under the acronym SMARTER—specific,

measurable, accountable, results, time bound, encompassing, and reviewed. SMARTER objectives are

defined as:

Specific: States specific end points desired.

Measurable: Measures results usually by a number

or percentage.

Accountable: Identifies and holds individual, team,

department, section or unit accountable for

action and outcomes.

Results: Identifies the outcomes desired, not the

process to get results.

Time-bound: Specifies when results are to be

achieved.

Encompassing: Aligns with and supports all other

objectives (ie, inclusive and linked or nested

with higher headquarters).

Reviewed: Evaluated to check relevance and progress towards results.

These principles helped the brigade staff shape the

measurable objectives for their individual staff

sections. These objectives must fit into the task force

commander’s vision, framed by Ends, Ways, and

Means.

Ends

As discussed on previous pages, the task force used 3

achievable Ends to focus the collective efforts and

define left and right limits. There are 3 major ends to

the TF62 MED strategy map:

1. Optimize Return-to-Duty and Conserve Combat

Power. The intent is to optimize Warrior returnto-duty and conserve combat power. This

focuses on medical treatment of both battle

injury and DNBI, and care for the injured and ill.

2. Maximize Well Present-For-Duty and Reduce

DNBI. The intent is to maximize present-for-duty

and reduce DNBI. This focuses on proactive,

systematic surveillance and prevention of threats

to service member health.

3. Improved Health Status, Public Confidence,

Increased Capability and Capacity. The intent is

the promotion of medical diplomacy and the

enhancement of the GoI’s credibility. Focuses

on efforts and systems to support the GoI’s

ability to effectively defend itself, and ensure

basic services for the Iraqi people.

Ways

The Ways deliver the “how” to the organizational

goals at the top of the strategy map. Our internal

process and systems provide those Ways in which we

conduct our daily operations. The internal process and

systems are subdivided into the following 3

components:

Warrior Healthcare Systems—consist of hospitalization, surgery, diagnostic and specialty care; the

primary and dental care system; trauma and chronic

care clinical practice guidelines; medical regulation;

and clinical integration. The warrior healthcare system

focuses on providing emergency, acute, and chronic

care, hospitalization, and surgery to US and coalition

forces and other beneficiaries. It also ensures that,

when applicable, providers use clinical practice

guidelines to capitalize on best practices and the

management care of patients relying on the integrated

health system medical units.

Force Health Protection Systems—consist of preventive medicine systems, veterinary care systems, mental

health care, and building resiliency. The focus of this

component is to proactively identify environmental

and health risks to the force, develop systems to

monitor and mitigate risks, maximizing (well) presentfor-duty strength. Additionally, the resources of these

specialty areas systematically develop and implement

interventions to enhance the future health and

resilience of the service member.

Medical Civil-Military Operations Systems—consist of

professional meetings, engagements, public education,

and medical training (Pro-MEET). Cooperative

medical engagements facilitate improved access to

Iraq health services, timely Iraqi patient transfers/

discharges from US to Iraqi facilities, including the

detainee healthcare system. The medical task force can

capitalize on an increased level of security to develop

the host nation’s medical competency, prestige, salary,
22 www.cs.amedd.army.mil/references_publications.aspx

and employment conditions. The training the task

force provides Iraqi physicians and medical staff are

events that can be leveraged for positive local media

efforts to both promote Iraqi public confidence and

legitimize the Ministry of Health in particular, and the

GoI in general, by synchronizing information, public

affairs, and psychological operations enablers.

The first element of medical civil-military operations

is health sector legitimacy and efficiency. Legitimacy

and efficiency of local healthcare services support

efforts which build the Iraqi people’s confidence in

their health services, and encourage wise use of

resources. The second element is professional medical

engagement, education and training (Pro-MEET)

which provides professional training, education, and

counsel to improve the effectiveness of the GoI patient

care and health system management. The third element

is US/Iraqi focused and strategic partnership which

selectively joins resources of Coalition and Iraqi

government and private sector entities to enhance Iraqi

self-sufficiency.

Means

Learning and growth encompass the Means by which

we conduct our daily operations. The following are

applications, enablers, and programs that provide the

Means by which the TF62 MED executes the

previously delineated 3 components of the internal

processes and systems which define the Ways:

 Clinical Quality Management: Ensure healthcare

delivered within accepted standards.

 Comprehensive Risk Management: Retrospective

review sampling normal cases (morbidity and

mortality, sentinel events, etc).

 Electronic Clinical Documentation: Integrated

information systems to document care and

communication within and across the continuum

of care.

 Logistics and Maintenance Management:

Proactive and responsive systems to provide and

maintain the supplies and equipment.

 Health Facilities Planning and Management:

Establish and maintain physical plants and

environment of care.

 Continuing Education and Training: Providing,

improving, and refreshing individual and

collective skills.

 Agile Joint/Multination Command and Control

Structure and Methods: Agile organization and

leadership based on forces, function, and

geography.

 Organizational Assessment: Physical and virtual

assessments and reviews.

 Efficiency, Effectiveness, Outcome, Measurement and Accountability Systems: Means to

ensure we are achieving desired outcomes

effectively and wisely.

 Moral Compass, Ethical System Framework: Do

the right thing respecting others.

 Develop Adaptive Leaders: Leaders who are

values-grounded and who lead in accordance

with the standards of Army Command Policy.

5

Resources

The resources block is integral to the foundation of the

model, upon which sit the Ends, Ways, and Means.

People, fiscal management, and information system

structures must be present and follow a solid process

to provide an inimitable and invaluable product. The

following resources support the overall strategy of the

TF62 MED CHSS:

Force and Human Resources Management: Competent, cared-for personnel with the intent skills

at the right sites.

Fiscal Stewardship: Adequate operating funds

managed with taxpayers’ interests in mind.

Medical Information Management/Information

Technology, Military Health System Acquisition,

Research/Development, and Infrastructure: Robust information technology, acquisition, and

research systems and infrastructure.

FOUNDATION OF THE TF62 MEDICAL BRIGADE CHSS

All successful strategies must have a foundation. The

TF62 MED strategic foundation is nested in the

acronym F.L.A.G.—family, leadership, ambassadorship, and growth. The tenets of the philosophy of

F.L.A.G. are presented on the facing page.

Implementation Strategy

Without quantifying, a strategic objective is simply

a passive statement of intent.4(p365)

A Systematic Approach to Combat Healthcare Improvement:

Task Force 62 Medical Brigade Combat Healthcare Support System Model
October – December 2008 23

THE ARMY MEDICAL DEPARTMENT JOURNAL

The medical task force developed metrics in concert

with the commander’s vision of providing US

healthcare through a systematic process improvement

culture. Each section developed these metrics based on

their respective contribution to the framework of the

system, or on each of their “buttons” on the strategy

map. In order to build consistently developed

measurements, the staff used the following 3-point

framework for each objective:

1. Objective: Defines the purpose of the metric in

quantified and achievable terms.

2. Benchmark: Defines comparable standards; first

in Army standards, then Joint Commission*

standards, and finally brigade standards. Each

succeeding standard is used only if the higher

level one is nonexistent.

3. Assessment: Defines how the brigade is meeting

the objective in temporal objectives and task

accomplishment.

It must be stated here that not all

objectives are quantifiable. Where this

was the situation, the task force used a

qualitative demonstration of how we

targeted the problem or issue. The staff

section used either a storyboard or

project map to show the progress of an

action or project to update the

commander.

The staff had to incorporate an understanding of the quantification process

into the task force organizational

strategy and vision. The staff considered 3 ingredients of the dynamics of

strategy and added them to our strategy

map processes. These ingredients also

kept the staff focused on achievable and

feasible tasks and objectives that were

all related to the ends and centered on

our stakeholders.

 Quantify: Establish targets and

va lid ate th e c au se - a nd - e ffe ct

relationships in the strategy map.

 Define the Timeline: Determine how

strategic themes will create value in

short-, medium-, and long-term

horizons to create balanced and sustained value

creation.

 Select Initiatives: Choose the strategic investments

and action programs that will enable the

organization to achieve its targeted performance in

the stated time frames.

The task force implemented the combat healthcare

support system model with the publication of

Fragmentary Order #291 to TF62 MED Operations

Order 07-09,†a directive which provided a top-down

communication of strategy and implementation. This

ensured common understanding of the task force

mission, vision, and values, and enabled

communication of organizational goals and objectives

through an implementation briefing. This strategy was

implemented by subordinate staff sections and

commands within 30 days of its creation. This was

accomplished by using a chain-teaching presentation

provided in the published directive. The direct

*Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Blvd, Oakbrook Terrace, Illinois 60181

†Internal military document not readily accessible by the general public.

Reproduction of the in-theater poster displaying the tenets of the

F.L.A.G. institutional philosophy developed by the TF62 Medical Brigade

as the foundation for the combat healthcare support system.

I will never leave a fallen comrade

We not only fight for the Constitution and our Democracy,

We fight for each other.

Families take care of each other and treat one another

with dignity and respect.

You enlist Soldiers, Sailors, Airmen, and Marines, but

reenlist Families.

I will never accept defeat

No one is more professional than I.

Lead from the front with personal and organizational

integrity.

Leadership is a TEAM sport-counsel, coach, and mentor.

I will always place the

mission first

Duty, Honor, Country!

Your character must honor our nation, your service, unit

and Family.

Ethical conduct and medical diplomacy are force

multipliers.

I will never quit

Know your job, do your best, and develop your abilities to

the utmost.

Always seek to improve your physical and spiritual fitness.

We are a learning organization and must maintain a

perpetual quest for knowledge.

S O HE L P M E G O D !

Family, Leadership,

Ambassadorship, and

Growth

“Your life is not important except for

the impact it has on anoth er life”

Jackie Robinson
24 www.cs.amedd.army.mil/references_publications.aspx

reporting units were tasked to notify the TF62 MED

deputy commanding officer once all officers and

senior noncommissioned officers have been briefed on

the modified strategy map.

The headquarters staff was responsible for further

development of the strategy and metrics to measure

performance and progress by asking 2 simple

questions:

Are we aligned with the strategy?

Are we making progress?

The clinical operations section gained ownership of

the warrior healthcare system and force health

protection systems. The Civil-Military Operations

Officer gained ownership of the medical civil-military

operations system. The rest of the staff sections gained

ownership of the elements within the ways and means.

Additionally, the TF62 MED commander is provided a

monthly strategy assessment using an interactive

model of the strategy map, in which each button is

linked to the objectives and measurements in a

PowerPoint®“dashboard.” This operates just like a

webpage, which eventually is one of the end-products

of this project. The commander and staffs are also

provided with a binder (updated monthly) with

documentation of metrics in a snapshot.

SUMMARY

An organization’s mission, vision, and values are just

words—intangible concepts, unactionable directives,

and inconsequential thoughts. Without the emphasis,

energy, and a defined process and framework, the

words have little meaning to the organization. Task

Force 62 created this organizational vision and

communications strategy through a tested model based

on Kaplan and Norton’s4continuing studies on

organizational strategy. The task force accomplished

its strategy only by overcoming the most difficult

hurdle in changing organizational culture—accepting

change. Over time, the staff evolved from compliance

to commitment to the culture of process improvement

and organizational introspection. We could do this

because the climate during our weekly reviews was not

punitive or defensive, but collaborative and

challenging. We also saw the value added to our unit

and task force growth and development and, in the

process, learning and development as individuals.

Future medical task forces will have the ability to gain

ground and develop this model for conclusion. As the

Army Medical Department (AMEDD) continues to

develop and refine lessons learned, the CHSS model

presented here can be the foundation for the AMEDD

and DoD’s vision in the creation and modification of

schoolhouse programs of instructions and doctrine to

be relevant to the maturing combat theater of

operations.

REFERENCES

1. Porter ME. Competitive Strategy: Techniques for

Analyzing Industries and Competitors. New York,

NY: The Free Press; 1980.

2. Balanced Scoreboard Institute. What is the balanced

scoreboard?. Available at: http://www.balancedscore

card.org/BSCResources/AbouttheBalancedScorecard/

tabid/55/Default.aspx. Accessed October 6, 2008.

3. Mental Health Advisory Team (MHAT) V: Operation

Iraqi Freedom 06-08, Iraq; Operation Enduring

Freedom 8, Afghanistan. Washington, DC: Office of

The Surgeon General, US Dept of the Army; February 14, 2008:26. Available at: http://www.armymed

icine.army.mil/reports/mhat/mhat_v/MHAT_V_

OIFandOEF-Redacted.pdf.

4. Kaplan RS, Norton DP. Strategy Maps, Converting

Intangible Assets into Tangible Outcomes. Boston,

MA: Havard Business Press; 2004.

5. Army Regulation 600-20: Army Command Policy.

Washington, DC: US Dept of the Army; March 18,

2008.

AUTHOR

When this article was written, MAJ Ueoka was the

Chief of Operations for the Operation Iraqi Freedom

Medical Task Force (62nd Medical Brigade) in

Baghdad, Iraq.

A Systematic Approach to Combat Healthcare Improvement:

Task Force 62 Medical Brigade Combat Healthcare Support System Model
October – December 2008 25

The people were neither friendly, nor unfriendly,

they were seeking only survival.

Robert Wilensky1

COIN [counterinsurgency operations] can be

characterized as armed social work. This makes

CMO [civil-military operations] a central COIN

activity, not an afterthought. CMO is one of the

means of restructuring the environment to displace

the enemy from it.2

What are medical civil-military operations (CMO)? As

the deployed Task Force 62 Medical Brigade (TF62

MED) Civil-Military Operations Section (S9) working

in the Iraq theater of operations over the past 14

months, we have encountered numerous challenges

while expanding, contracting, deconflicting, and

integrating the role of civil affairs into the medical

mission. There is no doubt that health services can

have a significant positive impact in counterinsurgency

operations and stability operations when it is properly

planned and executed.

The only current doctrine that specifically addresses

medical CMO is Joint Publication 4.02; Health

Service Support,

3 which defines medical civil-military

operations as health-related activities in support of a

joint forces command that establish, enhance,

maintain, or influence relations between the joint or

coalition force and host nation, multinational

governmental, and nongovernmental civilian

organizations and authorities, and the civilian

populace, in order to facilitate military operations,

achieve US operational objectives, and positively

impact the health sector.3(pIV-7)

There are a significant number of entities or

stakeholders involved in medical civil-military

activities, including host nation government agencies

such as the ministry of health (MoH) and ministry of

defense (MoD), international organizations,

nongovernmental organizations, interagency departments, the US Department of State, and Coalition

forces, each with unique capabilities and objectives.

This article focuses on how the Medical Brigade and

its direct reporting units are spanning the health care

spectrum working with civilian and military host

nation medical and veterinary organizations to enhance

the host nation’s credibility by supporting self-reliant

Iraqi public health systems.

When determining the medical CMO mission, it is

imperative to understand that medical CMO, although

important, is secondary to the medical brigade’s

primary mission of providing world-class Warrior

healthcare to US and Coalition forces. The organic

medical brigade has numerous strengths and is

uniquely qualified to provide training to personnel at

Medical Civil-Military Operations: The

Deployed Medical Brigade’s Role in

Counterinsurgency Operations

LTC Jeffrey Bryan, USA

CPT Danelle Miyamoto, MS, USA

LTC Vincent Holman, MS, USA

ABSTRACT

Medical civil-military operations are a critical combat multiplier directly supporting the counterinsurgency fight.

Army Medical Department Soldiers support medical civil affairs activities at all levels from platoon to the United

States Mission-Iraq (Department of State) initiatives enhancing the legitimacy of medical services in the Iraq Ministry

of Health, Ministry of Defense, Ministry of the Interior, and Ministry of Justice.

The civil-military operations mission of the deployed Task Force 62 Medical Brigade has also evolved into a broad

mission encompassing over 120 contractors including Iraqi-American, Bilingual Bicultural Advisors–Subject Matter

Experts serving as case management liaison officers and medical trainers, as well as Iraqi Advisor Task Force

members providing medical atmospherics, assessments, training, and the overall management of Iraqi linguists

supporting all level III medical facilities.
26 www.cs.amedd.army.mil/references_publications.aspx

all levels in the healthcare industry, and direct

healthcare to eligible Iraqis. It also has numerous

constraints and limitations that other medical support

Coalition force units do not have. We have worked to

mitigate those limitations. For example, the brigade is

not equipped, staffed, nor trained to conduct tactical

missions outside of a secure area without support from

maneuver elements or specialized contractors. TF62

MED does not own battle space, limiting engagements

to specific MoH and MoD representatives that have

access to Coalition force facilities. Understanding the

strengths, limitations, constraints, and mitigating

factors of the deployed medical brigade is critical

when planning medical civil-military activities

(MCMA). While refining MCMA, the S9 section

should be planned from the focus of the 5 factors from

Army Field Manual 8-42,

4 which lays out specific

planning considerations for foreign internal defense

missions that apply equally to current COIN

operations. All brigade MCMA initiatives must

address these 5 factors from Field Manual 8-42 prior

to approval of mission execution:

 Plan is developed with the host nation’s assistance.

 Plan enhances rather than replaces the host

nation’s existing programs.

 Host nation has the resources to continue the

programs if the US military effort is sharply

curtailed or discontinued.

 Host nation receives the credit for the program

rather than the US military. This is accomplished

by ensuring that all combat health service

operations include representatives of the host

nation or its military.

 Health Service Support goals and objectives are

considered for each region or province.

As a result of mission analysis, the mission of medical

civil-military operations has evolved and been refined

to improve the health status, public confidence, and

increasing capability and capacity. To successfully

accomplish this mission, the CMO section is further

divided to address 3 distinct objectives:

 Professional meetings, engagements, education,

and training (Pro-MEET) and cooperative medical

engagements

 Facilitate improved access to host nation health

services

 Facilitate timely host nation patient transfers/

discharges from US to host nation facilities

PROFESSIONAL MEETINGS, EDUCATION, ENGAGEMENTS

AND TRAINING, COOPERATIVE MEDICAL

ENGAGEMENTS

The Medical Brigade conducts a significant amount of

professional medical training. When planning medical

training programs in the COIN environment, we have

found that the guidance in Army Field Manual 3-24 is

critical: “Keep programs small. This makes them

cheap, sustainable, low-key, and (importantly)

recoverable if they fail.”2(pA-8) The Medical Brigade

supports 2 long-term training programs: a 10-week

MoD sponsored trauma training course in the

international zone, and the 8-week Iraqi correctional

medic courses on Camps Cropper and Bucca. The

remaining courses that the Medical Brigade has

established across the theater are smaller scale, shortterm, noncertificate-producing “train the trainer

courses” designed to increase the professionalism and

build the civil capacity of the Iraqi health care system.

Over a 12-month period, the Medical Brigade

conducted 82 events providing full spectrum health

services training to 824 students. The Medical Brigade

held courses in dentistry, veterinarian services,

medical logistics, oxygen generation, basic to

advanced lifesaving, burn care, trauma, and ground

ambulance training, to name a few.

The Medical Brigade planned and conducted 15

cooperative medical engagements (CMEs) and assisted

with numerous others throughout Iraq. The CMEs are

designed to gain Iraqi support and facilitate the

establishment and restoration of basic health services

(see Figure 1). Our contracted Iraqi-American doctors,

along with local physicians, dentists, and healthcare

workers provide the patient care, ensuring the

engagements have an Iraqi face. We also precoordinate

with local leadership and MoH facilities for possible

referrals. During these 15 engagements, we have had

6,447 patient encounters. The use of local Iraqi doctors

and locally procured medication ensures the patients

see their government providing essential services. Just

over the past few months, these CMEs have evolved

from primarily providing medical care and referrals to

the teaching of preventive measures. The focus of this

training is to teach the women and children ways they

can improve the quality of their health, while keeping

it simple enough to allow them to share the knowledge

with their family members. Educating the Iraqis and

building awareness is just one of the ways that CMEs

are helping to enforce the legitimacy of the Iraqi

medical system.

Medical Civil-Military Operations: The Deployed Medical Brigade’s Role in Counterinsurgency Operations
October – December 2008 27

THE ARMY MEDICAL DEPARTMENT JOURNAL

FACILITATE IMPROVED ACCESS TO IRAQI HEALTH

SERVICES

The Iraqi Advisor Task Force (IQATF) team, detailed

in Figure 2, has visited and assessed 255 new medical

and health care facilities and updated over 500

previously assessed facilities. This improved visibility

on Iraqi facility’s capacity and capabilities expands

our ability to refer Iraqi patients to the correct facilities

for treatment. The S9 section produces an average of

50 reports per month, including executive summaries

and Iraqi-specific requests for medical information

across the Iraq theater of operations, which are used to

generate numerous intelligence summaries. We have

also placed an IQATF liaison officer into various

positions, including the Multi-National Force-Iraq

surgeon cell, to provide a strategic link between them

and the Ministry of Health.

FACILITATE TIMELY IRAQI PATIENT TRANSFERS/

DISCHARGES FROM US TO IRAQI FACILITIES

The Medical Brigade’s 17 case management liaison

officers (CMLOs) are responsible for managing the

transition of Iraqi patients back into the Iraqi

healthcare system for further care after they are

stabilized at one of our facilities. The other task is to

assist them in their return home once treatment is

complete. In the last 10 months, the CMLOs have

assisted 5,746 Iraqi patients, including 966 direct

transfers to host nation facilities.

The Medical Brigade is committed to planning and

conducting initiatives that support the Iraqi Security

Forces and build civil capacity. As described in Field

Manual 3-24:

5-3. COIN operations combine offensive, defensive,

and stability operations to achieve the stable and secure

environment needed for effective governance, essential

services, and economic development. The focus of

COIN operations generally progresses through 3

indistinct stages that can be envisioned using a medical

analogy:

 Stop the bleeding.

 Inpatient care—recovery.

 Outpatient care—movement to self-sufficiency.

Understanding this evolution and recognizing the

relative maturity of the operational environment are

important to the conduct (planning, preparation,

Cooperative Medical Engagements

The 3 characteristics aimed to increase the capacity

and legitimacy of the provincial and national

governments of Iraq:

 Medical treatment and engagements must be

provided by Iraq personnel with Coalition forces in

the advisory and support role. KEY: Show the

Ministry of Health and Ministry of Defense to be in

the lead.

 Capabilities provided at the cooperative medical

engagement (CME) must be sustainable given the

current capabilities of the Ministry of Health.

 CMEs will afford the same treatment to the

populace regardless of religious or political

affiliation.

CMEs are not free clinics. This is not sustainable and

undermines the legitimacy of the Government of Iraq

CMEs must complement the strategic goals and objecttives of the Ministry of Health to shift from a centrally

controlled curative care model of health service to a

more decentralized primary care model with emphasis

on prevention measures and maternal and child health.

Figure 1. Characteristics of cooperative medical engagements as applied in the Iraq theater of operations

in the current counterinsurgency environment.

Iraqi Advisor Task Force (IQATF)

The IQATF is a contract force multiplier which provides

the means to gather “atmospherics” on local national

medical facilities and capabilities. It also provides

advisory and assistance services to assist military

commanders and staff to understand atmospheric

information in the areas of social, religious, economic,

political, public perceptions, and tribal issues through

trend and event analysis.

IQATF Positions

Special Advisor. A physician who is the link to

highest levels of the Ministry of Health.

Military Analyst. Special Forces/Special Operations, preferably a medic, to provide continuity for

operations.

Iraqi Advisor. Native Iraqi able to recruit and direct

local nation advisor teams.

Local National Advisors. Live and work in local

communities; gather local medical atmospherics.

Figure 2. The Iraqi Advisor Task Force as organized in

the Iraq theater of operations in the current counterinsurgency environment.
28 www.cs.amedd.army.mil/references_publications.aspx

execution, and assessment) of COIN operations. This

knowledge allows commanders to ensure that their

activities are appropriate to the current situation.2(p5-2)

As the security situation allows and we begin to

transition from inpatient care to outpatient care, the

Medical Brigade will continue to expand its medical

civil-military operations role in engaging all entities

involved in health care to foster host nation legitimacy.

The Medical Brigade should concentrate on programs

that have proven effectiveness similar to the local

nonresident continuing education programs currently

being conducted by forward surgical teams. Training

should be especially focused on the needs of that

particular hospital or region, and based on the

logistical capabilities of that hospital. This will

reinforce existing Iraqi medical education facilities for

medical professionals and expand national programs,

including educational opportunities in prehospital care

to achieve the ultimate goal of legitimacy and selfreliance.

Currently, there is an initiative for US combat support

hospitals to provide a platform for Iraqis to learn

effective healthcare team training by watching and

interacting with US healthcare professionals. The

health professional training course concept includes

mentorship on interdisciplinary care, team-oriented

patient safety culture, environment of open

communication, and environment of care management

and infection control. Although the program is

centrally designed and managed, courses will be

executed locally in accordance with the facility’s

ability to host. All of the programs are designed to be

kept at 4 weeks or less in residence, and to minimize

dependency on coalition force medical facilities.

SUMMARY

Medical civil-military operations are a critical combat

multiplier directly supporting the COIN fight.

AMEDD Soldiers support medical civil affairs

activities at all levels, from platoon to United States

Mission-Iraq initiatives enhancing the legitimacy of

medical services in the Ministry of Health, Ministry of

Defense, Ministry of the Interior, and Ministry of

Justice.

The CMO mission of the deployed medical brigade

has also evolved into a broad mission employing

numerous contractors including Iraqi American, BiLingual Bi-Cultural Advisors –Subject Matter Experts

serving as case management liaison officers, and

medical trainers, Iraqi Advisor Task Force members

providing medical atmospherics, assessments and

training and the overall management of Iraqi linguists

supporting all level III medical facilities.

This unique mission demonstrates the need for a

deployed medical brigade S9 staff of at least 3 Civil

Affairs trained personnel—preferably 2 officers in the

grade of lieutenant colonel through captain, and a

senior noncommissioned officer in the grade of

sergeant first class or master sergeant—in order to

lead, plan, and execute these elaborate CMO functions.

In view of the evolved mission, it is recommended that

the deployed medical brigade’s modified table of

organization and equipment be expanded to reflect the

requirement, and medical service officers and

noncommissioned officers be identified to fill these

slots and attend the resident civil affairs course.

REFERENCES

1. Wilensky, RJ. Military Medicine to Win Hearts and Minds: Aid to Civilians in the Vietnam War. Lubbock, TX:

Texas Tech University Press; 2004.

2. Field Manual 3-24: Counterinsurgency. Washington, DC: US Dept of the Army; 15 December, 2006.

3. Joint Publication 4-02: Health Service Support. Washington, DC: Joint Staff, US Dept of Defense; 31 March 2006.

4. Field Manual 8-42: Health Service Support in Stability and Support Operations. Washington, DC: US Dept of the

Army; 27 October 1997: chap 3.

AUTHORS

When this article was written, the coauthors were assigned as follows:

LTC Bryan was the Civil-Military Operations Officer, Task Force 62 Medical Brigade, Baghdad, Iraq.

CPT Miyamoto was the Deputy Civil-Military Operations Officer, Task Force 62 Medical Brigade, Baghdad, Iraq.

LTC Holman was the Operations Officer, Task Force 62 Medical Brigade, Baghdad, Iraq.

Medical Civil-Military Operations: The Deployed Medical Brigade’s Role in Counterinsurgency Operations
October – December 2008 29

It is said that no one truly knows a nation until one has

been inside the jails. A nation should not be judged by

how it treats its highest citizens, but its lowest ones.

Nelson Mandela1

INTRODUCTION

Coalition forces in the Iraq theater of operations will

progressively transfer theater detention operations to

the Government of Iraq (GoI) in the near future. This

will occur by training Iraqi personnel and transferring

facilities to the GoI in accordance with international

standards, completing the transition in phases,

promoting Iraqi sovereignty while protecting the

public and the rights of the detainees. Healthcare is an

integral part of this transition. To ensure an appropriate transition of the detainee healthcare, the US

must facilitate identification and participation of

nongovernmental and other government agency subject matter expertise to assist in the interagency

planning, developing and executing detainee healthcare transition from a military-centric to a civiliancentric correctional model. The purpose of this article

is to highlight the framework of the US correctional

model and identify a plausible strategy for transitioning detainee healthcare to the GoI and provide a

recommended way ahead for the military health

system’s understanding and development of a correctional healthcare model for combat operations.

BACKGROUND

United Nations Security Council Resolution (UNSCR)

1511 2authorizes coalition forces to detain any person

they deem an “imperative security threat.” Detainee

operations within the Iraq theater of operations are

instrumental to sustained peace. What happens to the

programs, and the detainees, will depend on what the

government of Iraq makes of them when it takes the

reins after the expiration of UNSCR 1511. American

control over detention expires after December 2008,

though a bilateral agreement between the US and Iraq

is in development to extend that deadline. Meanwhile,

the Multi-National Force-Iraq (MNF-I) command

responsible for detention operations, Task Force 134 is

training more Iraqi correctional officers to ensure an

appropriate level of host nation capability and

capacity.

Detainees are not technically prisoners or enemy

prisoners of war. The Department of Defense (DoD)

defines a detainee as any person captured, detained,

held, or otherwise under the control of DoD personnel

(military, civilian, or contractor employees). It does

not include persons being held primarily for law

enforcement purposes, except where the United States

is the occupying power. Similarly, different words are

used for various groups of people who are detained.

Those awaiting trial may be known as pre-trial, undertrial, or remand, and are often referred to as detainees.

In this article, the word prison is used for all places of

detention and the word prisoner is used to describe all

who are held in such places.

ESTABLISHING A CORRECTIONAL/PRISON FRAMEWORK

Detainee operations, like correctional or prison

management, is a very complex undertaking requiring

a wide range of skills from those whose task it is to

Transition of the Detainee Healthcare

System to a Correctional Model:

An Interagency Approach

LTC Vincent Holman, MS, USA

ABSTRACT

The Army Medical Department (AMEDD) will play a key role in the transition of detainee healthcare operations from

US control to a designated authority, whether it is Iraq or a third party. Although the AMEDD has garnered significant

experience in the provision of detainee healthcare over the past 5 years, it would be prudent to implement an interagency

approach to transitioning detainee healthcare. That transition must start with leveraging of the subject matter expertise of

the US Bureau of Prisons and National Commission on Correctional Healthcare. Curriculum development of detainee

healthcare in the program of instruction at the AMEDD Center and School is critical.
30 www.cs.amedd.army.mil/references_publications.aspx

direct prisons. There is a common set of factors which,

when taken together, constitute a model for good

prison management which can serve as a model for the

Government of Iraq.

In any democratic society, work in prison is a public

service. Prisons are places, like schools and hospitals,

which should be run by the civil power with the

objective of contributing to the public good. Prison

authorities should have some accountability to an

elected parliament, and the public should be regularly

informed about the state and aspirations of the prisons.

Government ministers and senior administrators

should make it clear that they hold prison staff in high

regard for the work they do, and the public should be

frequently reminded that prison work is an important

public service.

Virtually all prisoners will one day return to life in

civil society. If they are to live within the law it will be

important that they have somewhere to live, that they

have the opportunity of employment, and that they

have a proper social support structure. It is very

important, therefore, that the prison administration

have close links with other public service agencies,

such as the social welfare and health authorities. This

is more likely to happen if the prison administration

itself is a civil organization, not a military one.

When people think of prisons they tend to consider the

physical aspects: walls, fences, a building with locked

doors and windows with bars. In reality the most

important aspect of a prison is the human dimension,

since prisons are primarily concerned with people. The

2 most important groups of people in a prison are the

prisoners and the staff who look after them. The key to

a well managed prison is the nature of the relationship

between these two groups. The role of the prison staff

is:

 to treat prisoners in a manner which is decent,

humane and just;

 to ensure that all prisoners are safe;

 to make sure that dangerous prisoners do not

escape;

 to make sure that there is good order and control in

prisons; and

 to provide prisoners with the opportunity to use

their time in prison positively so that they will be

able to resettle into society when they are

released.3

BUREAU OF PRISONS

According to the US Federal Bureau of Prisons

website:

The Federal Bureau of Prisons (BOP) was established

in 1930 to provide more progressive and humane care

for federal inmates, to professionalize the prison

service, and to ensure consistent and centralized

administration of the 11 federal prisons in operation at

the time....The Bureau protects public safety by

ensuring federal offenders serve their sentence of

imprisonment in institutions that are safe, humane, costefficient, and appropriately secure.4

The BOP is heavily involved in the effort to reduce

future criminal activity by providing inmates with a

range of programs that have been proven to help them

adopt a crime-free lifestyle upon their return to the

community.

The Bureau’s most important resource is its staff. The

more than 35,000 employees of the Bureau of Prisons

ensure the security of Federal Prisons; provide inmates

with needed programs and services, and serve as

models for mainstream values. The Bureau’s

employees are the means by which the agency meets

its obligation to protect public safety and provide

security and safety to the staff and inmates in its

facilities.

The philosophy of the Bureau is that release

preparation begins on the first day of imprisonment.

Accordingly, the Bureau provides many selfimprovement programs, including work in prison

industries and other institution jobs, vocational

training, education, substance abuse treatment,

parenting, anger management, counseling, religious

observance opportunities, and other programs that

teach essential skills. Research shows that industrial

work programs, vocational training, education, and

drug treatment in prison play a major role in

improving public safety. These programs reduce

recidivism and misconduct in prison. Drug treatment

programs also decrease offender’s relapse to drug use

after release. Many correctional systems, including the

Bureau, have documented the success of these

programs.

Transition of the Detainee Healthcare System to a Correctional Model—An Interagency Approach
October – December 2008 31

THE ARMY MEDICAL DEPARTMENT JOURNAL

Inmate program involvement is ultimately geared

toward helping inmates prepare for their eventual

release. The Bureau complements its array of

programs with a specific Release Preparation Program,

Residential Re-Entry Centers (halfway houses) and an

Inmate Transition Branch which provides post-release

employment assistance to inmates.

The Health Services Division of the Bureau is

responsible for the mental health (psychiatric) services

provided to federal inmates in Bureau facilities,

including delivery, infectious disease management,

and medical designations. The Division also

coordinates a safety program (occupational safety,

environmental health, and life safety and fire safety)

that ensures a safe, healthy environment for staff and

inmates.

The BOP has over 3,000 health care positions,

including approximately 750 Public Health

Commissioned Officers detailed from the Department

of Health and Human Services. These providers have

been supporting the medical mission of the BOP since

1930.

TRANSITION—THE PROPOSED SOLUTION

The National Commission on Correctional Health Care

(NCCHC) is a private organization committed to

improving the quality of care in our nation’s jails,

prisons, and juvenile detention and confinement

facilities.5 The NCCHC is supported by national

organizations representing the fields of health, law,

and correctional custody.

The NCCHC has unparalleled expertise in the creation,

implementation, and monitoring of national

correctional healthcare standards that are based on

widely accepted principles of care. It has proposed a 3-

phase, multiyear project to assist MNF-I and

Department of Justice (DoJ) in transitioning coalition

control of the correctional healthcare of its security

detainees to the GoI. Additionally, this effort is

designed to achieve an efficient and effective transfer

of military standards into an internationally recognized

civilian model of correctional healthcare services

which is accepted by Iraqis and their government.

The first and second phases of the project are designed

to prepare and assist the MNF-I and the GoI in the

establishment of culturally relevant healthcare

standards for use in the Iraq criminal justice system.

The third phase involves the planning, application, and

monitoring of the Iraqi correctional health standards.

The NCCHC recognizes the unique challenges to the

goal of transitioning the current healthcare operations

from military control to provision of services under a

civilian model, as well as the challenges to the Iraqi

people in establishing a respected criminal justice

correctional health system. An important objective is

for the international community to respect and have

confidence in an Iraqi criminal justice system.

Consequently, there must be adherence to

internationally recognized standards. To achieve this

goal and objective, the NCCHC proposes:

 An introductory meeting of key representatives

from various military and Iraqi organizations, and

training of 50 MNF-I and Iraqi personnel to

improve their skills in setting and monitoring

standards.

 Development of culturally relevant healthcare

standards for the Iraqi criminal justice system.

 Assistance to the MNF-I and Iraqi government in

the development of an implementation plan to

ensure the efficient and effective application of

standards, policies, and procedures in the Iraqi

criminal justice system.

 Assistance in the application of correctional

healthcare standards to Iraqi correctional facilities.

 Assistance in the development and implementation

of a monitoring system to assure the international

community that the correctional healthcare for

Iraqi prisoners is humane and meets recognized

standards.

In phase one, the NCCHC proposes 2 meetings:

The first is a one-day introductory meeting in the

United States with key official representatives of the

DoD, MNF-I, Department of Justice, Iraqi Ministry of

Justice/Ministry of Health, the NCCHC, and others

deemed necessary in achieving the goals and

objectives of this proposal. The purpose of this

meeting is to discuss the common issues and

expectations for the project; determine the participants

for training (phase one), standards development (phase

two), and system implementation and monitoring

(phase three); and the creation of a commitment for the

long-term effort with key Iraqi decision-makers. As a

result of this meeting, individuals will be identified
32 www.cs.amedd.army.mil/references_publications.aspx

and selected to participate in the specified phases of

this plan.

The second meeting, a 5-day training session, will be

held to orient MNF-I staff and selected Iraqi personnel

in the development and maintenance of a correctional

healthcare system. A suggested criteria for selection of

participants will be those who are necessary to advise

on an appropriate correctional healthcare system for

Iraq, and who can reasonably be expected to be among

those eventually overseeing or actually implementing

the standards. The objectives for this meeting are to

provide a foundation for MNF-I staff and Iraqi

participants to understand what is involved in a

standard setting process, to gain an overall

understanding of the NCCHC standards and approach,

and to raise issues integral to the eventual advise/

consent process for Iraqi correctional healthcare

standards. The individuals involved in the introductory

meeting will be select executives and government

officials who can create an environment for the overall

success of the transition.

In phase two, the NCCHC proposes to assist in the

development of Iraqi correctional healthcare standards.

Phase two builds on the activities of phase one, but

could be taken as a standalone project. Outcomes for

phase two include a manual of Iraqi standards for

correctional healthcare services and an evaluation

report of the activities provided to MNF-I.

In phase three, the NCCHC proposes to assist the

MNF-I in developing a detailed plan to implement and

monitor the Iraqi correctional healthcare standards

within the Iraqi criminal justice system. This includes

the establishment of detailed plans to implement Iraqi

standards, creation of a quality assurance monitoring

system, and a “train-the-trainer” program. The

implementation of Iraqi correctional healthcare

standards will begin with a pilot project. What is

learned from that project will result in applications

developed and implemented throughout the system.

Good health is important to everyone. It affects how

people behave and their ability to function as members

of the community. It has a particular significance in

the closed community of a prison. By its nature, the

condition of imprisonment can have a damaging effect

on both the physical and mental well-being of

prisoners. Prison administrations have a responsibility,

therefore, not simply to provide medical care, but also

to establish conditions which promote the well-being

of both prisoners and prison staff. Prisoners should not

leave prison in a worse condition than when they

entered. This applies to all aspects of prison life, but

especially to healthcare.

A prisoner often arrives in prison with preexisting

health problems which may have been caused by

neglect, abuse, or by the prisoner’s previous lifestyle.

Prisoners often come from the poorest sections of

society and their health problems reflect this. They

will bring with them untreated conditions, addictions,

and mental health problems. These prisoners will need

particular support, as will those many others whose

mental health may be significantly and adversely

affected by the reality of imprisonment.

ETHICAL FRAMEWORK

It is also important that the Iraqi public and media are

aware of the values within which Iraqi prisons would

operate. If the role of the prison in a civil society is

properly understood, it is more likely that the public

will appreciate efforts made by the prison authorities

to implement good practice. To that end, the basics of

the necessary ethical framework for the medical

healthcare provided within an Iraqi prison system is

clearly defined in the “Oath of Athens”6(below), an

ethical code adopted by the International Council of

Prison Medical Services in 1979.

Transition of the Detainee Healthcare System to a Correctional Model—An Interagency Approach

Oath of Athens

In keeping with the spirit of the Oath of Hippocrates,

that we shall endeavor to provide the best possible

health care for those who are incarcerated in prisons

for whatever reasons, without prejudice and within our

respective professional ethics. We recognize the right

of the incarcerated individuals to receive the best

possible healthcare. We undertake

1. To abstain from authorizing or approving any physical punishment.

2. To abstain from participating in any form of torture.

3. Not to engage in any form of human experimentation amongst incarcerated individuals without

their informed consent.

4. To respect the confidentiality of any information

obtained in the course of our professional relationships with incarcerated persons.

5. That our medical judgments be based on the needs

of our patients and take priority over any nonmedical matters.
October – December 2008 33

THE ARMY MEDICAL DEPARTMENT JOURNAL

RECOMMENDED ENDSTATE

The detainee healthcare operations will be successfully

transferred to the GoI correctional healthcare

operations when the following conditions are met:

 GoI correctional healthcare standards are codified

incorporating regional, internationally accepted

standards and the Oath of Athens.

 Correctional medical facilities are operational

(staffed, trained, equipped).

 Essential medial services are available and

provided:

 Emergency medical services

 Sick call

 Acute care

 Dental care

 Diagnostic services

WAY AHEAD

The AMEDD will play a linchpin role in the transition

of detainee healthcare operations from US control to a

designated authority, whether it is the host nation or a

third party. Although the AMEDD has garnered

significant experience in the provision of detainee

healthcare over the past 5 years, it would be prudent to

implement an interagency approach to the transition of

detainee healthcare. This approach must start with

leveraging the subject matter expertise of the Bureau

of Prisons and National Commission on Correctional

Healthcare. Detainee healthcare curriculum

development in the program of instruction at the

AMEDD Center and School (AMEDDC&S) is critical.

A representative from the Bureau of Prisons Health

Service Division, operated by the Public Health

Service, would be an appropriate addition to the

AMEDDC&S faculty. Such expertise would assist the

development of a comprehensive approach to the education of the DoD medical community in detainee and

correctional healthcare, with the creation of a Detainee

Healthcare Center of Excellence as the AMEDDC&S

transitions into the Medical Education and Training

Campus (METC).

The Army Training With Industry (TWI) program7is

an excellent front seat approach to providing AMEDD

personnel with the knowledge and experience of the

best business practice of a civilian organization or

agency. To ensure the best business practices of

correctional healthcare are gathered and codified into

the Army and military health system doctrine, DoD

military personnel should be provided an opportunity

to experience a one-year TWI with the Bureau of

Prison’s Health Services Division, followed

immediately by a one-year utilization tour at the

METC to codify doctrine, policy, and tactics,

techniques and procedures. This TWI opportunity

should include a simultaneous fellowship of Medical

Corps, Army Nurse Corps, Dental Corps, Army

Medical Specialist Corps, Medical Service Corps, and

AMEDD enlisted participants.

Identification of AMEDD personnel who have served

in positions directly involved in delivery or

administration of healthcare to detainees should be

captured by an additional skill identifier (ASI) entitled

“Detainee/Correctional Healthcare Staff,” to readily

identify personnel and leverage their capabilities at

both the future METC and the Joint Force Medical

Readiness Training Center as consultants. To ensure

continuous growth in capacity of the knowledge base,

support should be gained from the NCCHC and

institute their Certified Correctional Health

Professional (CCHP) certification and continuing

education program. This would be another path

towards achieving the detainee healthcare ASI.

Medical personnel working in detainee settings face

unique challenges: working within strict security

regulations, dealing with crowded facilities, understanding the complex legal and public health

considerations of providing care to incarcerated

populations, and more. Establishing a cadre of

certified correctional health professionals is the surest

way for the Army and the military health system to

sustain personnel, a knowledge base, and tools to meet

these challenges. The CCHP designation identifies an

individual as one who has demonstrated mastery of

national standards and the knowledge expected of

leaders working in the field of correctional health care.

The NCCHC offers a complete selection of applicable

publications* which could be institutionalized by the

AMEDD and DoD as the authorized “Medical

Equipment Book Set–Detainee Healthcare Operations.” Along with the appropriate DoD regulations

and manuals, this would greatly increase the knowledge base of the medical staff tasked to provide

healthcare in a detainee setting.

*http://www.ncchc.org/pubs/catalog.html
34 www.cs.amedd.army.mil/references_publications.aspx

By bringing to bear the full technical expertise of our

nation, we will ensure our sustained excellence in

detainee healthcare operations for the years, generations, and conflicts to come.

REFERENCES

1. Mandela N. Long Walk to Freedom. London: Little

Brown; 1994.

2. United Nations Security Council. UN Security

Resolution 1511. New York, NY: United Nations; 16

October 2003. Available at: http://daccessdds.un.org/

doc/UNDOC/GEN/N03/563/91/PDF/N0356391.pdf?

OpenElement.

3. Coyle A. A Human Rights Approach to Prison

management: Handbook for Prison Staff. London:

International Center for Prison Studies; 2002:14.

4. About the Bureau of Prisons. Federal Bureau of

Prisons website. Available at: http://www.bop.gov/

about/index.jsp.

5. About NCCHC. National Commission for

Correctional Health Care website. Available at: http://

www.ncchc.org/about/index.html.

6. Medical Ethics in the Prison context. Prison Health

Care Practitioners website. Available at: http://

w w w . p r i s o n h e a l t h c a r e p r a c t i t i o n e r s . c o m /

Medical_ethics.shtml#International_Council_of_Pris

on_Medical_Services.

7. AAC Training With Industry. US Army Acquisition

Support Center website. Available at: http://

asc.army.mil/career/programs/twi/default.cfm.

AUTHOR

At the time this article was written, LTC Holman was

the Operations Officer, Task Force 62 Medical Brigade,

Baghdad, Iraq.

A US Army combat support hospital in Iraq during the early phases of Operation Iraqi Freedom

Transition of the Detainee Healthcare System to a Correctional Model—An Interagency Approach
October – December 2008 35

This is a game of wits and will. You’ve got to be

learning and adapting constantly to survive.

General Peter J. Schoomaker, USA1

BACKGROUND

In early 2003, US forces crossed the border of Kuwait

into Iraq in what has become known as the road to

Baghdad. A complete medical task force under the

30th Medical Brigade were a part of those forces. All

the medical functional areas were represented in the

Task Force 30th Medical Brigade. The 212th Mobile

Army Surgical Hospital deployed far forward to

provide resuscitative surgery for our wounded Soldiers

to stabilize them for swift evacuation to Kuwait,

further to Germany, and on to hospitals in the

continental United States (CONUS). Combat support

hospitals (CSH) were established along the axis of

advance at major logistics bases, such as the 28th CSH

at Tallil. Medical evacuation helicopters filled the

airfields in Kuwait, Tallil, Baghdad, and ultimately

were postured to provide wounded Soldiers dedicated

support—always less than 90 minutes after emergency

surgical intervention. The US military quickly

declared victory over the Iraqi forces and settled in for

what has become an occupation of Iraq that has lasted

5 years, and continues. The competency and efficiency

of US medical professionals, coupled with the

tremendous strategic evacuation capabilities of the US

military have provided our wounded Warriors with a

lifeline that has literally saved thousands of lives since

the beginning of Operation Iraqi Freedom.

In late 2003, the complexity of the security situation in

Iraq began to change. For example, convoys were

being ambushed and snipers were indiscriminately

targeting not only the US forces, but also the local

population. The US was engaged in a

counterinsurgency fight in Iraq. What was once

thought to be an open-arms welcome as liberators of

Iraq from the harsh dictator Saddam Hussein was now

a fight for survival on the streets of Baghdad, Fallujah,

and Mosul. Violence had erupted throughout Iraq as

the Shia, Sunni, and Kurdish militants all vied for

power in post-Saddam Iraq. US forces were targeted

and casualties grew. Improvised explosive devices in

all forms emerged as the greatest indiscriminate threat

Employment of a Joint Medical Task Force in

a Counterinsurgency Operational

Environment

COL Scott Avery, MS, USA

LTC Vincent Holman, MS, USA

ABSTRACT

To understand the complexity of the medical task force mission in support of Operation Iraqi Freedom, we must first

understand the operational environment and its impact on the military healthcare system and the medical task force

charged with its execution in theater.

Historically, the medical task force has focused almost exclusively on delivering a robust and accessible set of level II

and III care and force health protection support since operations began in Iraq. Consequently, after 5 years of stable

positioning, security, and infrastructure within our bases, there were no discernable standardization of healthcare support, clinical quality, or medical equipment beyond what the units had chosen to adopt.

Task Force 62 Medical Brigade has taken advantage of this unique time in history to place a concerted focus on

institutionalizing our combat healthcare system and meeting the challenges of the counterinsurgency operational

environment. Whereas our predecessors rightly focused on delivering combat health support during their tenure, we

focused on the future, laying the foundation for the eventual transition to an environment similar to that in the Republic

of Korea as the security situation improves. The foundation laid during Operation Iraqi Freedom 07-09 can be the

foundation for the Army and the military healthcare system’s vision in creating and modifying the delivery of US

standard healthcare in a combat theater.
36 www.cs.amedd.army.mil/references_publications.aspx

on the battlefields. Casualties, both US and Iraqi

civilian, mounted and support for the war in Iraq began

its quick decline.

The medical force that had supported the road to

Baghdad and the initial occupation of Iraq was greatly

tested. Over the next 5 years the US casualty toll in

Iraq would surpass 4,000 dead and 30,000 wounded.

The medical task forces would rotate through Balad,

the International Zone in Baghdad, and ultimately

settle at Camp Victory, near Baghdad. The 30th

Medical Brigade (MED BDE) would be replaced by

the 2nd MED BDE, and then the 44th Medical

Command (MEDCOM), the 30th MED BDE again,

the 3rd MEDCOM, and now the 62nd MED BDE,

which will be replaced by the 44th MEDCOM in the

fall of 2008. Each command would establish its

procedures to provide world-class healthcare to our

supported forces. Each would reshape the medical

environment, and each would maintain a 97% to 98%

survival rate for anyone that arrived at a level III

hospital alive. The phenomenal success of our medical

forces in supporting US, Coalition, Iraqi Security

Forces (ISF), as well as in the provision of life-saving

medical care to civilians within the medical rules of

eligibility, is altogether the result of superior medical

leadership and the adaptability of our medical forces in

supporting the counterinsurgency (COIN) fight in Iraq.

THE ENVIRONMENT

To understand the complexity of the medical task force

mission in support of Operation Iraqi Freedom COIN

operations, we must first understand the operational

environment and its impact on the military health

system and the medical task force charged with its

execution in theater. COIN operations combine

offensive, defensive, and stability operations to

achieve the stable and secure environment needed for

effective governance, essential services, and economic

development. Successful conduct of COIN operations

depends on thoroughly understanding the society and

culture within which they are being conducted. Forces

must understand:

 Organization of key groups in the society

 Relationships and tensions among groups

 Ideologies and narratives that resonate with groups

 Values of groups (including tribes), interests, and

motivations

 Means by which groups (including tribes)

communicate

 The society’s leadership system.

STRATEGIC GOALS

The first principle of force health protection is

conformity. As such, the medical task force has

adopted 3 strategic goals to nest with the MultiNational Coalition-Iraq and Multi-National Force-Iraq

commanders’ goals. These goals are completely

consistent with the US national goals as well as those

of the military commanders on the ground.

 Provide world-class Warrior healthcare to US and

coalition forces

 Protect the health of US and coalition forces

 Enhance the Government of Iraq (GoI) credibility

by supporting a self-reliant Iraqi public health

system

These goals ultimately aim toward limiting the loss of

life in Iraq, preserving the health of the force on the

ground, and supporting the GoI in their development

of a self-reliant healthcare system.

MULTI-NATIONAL FORCE-IRAQ COMMANDER’S

COUNTERINSURGENCY GUIDANCE

The Coalition performed a wide range of missions to

provide security and improved quality of life for

population of Iraq. On missions ranging from full

spectrum combat operations against terrorist and

criminal elements, to convoy escort, to explosive

ordnance disposal, civil military affairs, reconstruction,

medical support, and military and police training,

members of Multi-National Force-Iraq have acquitted

themselves with skill and professionalism.

General David Petraeus, Commanding General

Multi-National Forces–Iraq2

On June 21, 2008, General Petraeus published a

“Commanding General’s Message”* highlighting his

25 points of guidance concerning the COIN fight for

the Iraq theater of operations. The following

paragraphs describe the 62nd MED BDE (Task Force

62) imperatives which were developed and adopted to

support operations in the COIN environment in

concert with the applicable points of GEN Petraeus’

Employment of a Joint Medical Task Force in a Counterinsurgency Operational Environment

*Internal military document not readily accessible by the

general public
October – December 2008 37

THE ARMY MEDICAL DEPARTMENT JOURNAL

Commanding General’s Message (indicated in

parentheses as COIN guidance):

Follow the battle. In a COIN environment, the next

mass casualty event is only one improvised explosive

device detonation away. Battle tracking is imperative

in order for the medical task force to monitor the

battlefield situation to provide responsive support, as

well as to anticipate combat healthcare support

requirements. Accessibility to forward surgical

intervention is a key component of a solid plan to

increase kinetic or lethal operations. (COIN guidance

#12: Fight for intelligence.)

Ensure the gap is covered. Coalition maneuver units

implement COIN guidance and move off of the

forward operating base to walk among the population

they secure and serve. It allows for the extension of

operational reach via command outposts/joint security

station/patrol base expansion. However, this activity

impacts the health service support footprint as the level

I/II capability is displaced from the forward operating

base, creating a gap of coverage for the remaining

population at risk. The medical task force, in

coordination with the theater surgeon and maneuver

unit command surgeons, forecast these gaps to ensure

continuity of care of the population at risk which

remains without level I/II services. As security gains

are realized from the ongoing surge operations and the

surge brigade combat teams are not backfilled, the gap

is widened. Additionally, the introduction of

nonstandard maneuver brigades deployed without

organic or habitual level I/II creates another gap in

level I/II medical capacity. Medical forces during

Operations Desert Shield/Desert Storm (1991) were

14% of total forces, 3% in Operation Enduring

Freedom (Afghanistan theater), and 4% in Operation

Iraqi Freedom during 2004. The small medical

footprint demands that we not only provide efficacious

and efficient health service support, but also that we

synchronize our medical forces in a collaborative

effort to resolve issues. Through the collective efforts

of the military health system–forward and use of stateof-the-art technology, conditions are set for a continual

increase in hostile survivability, as seen in the

improvement from 78.3% in 1991 to 90% in 2007.

(COIN guidance #2: Live among the people. COIN

Guidance #3: Hold areas that have been secured.)

Nest combat healthcare support operations. The

objectives of the US Departments of State and Defense

are nested when employing the instruments of national

power. In the Iraq theater of operations, the

instruments available to the theater commander must

be nested and employed to meet the tactical,

operational, strategic, and national objectives. The

medical task force provides a strategic bridge to

accomplishing these objectives through the execution

of medical diplomacy and medical civil-military

operations. (COIN guidance #6: Generate unity of

effort. COIN guidance #15: Build relationships.)

Perfect combat healthcare one patient at a time. The

medical team treats one patient at a time ensuring US

standard of quality care. The medical task force’s

covenant with the patient is to ensure that appropriate

care is provided by the appropriate medical team, at

the appropriate location, with the appropriate supplies

and equipment. (COIN guidance #21: Empower

subordinates. Resource to enable decentralized action.)

Honor the host nation’s legitimacy. The medical rules

of eligibility have great significance when it comes to

healthcare on the battlefield. Legitimacy is the

perception that a government is fair and is working in

the interests of a nation as a whole. The government

does not have to be efficient but must be effective.

Governments may be legitimate (or not), but it is civil

society that confers legitimacy (or not). Governments

can rule in a way that seems effective, but it is civil

society’s reaction to that rule that actually determines

whether or not it is effective. (COIN guidance #9:

Foster Iraqi legitimacy.)

Tell the medical task force story. Independent local,

national, and international media coverage of our

military operations and our enemies’ activities is

critical to our success in the global information

environment. This is particularly true in today’s 24-

hour news environment. Unfortunately, our enemies in

Iraq have won a significant victory by forcing most

Western media to report only from secure compounds,

to use embeds with coalition forces, or to retell

second-hand information gained from local Iraqi

stringers, some of whom have questionable agendas

and loyalties. To address this situation, we must

develop solutions for improving media access to the

battlefield and our activities without compromising the

media’s independence or our operational security. This

could include relatively simple actions such as making

it easier for journalists to get accredited and
38 www.cs.amedd.army.mil/references_publications.aspx

transported to the combat zone, and offering increased

logistical support to help defray escalating costs. It is

important, too, despite what we may sometimes

perceive as unfair treatment from the media, that we

understand and support the crucial role they play in

reporting the realities of our combat operations to the

world. (COIN guidance #19: Be first with the truth.

COIN guidance #20: Fight the information war

relentlessly.)

THE WARFIGHTING MEDICAL TASK FORCE

Combat Healthcare Support

Combat healthcare support falls under 2 separate yet

mutually supporting warfighting functions,

sustainment and force protection. The sustainment

warfighting function is the related tasks and systems

that provide support and services to ensure freedom of

action, extend operational reach, and prolong

endurance. The endurance of Army forces is primarily

a function of their sustainment. Sustainment

determines the depth and duration of Army operations,

it is essential to retaining and exploiting the initiative.

Sustainment is the provision of the logistics, personnel

services, and combat healthcare support necessary to

maintain operations until mission accomplishment.

Internment, resettlement, and detainee operations fall

under the sustainment warfighting function and

include elements of all 3 major subfunctions.

Combat healthcare support consists of all support and

services performed, provided, and arranged by the

Army health system. It promotes, improves, conserves,

or restores the mental and physical well-being of

Soldiers and, as directed, other personnel. This

includes casualty care, which involves all Army and

military health system functions and detainee

healthcare. The protection warfighting function

includes force health protection. Force health

protection includes all measures to promote, improve,

or conserve the mental and physical well-being of

Soldiers. These measures enable a healthy and fit

force, prevent injury and illness, and protect the force

from health hazards. The measures include the

prevention aspects of a number of Army health system

functions.

Security Environment

Managing the threats of the environment will greatly

impact the ability of the medical force to influence the

outcome during COIN operations. In a permissive

security environment, medical forces have the freedom

of maneuver to operate throughout the countryside and

partner with governmental healthcare professionals to

provide the populace with the appropriate health

support. In Iraq, however, the security situation does

not lend itself to a variety of decentralized medical

operations to assist the local population. Competing

interests between Shia, Sunni, Kurdish, and Christian

populations limit the availability and capability of both

US and indigenous healthcare workers.

REVOLUTIONIZING COMBAT HEALTHCARE SUPPORT:

SYSTEMATIC APPROACH TO COUNTERINSURGENCY

Historically, since operations began in Iraq 5 years

ago, the medical task force has focused almost

exclusively on the delivery of a robust and accessible

set of level II and III care and force health protection

support capabilities. Immediately upon assuming the

mission, the 62nd MED BDE noted that the task force

is charged to deliver 3 essential dimensions of combat

health support:

 Provide world-class Warrior healthcare to US and

coalition forces,

 Protect the health of the US and coalition forces,

and

 Support self-reliant Iraqi Security Forces and

government of Iraq healthcare and public health

systems.

Although there have been numerous rotations and a

fresh look at the delivery of healthcare each year, there

were very few signs of health system integration

beyond trauma management. The high rate of turnover

of units led to gaps or seams in our services. Each

newly arrived unit essentially reinvented their

approach to executing the mission that their

predecessors had refined during their tours. This

resulted in an unacceptably high degree of variance in

the quality and accessibility of services across the

battle space. An integration and standardization of

systems in use and increased emphasis on task forcewide performance improvement was identified as

required by the commander and senior leaders of the

task force. The vehicle to implement a strategy was

modeled after the balanced scorecard.3 A graphical

representation of the Task Force 62 Combat

Healthcare Support System is presented as Figure 1 on

Employment of a Joint Medical Task Force in a Counterinsurgency Operational Environment
October – December 2008 39

THE ARMY MEDICAL DEPARTMENT JOURNAL

*Area of Concentration 70H: Health Services Plans, Operations, Intelligence, Security, and Training Medical Operations

Officer

†Military Occupational Specialty 38B: Civil Affairs Specialist

‡Military Area of Concentration 70A: Healthcare Administration Officer

§Military Occupational Specialty 42A: Human Resources Specialist

page 6. It provides the overall structure—the map—for

implementation of the system.

This method would enable the task force commander

and senior leaders to show the task force how to create

a customized strategy map that allows the task force

to:

 Clarify task force strategies and communicate

them across the organization.

 Identify the key internal processes that drive

strategic health service support success in the Iraq

theater of operations.

 Align the DoD’s investment in people, technology,

and organizational capital for the greatest impact

in combat casualty care.

 Expose gaps in the Military Health System

strategies and take early corrective action.

This model is the way in which to communicate the

medical task force strategy and monitor and measure

the progress of our advancements in the 3 major Ends:

 Provision of world-class Warrior healthcare

 Health protection of US and Coalition forces

 Support for self-reliant ISF and GoI healthcare

These major Ends are only possible through close

coordination with the MNF-I Surgeon to validate our

alignment with the medical strategic plan; and the

synchronization across all multination divisions/force

to provide a seamless and integrated health system for

the Warrior.

COUNTERINSURGENCY DOCTRINE IMPACT ON HEALTH

SERVICE SUPPORT

Command and Control

The COIN operational environment requires an

echelon-above-division command and control structure

that covers the breadth of medical functional

responsibilities represented in the theater. Medical

command and control for a theater of operations

requires key personnel enablers. These subject matter

experts provide a unique contribution to the fight with

their knowledge, skills, and abilities. This manning

should include the following additional personnel:

public affairs noncommissioned officer, medical

operations officer (Captain, AOC 70H*), medical

plans officer (Captain, AOC 70H), civil affairs

noncommissioned officer (Master Sergeant, MOS

38B5L†). Additionally, the following positions are

critical and key enablers for the commander and

medical task force: deputy commanding officer

(Colonel, AOC 70A‡), inspector general (Lieutenant

Colonel), and equal opportunity noncommissioned

officer (Sergeant First Class, MOS 42A40§). The

addition of these specialty areas brings the right

enablers for effective command and control by an

echelon-above-division medical brigade.

Hospitalization

A workhorse in the COIN environment is the combat

support hospital (CSH). The CSH brings a plethora of

life saving and life sustaining capability that can

provide split-based operations. Additionally, the CSH

brings a medical diplomacy aspect to the strategic

objectives within the theater. As a theater matures, the

CSH’s enduring operation is degraded, and split-based

operations present unique challenges that are difficult

to resolve with the manpower that remains after a CSH

is divided into 2 elements. Current mission

requirements in Iraq have created a demand for

multiple services that are not part of the standard

combat-focused mission. A CSH personnel and

equipment authorization document is not designed for

enduring split-based operations in a lethal COIN

environment. The population at risk is significantly

different, presenting requirements such as OB-GYN,

pediatrics, chronic diseases, and geriatrics derived

from the local population and contractors. There is a

requirement for specialty clinical staff in the areas of

pediatrics, fellowship trained trauma surgeons,

additional emergency medicine physicians,

gastroenterology, cardiothoracic surgeon, infectious

disease specialist, vascular surgeon, OB-GYN,

pulmonologist, urologist, and a burn surgeon. The

situation of the Ibn Sina CSH presents another

problem with resource allocation. Although they are

not authorized a trained public affairs officer or a

protocol officer, the Ibn Sina CSH hosts multiple
40 www.cs.amedd.army.mil/references_publications.aspx

military and civilian dignitaries, as well as US, Arab,

and international media agencies due to its location in

Baghdad. Lastly, personnel depth does not allow

enough resources to conduct safe or efficient 24/7

operations. To sustain split-based operations,

additional authorizations are required in the following

specialties: emergency medicine physician (AOC

62A), diagnostic radiologist (AOC 61R), operating

room nurse (AOC 66E), critical care nurse (AOC

66H8A), emergency medicine nurse (AOC 66HM5),

operating room specialist (MOS 68D), and pharmacist

(AOC 67E).

Critical Medical Team Sourcing

The implementation of COIN doctrine for maneuver

units has, as an unanticipated consequence, resulted in

a degradation of critical medical teams (treatment,

trauma, behavioral health, and critical care) capability

and capacity in the Iraq theater of operations. The

doctrine has decreased available level I/II on forward

operating bases (FOBs). As maneuver units are

moving off FOBs, the operational reach is extended

via command outpost/joint security station/patrol base

(COP/JSS/PB) expansion to maintain control of battle

space. This COP/JSS/PB expansion plan impacts the

theater’s healthcare support system footprint as the

organic or habitual level I/II capability is displaced

from the FOB. Additionally, the deployment of

nonstandard maneuver brigades into the theater has

created a gap in level I/II medical capacity.

An additional critical concern is that medical units are

deployed at a P-2* unit status reporting personnel

rating without regard to the manning of critical

medical teams and key individuals, which in turn

creates a shortage of medical team capacity. Minimal

manning of the critical medical teams is not acceptable

without the key individuals and places an increased

reliance on echelon-above-division medical assets for

nondoctrinal missions. A corporate change to Army

Regulation 220-1

4

is warranted to track critical

medical teams as reportable in accordance with Table

7-5 “Squad/crew/team/system manning and

qualification criteria.” Also, this will enable validation

of training of medical units and maneuver units with

medical elements only if the medical team is fully

manned with the designated “key individual,” minimal

manning is not an option.

SUMMARY

The foundation laid during OIF 07-09 can be the

foundation for the Army and Military Health System’s

vision in creating and modifying the delivery of US

standard healthcare in a combat theater. The COIN

environment presents unique challenges for medical

forces providing support to our Warfighters in Iraq and

Afghanistan. Medical infrastructure in second and

third world countries presents challenges for our

national and military leadership that must be addressed

to be successful in the long term campaign planning

associated with counterinsurgency operations.

Depending on the security situation, governmental and

nongovernmental healthcare organizations may not be

able to provide the nexus for long-term recovery in

these regions. Although all medical operations must be

linked to a long-term recovery of the indigenous health

system, the medical task force possesses unique

capabilities and capacity in their lexicon that must be

leveraged. Medical leadership must be creative,

adaptive, and disciplined to provide resources for the

eventual success of COIN operations.

REFERENCES

1. Field Manual 3-24: Counterinsurgency. Washington,

DC: US Dept of the Army; 15 December 2006:ix.

2. Headquarters, Multi-National Force-Iraq. The Coalition Operations 2007 Year in Review. Multi-National Force-Iraq website. February 7, 2008: page 4.

Available at: http://www.mnf-iraq.com/images/sto

ries/Press_briefings/2008/april/2007_year_in_

review_final_2.pdf.

3. Balanced Scorecard Institute. What is the balanced

scorecard?. Available at: http://www.balanced

scorecard.org/BSCResources/AbouttheBalan

cedScorecard/tabid/55/Default.aspx. Accessed

October 6, 2008.

4. Army Regulation 220-1: Unit Status Reporting.

Washington, DC: US Dept of the Army; December

19, 2006.

AUTHORS

At the time this article was written, COL Avery was the

Chief of Staff, Task Force 62 Medical Brigade,

Baghdad, Iraq.

At the time this article was written, LTC Holman was

the Operations Officer, Task Force 62 Medical Brigade,

Baghdad, Iraq.

*Personnel manning of qualified personnel and senior

leadership between 75% and 84% of authorized personnel

strength.4(p35)

Employment of a Joint Medical Task Force in a Counterinsurgency Operational Environment
October – December 2008 41

In late August 2007, approximately 2 weeks after Task

Force 62 Medical Brigade (TF62 MED) assumed the

medical command and control mission in Iraq, the

theater medical regulating officer (MRO) received an

email with a red exclamation point from the TF62

MED commander requesting an explanation as to why

2 Iraqi patients were regulated from “Medical City” in

Baghdad to the Air Force Theater Hospital (AFTH) in

Joint Base Balad. The MRO responded that the theater

MRO does not regulate patients from Medical City to

Joint Base Balad because, without proper authority,

that would be a clear violation of the medical rules of

eligibility. The MRO stated that there would be an

inquiry about how the patients arrived, focused on the

email from the commander of the Joint Base Balad

hospital which clearly implied that the theater MRO

had in fact regulated these Iraqi patients from Medical

City to his hospital.

Earlier in the day the AFTH at Joint Base Balad had in

fact received 2 Iraqi patients who had obviously

received medical treatment prior to arriving at that

facility, and it was clear that the medical treatment had

been ongoing for days. One patient in particular was

paralyzed with gunshot wounds to his upper torso. The

other patient had various serious wounds which had

been inflicted during combat operations. Both patients

were in need of continued urgent medical care. During

the hours-long investigation as to how these patients

came to arrive at the Joint Base Balad hospital, all

parties involved in the patient transfer were contacted.

This included the medical evacuation (MEDEVAC)

company that flew the mission, the battalion command

post that called in the MEDEVAC request, the troop

medical clinic to which the patients were initially

brought by the unit patrolling the area, and the

command sergeant major (CSM) of the battalion

involved. Basically, at the time of the incident, the

region from which these patients came was

experiencing most of the effective enemy attacks

against Coalition Forces in the entire Iraq theater of

operations (ITO). The CSM detailed the mission that

preceded the patient transfer and indicated that a high

level insurgent was now in custody because of the

operation. During the followup missions with local

leaders, there was a request from one of those leaders

to have a US military physician look at these patients

to determine if Coalition Forces (CF) could help them.

The patients were transported to a small troop medical

clinic with one healthcare provider who determined

that these patients would die if they did not receive

competent medical attention. An evacuation request

was made, a MEDEVAC unit responded and took the

patients to the closest level III facility, which was the

Joint Base Balad hospital. After informing the CSM of

the second and third order effects of such a transfer

and reiterating the medical rules of eligibility

(MROE), the CSM stated that, because of this transfer,

the next street they patrol in this town will not be

littered with improvised explosive devices. That is a

difficult position to challenge. The theater MRO’s

responsibility is to receive and respond to countless

inquires of this type to determine how patients that

appeared to violate the MROE could be “regulated” to

CF hospitals.

To understand the link between medical regulating

operations and the MROE, this article addresses

The Complexity of Moving Patients in Today’s

Maturing Counterinsurgency Environment:

Whom, When, and How

LTC Michael C. Richardson, MS, USA

ABSTRACT

Medical regulating operations and the theater medical rules of eligibility are inextricably linked in the delivery of

combat health service support in the Iraq theater of operations. The link between medical regulating operations and the

medical rules of eligibility is more than the medical regulating operations officer (MRO). In an operational environment

as vast as Iraq involving host nation civilians, Iraqi military personnel, Iraqi dignitaries, and a host of other potential

patients, the complex mission of executing medical regulating operations while adhering to medical rules of eligibility is

an extremely dynamic undertaking. The theater MRO is always expecting—but never knows—what to expect in that

next call or that next email.
42 www.cs.amedd.army.mil/references_publications.aspx

The Complexity of Moving Patients in Today’s Maturing Counterinsurgency Environment:

Whom, When, and How

medical regulating operations, then the MROE, how

they each play a role in the maturation of the delivery

of combat health service support, and how they each

can be used to assist in the successful counterinsurgency operations expected in Iraq for years to

come.

MEDICAL REGULATING OPERATIONS

Doctrinally, the MRO at the medical brigade (medical

task force) regulates hospital transfers between US and

Coalition Forces level III facilities and coordinates for

the strategic aeromedical evacuation (AE) flights

leaving theater. The theater MRO in the ITO operates

far from the doctrinal blueprint.

Medical regulating operations at the medical task force

level spans the tactical, operational, and strategic

influences throughout the entire ITO. Medical

regulating gets the right patient to the right place, at

the right time, by the right means. The MRO

coordinates and synchronizes a vast array of resources

to ensure lives are saved and the resources are used as

efficiently and effectively as possible. During the

initial stages of conflict, effective is more critical than

efficient. However, as the theater matures and

footprints shrink, as in level III facilities becoming

Level II, or a reduction in the number of MEDEVAC

helicopters available in theater, or perhaps the decrease

in the number of aeromedical evacuation flights

leaving the ITO, efficiency plays an increasingly

important role.

The resources include every level of US medical care

in-theater, from the smallest of clinics to the largest of

hospitals, which are not all equal in capability or

capacity, as well as the military hospital in Germany

and the most advanced medical facilities in the United

States. In addition to US military medical care,

NATO* and non-NATO medical units from Britain,

Poland, Korea, and Armenia are medical resources intheater which are part of the medical regulating puzzle

that is assembled in various ways every day to ensure

success in caring for the theater’s patients. Medical

regulating resources also include the helicopters

dispersed throughout the ITO, which includes US

Army, Navy, Marine Corps, Coalition Force, and Iraqi

Air Force, as well as airplanes from those sources and

the US Air Force and civilian air ambulances.

PATIENT REGULATING RESOURCES

Medical Treatment Facilities

The medical task force does not exercise command

and control over all medical assets in theater, only

those that are echelons-above-division (EAD).

However, there are EAD medical resources, such as

the Air Force theater hospital or the Air Force

expeditionary medical squadron, that may or may not

have a command relationship with the medical task

force. This lack of command and control creates

challenges for medical regulating in that patients flow

from numerous clinics to hospitals without the

knowledge of the MRO. Only those EAD medical

treatment facilities that fall under the purview of the

medical task force are required by order to report

patient transfers to the theater MRO for appropriate

regulation. As such, patients often arrive at a hospital

that does not have the capability to care for the patient.

As discussed previously, not all hospitals are equal in

capability or capacity. They all have inpatient

capability, CT†scanners, operating rooms, laboratory,

etc. However, in most cases patients requiring

movement after initial resuscitation need a specific

specialty such as neurosurgery, ophthalmology or

gastrointestinal intervention to address their medical

conditions. It is the lack of a specific medical specialty

at the facility where the patient first arrives that

accounts for most of the errors in patient movement

among clinics outside of the control of the theater

MRO. Regardless, it is imperative that the MRO know

the current capabilities and capacity of every level III

and level II+ medical facility in the ITO, as well as in

Kuwait and Qatar, to ensure the appropriate regulation

of patients.

Kuwait and Qatar have their own medical treatment

facilities which the theater MRO uses as necessary to

appropriately regulate patients. The Expeditionary

Medical Facility-Kuwait (EMFK), a Level III hospital

operated by US Navy, has increased capability due to

the availability of civilian assets in Kuwait City.

Specifically, Kuwait City has an MRI‡scanner that is

available for diagnostic purposes. In addition, both

Kuwait and Qatar have the ability to allow Coalition

Forces and some civilians to receive treatment and/or

recuperate at their locations for up to 30 days. The

Warrior Return Unit is located in Kuwait and the

Theater Transient Holding Detachment (TTHD) is

located in Qatar. This 30-day recovery period allows

injured Warriors to remain in the US Central

*North Atlantic Treaty Organization

†Computed tomography

‡Magnetic resonance imaging
October – December 2008 43

THE ARMY MEDICAL DEPARTMENT JOURNAL

Command area of responsibility, conserving fighting

strength, increasing the return to duty rate, and

optimizing the health of the force. If it were not for the

Warrior Return Unit or the TTHD, the Warriors who

require an extended period of recovery would have to

be regulated to Germany, or, in many cases, to the

United States. The combined return to duty rate for

both the Warrior Return Unit and the TTHD is

approximately 94%, whereas the return to duty rate for

Landstuhl Regional Medical Center in Germany is

approximately 24%. Figure 1 shows the increase in

patients being regulated from the ITO to the Warrior

Return Unit and TTHD since October 2007. Through

education and increased emphasis on “regulating south

to Kuwait and Qatar versus north to Germany,” the use

of these facilities from the ITO is on the rise.

“Regulating south versus north” is not only for the

Warrior Return Unit and the TTHD, but is also driven

by geography and capability. The US hospital in

Bucca, Iraq, primarily treats detainees. There are also

2 clinics with surgical capability and a British hospital

located in the southern portion of Iraq. Each of these

facilities often receives patients beyond their capability

and, after initial resuscitation, the patients must be

further regulated to a higher level of care. Regulating

south to Kuwait from this area of Iraq for those

patients that are eligible is always the first choice. The

theater MRO instituted this regulating technique in

September 2007. Prior to that, most patients from these

facilities were regulated north to Baghdad or Joint

Base Balad which exhausted the limited MEDEVAC

assets in the southern portion of Iraq. It takes

approximately 4 to 5 hours and numerous MEDEVAC

aircraft to move one patient from Bucca to Balad,

whereas it takes 25 minutes and only 2 aircraft to

move a patient from Bucca to Kuwait. The greater

efficiency affected the MEDEVAC resource, which is

the primary transporter of patients between facilities

within the ITO, and to and from Kuwait.

Patient Movement by Helicopter

The vast majority (99%) of all the intratheater patient

movements regulated throughout the ITO are moved

via MEDEVAC helicopters. However, not all patients

moved via MEDEVAC helicopters in the ITO are

regulated through the theater MRO. Most of the point

of injury (POI) missions, such as an attacked convoy,

are called directly to the closest MEDEVAC company

from the forces at the scene. These POIs, as well as

those missions from non-EAD medical facilities, are

not typically regulated by the theater MRO. The

theater MRO does have visibility of these missions

through the use of Microsoft Internet Relay Chat

9

2

8

14

6

33

72

1 0

9

17

23

63

2 0

5

12

27

57

7

1

12 12

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88

20

1

19

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15

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0

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20

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5 7

11

29

68

31

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1

13 15 13

48

108

20

15

7

12 12

102

168

0

20

40

60

80

100

120

140

160

180

BAGHDAD MOSUL BALAD AL ASAD TIKRIT OTHER FACILITIES TOTAL

OCT 07 NOV 07 DEC 07 JAN 08 FEB 08 MAR 08 APR 08 MAY 08 JUN 08 JUL 08

Baghdad Mosul Balad Alasad Tikrit Other Facilities Total

Figure 1. Number of patients, by facility, transferred to the Warrior Return Unit in Kuwait, or the Theater

Transient Holding Detachment in Qatar, from October 2007 through July 2008 (data as of 4 August 2008).
44 www.cs.amedd.army.mil/references_publications.aspx

(mIRC), which is the single best innovation in medical

regulating and situational awareness since the high

frequency radio, in terms of communication capability.

For patient movement and situational awareness,

mIRC allows real-time chat among all involved

parties. All MEDEVAC requests are posted in mIRC

so the theater has visibility on what is happening, and

when. It is not perfect, but it comes very close to realtime awareness. The mIRC capability allows one of

the most significant deviations from doctrine in the

MRO’s available tools. It allows the theater MRO to

regulate patients from POI to the most appropriate

facility, especially during a mass casualty producing

event.

A case in point: as a result of a suicide bomber in a

market, 36 host nation patients, consisting of Iraqi

civilians and Iraqi Security Force (ISF) personnel with

horrendous injuries, were brought into a small forward

operating base which had only 2 healthcare providers.

The clinic called an urgent MEDEVAC request. The

MEDEVAC operations dispatcher posted the request

into mIRC to provide theater-wide visibility of this

mass casualty situation. Through mIRC chat, the

theater MRO directed the first lift to take its patients to

the closest facility, while directing the next 2 lifts, one

of which was from a completely different MEDEVAC

company, to evacuate the patients to 2 other facilities,

thereby distributing the patients among 3 hospitals.

This is an example of how regulating from POI is

crucial to ensure that best care is provided to those in

need, while efficiently and effectively employing the

theater healthcare and MEDEVAC assets.

The MEDEVAC capability in the ITO consists of US

Army, Coalition Force, and Iraqi Air Force assets. The

MEDEVAC resources are arrayed throughout the ITO

to support the primary mission of POI urgent and

priority requests. However, in reality, most of the

missions executed by MEDEVAC are transfers from

one hospital to the next as regulated through the

theater MRO. The theater MRO regulates much more

than patients. Blood, supplies, medical personnel,

medical equipment, escorts, etc. are all regulated and

tracked in the same manner as patients.

Figure 2 presents the weekly workload of missions

passed to the US MEDEVAC community by the

theater MRO from September 2007 through August

134

114

126

142

161

153

121125

136

147

99

107

99

116

146

108106

96

117

149

103

154

124

103107

133

123

142

196

116

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152

132

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119

8287

55

104

969188

99

112

8588

100

123

90

0

50

100

150

200

250

URGENT PRIORITY ROUTINE TOTAL PATIENTS MOVED TREND (TOTAL PATIENTS MOVED)

Figure 2. The number of missions tasked to US MEDEVAC helicopters by theater medical regulating operations weekly

from September 2007 through August 2008.

The Complexity of Moving Patients in Today’s Maturing Counterinsurgency Environment:

Whom, When, and How
October – December 2008 45

THE ARMY MEDICAL DEPARTMENT JOURNAL

2008. Figure 3 shows the movements by priority and

type from August 2007 through July 2008. The weekly

average remained relatively constant through the peak

in March 2008 during ISF led operations, and then

began a decline through the August 2008 numbers.

Patient Movement by Airplane

Helicopters account for more than 99% of all

intratheater movement, while airplanes perform more

than 99% of all intertheater patient transportation.

There are instances where patients are regulated intratheater via airplane, such as when weather restricts

helicopter flight, but does not hinder airplane operations. Also, sometimes the Iraqi Air Force is involved

in the movement or transfer of an Iraqi patient, or a

civilian air ambulance is used to move a contractor or

other patients approved to be moved outside of Iraq.

Regulating airplane-transported patients requires

significantly increased levels of coordination to synchronize patient movement. This synchronization involves the clinics and hospitals, the theater MRO, the

Joint Patient Movement Requirements Center (a US

Central Command asset located in Qatar), the US Air

Force, contractors, civilian air ambulance companies,

and other countries around the Middle East. Patient

movement by airplane is the prime example of spanning the tactical, operational, and strategic lines of the

operation.

The emphasis by the most senior leaders in the

Department of Defense (DoD) on intertheater patient

movement is remarkable. The process is fluid and

responsive. There are countless examples of the

expeditious movement of US urgent patients from Iraq

to Germany, and even to the United States, in as little

as 16 hours. Figure 4 depicts the weekly average of

patients moved via US Air Force airplanes out of the

ITO, July 2008 through August 2008. There is a slight

downward trend in the numbers over the course of the

last year, excluding the last week of the period.

Figure 3. US MEDEVAC helicopter missions by priority and type during July 2008, in comparison to June 2008.

As of 4 Aug 08

35, 5%

25, 4%

11, 2%

112, 16%

222, 32%

164, 24%

77, 11%

45, 6%

Urgent Litter

Priority Litter

Priority Ambulatory

Routine Litter

Routine Ambulatory

Attendants

Blood

Medical Supplies

JULY MONTHLY TOTALS

Urgent Litter 35 (2)

Priority Litter 25 (6)

Priority Ambulatory 11 (1)

Routine Litter 112 (12)

Routine Ambulatory 222 (48)

Attendants 164 (18)

Blood (boxes) 77 (6)

Medical Supplies 45 (8)

Total Moved on Evac 691 (93)

July Blood Movement

Urgent: 1 Missions (4)

Priority: 0 Missions (5)

Routine: 44 Missions (15)

Units: 1618 Units (410) Starting in April Blood was tracked by

number of missions and number of units.

Indicates an increase or decrease

( ) identifies the amount changed

from the previous month

Monthly Average Since TOA

Urgent Litter 44

Priority Litter 39

Priority Ambulatory 13

Routine Litter 158

Routine Ambulatory 268

Attendants 173

Blood 123

Medical Supplies 46

Average Moved on Evac 864

Monthly Average Sin ce August 7, 2007*

July 2008 MonthlyTotals

indicates increase

indicates decrease

Number in ( ) is the numeric change

f rom the prev ious month.
46 www.cs.amedd.army.mil/references_publications.aspx

Iraqi Air Force Transport of Iraqi Patients

As the theater matures, increased emphasis is placed

on the Government of Iraq healthcare/military system

to care for its citizens. The emphasis on patient

movement is no exception. There is evidence of

progress towards self-reliance in the Iraqi Air Force in

the movement of Iraqi patients throughout Iraq. All

Iraqi military airplanes and helicopters belong to the

Iraqi Air Force. They have 3 C-130 transport airplanes

and a fleet of UH-1 and MI-17 helicopters in their

inventory for many uses, including, of course, patient

transportation.

Through coordination and synchronization with the

theater MRO, the hospitals, and the Coalition Air

Force Transition Team, the Iraqi Air Force has completed 8 patient movements by airplane, totaling 18

patients, in the last year. Each of the 18 patients was

transferred from a US military hospital to an Iraqi

medical facility. Each Iraqi Air Force airplane mission

marks a successful step in the direction of selfreliance.

While those 8 missions were coordinated through the

theater MRO, during the ISF led operation in Basrah in

March 2008, the Iraqi Air Force executed more than

250 ISF patient moves from Basrah to the Baghdad

area, and further ground-evacuated the patients into

Iraqi medical facilities. The Iraqi Air Force moved almost 600 units of blood from the Baghdad area to Basrah to support combat operations. All of these missions

were executed using the Iraqi Air Force C-130s.

Self-reliance for patient movement is not limited to

airplanes. In March 2008, 2 Iraqi Air Force medics

graduated from the first class of the Iraqi Air Force

Flight Medics Course. In May and June 2008, the Iraqi

Air Force completed 2 helicopter patient movements

using both the UH-1 and the MI-17 helicopters, with at

least one of the flight medics on board each mission.

The 2 missions moved patients from the US hospital in

Joint Base Balad to the US military hospital in

Baghdad, where both patients were further regulated to

Medical City in Baghdad. With guidance, the Iraqi Air

Force will continue to move patients, with the goal of

Iraqis moving Iraqis to Iraqi health care facilities. This

will assist with the self-reliance of the Government of

Iraq, lessening the reliance on the US military health

care system, and allowing greater adherence to the

medical rules of eligibility.

Figure 4. The weekly average number of patients transported from the Iraq theater of operations on US Air Force

airplanes (STRATEVAC), July 2008 through August 2008.

157

224

156

131

190

200

229

183

199

172

213

142

173

164

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110

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163

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145 146

158 163

170

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140 140

173

179 184

151

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168

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164

221

0

100

200

300 STRATEVAC AVERAGE TRENDLINE

The Complexity of Moving Patients in Today’s Maturing Counterinsurgency Environment:

Whom, When, and How
October – December 2008 47

THE ARMY MEDICAL DEPARTMENT JOURNAL

MEDICAL RULES OF ELIGIBILITY

Medical Rules of Eligibility guide the DoD medical

elements with regard to whom they can treat, when

they can treat, and why they can treat. The MROE

have not changed significantly since the early 1990s,

and as such remain somewhat vague.

A RAND Corporation report, Securing Health:

Lessons from Nation-Building Missions,

1

looks at the

health aspects of nation building during the

occupations of Germany and Japan, as well as

operations in Somalia, Haiti, Kosovo, Afghanistan,

and Iraq. The following citation from that report on the

mission in Kosovo captures the essence of DoD/US

policy with regard to the provision of health care to

host nation civilians during operations:

US policy tended to favor a narrower definition of the

medical mission, one that focused on providing medical

support to the force and provided care to civilians only

in emergencies. According to US policy, military

medical units were not to get involved in refugee care

or in the rebuilding of health care infrastructure.

The MROE for Iraq is basically the same. Military

medical units are authorized to treat anyone to prevent

loss of life, limb, or eyesight. Other than Coalition

Forces, detainees, and select US civilian personnel,

there is ambiguity as to who is entitled to what care,

and when. This creates challenges to everyone

involved in patient treatment and movement. The

theater MRO is the subject matter expert on MROE.

Questions concerning eligibility number the hundreds,

answering them is challenging at best. For example:

If we don’t take this ISF out of this Iraqi facility he will

die. Does that make it life, limb, or eyesight?

This Ugandan contractor has a terminal disease but we

can’t do anything for him. Can we admit him and send

him to the US?

An Iraqi general’s single daughter is pregnant with

complications and will be killed if the locals find out.

We have to get her to Baghdad

Every one of these questions has the same answer—

perhaps. Some are much more executable than others,

but each one is real, each one is now, each one is

important, and, on any given day, many of them are

occurring at the same time. This is the ambiguity of

the MROE: Did we cause it? Do we care for it? Can

we care for it? What’s the process?

Therein exists the inextricable link between medical

regulating and medical rules of eligibility. There is

always “the process” alluded to above. That process

involves requesting exceptions to policy. This process

can be challenging, but, given the current policy of

restricting care versus complete access to care,

especially for host nation civilians, it is meant to be

challenging. It is challenging to protect US military

healthcare resources and support the legitimacy of the

Government of Iraq through allowing the Ministry of

Health to care for Iraq’s sons and daughters.

MEDICAL DIPLOMACY: MEDICAL REGULATING AND

MEDICAL RULES OF ELIGIBILITY

Nagl et al2speak to “securing the civilian,” “battle for

civilian support,” and focusing on the “neutral or

passive majority.” Medical diplomacy can help in

providing security for the civilian populace, while

battling for civilian support. Medical diplomacy

focuses on the passive majority in providing care as an

adjunct to the Iraqi healthcare system, not “as the Iraqi

healthcare system.” A player in the counterinsurgency

fight could be, and should be, medical diplomacy by

using the military medical capacity to treat Iraqi

civilians and “win the hearts and minds” of the local

populace.

A key component in medical regulating and strict

MROE is limited medical capacity and capability. If

the US had 10,000 inpatient beds spread across 500

hospitals with every conceivable specialty at each

facility, there would be no need to medically regulate

patients or adhere to the current MROE. The reality is

that DoD medical facilities are extremely limited in the

number of beds and specialties in theater, where they

are located, experience constant turnover of personnel,

are under pressure to downsize the medical footprint,

and function under a policy of not readily providing

care to other than those clearly eligible. Therefore,

there is a requirement for aggressive medical regulating and strict adherence to the published MROE.

Aggressive medical regulating begins with the

“stabilize to transport” mindset. This mindset is the

medical regulating mantra to ensure the DoD hospitals

transport Iraqi civilians from US facilities and into the

Iraqi healthcare system at the earliest opportunity, as

directed by competent medical authority. By

regulating patients earlier rather than later, the theater

is better able to manage bed capacity, hospital
48 www.cs.amedd.army.mil/references_publications.aspx

specialty, and movement resources. The Iraqi patient

transport is facilitated by the Civil-Military Liaison

Officers (CMLO) and the Bilingual Bicultural

Advisor-Subject Matter Experts (BBA-SME), which

are part of civil-military operations under the medical

task force. These CMLOs and BBA-SMEs ensure that

Iraqi patients are appropriately regulated to accepting

Iraqi facilities. The theater MRO and the civil-military

operations officer synchronize the coordination and

execution to aggressively regulate Iraqi patients into

the Iraqi health care system. The limiting factor for

both the US military and the Iraqi health care systems

is capacity.

US MILITARY MEDICAL CAPACITY

The limited US military inpatient beds spread across

the ITO are underutilized as evidenced by the bed fill

occupancy numbers. Since January 2007, the average

daily bed fill across all inpatient hospitals is 41%.

Figure 5 details the average bed fill through July 2008.

Further, as shown in Figure 6, the significant majority

of patients in those occupied beds are Iraqi, a fact that

has existed for the 20-month period covered by the

data (December 2006 through July 2008).

There were 1,346 admissions in January 2007, and

over 1,600 in May and June 2007. Since, we have seen

a steady decline in admissions with a low of 972 in

May 2008. June and July 2008 reflect only a slight

increase at 984 and 1,055 respectively.

The demographics of those admitted to US military

facilities are changing. Prior to June 2008, US military

admissions accounted for more than 40%, whereas

Iraqis accounted for almost 38%. In July 2008, US

military admissions accounted for a 15-month high of

51%, and Iraqis (host nation civilians and Iraqi

Security Forces) combined accounted for a 15-month

low of 17%.

Finally, the makeup of admissions is changing as well.

Since January 2008, the rate of admissions for battle

injury declined from over 400 in January through

March 2008, to just more than 180 for June and July

2008. Figure 7 presents the data.

From May to July 2008, an average of only 32% of the

beds were occupied, indicating excess capacity. There

is also excess capacity in our outpatient clinics as well.

This excess capacity allows implementation and

expansion of medical diplomacy in the

counterinsurgency fight.

MEDICAL DIPLOMACY

Nagl et al quote former Army Vice Chief of Staff,

General Jack Keane2(pxiv):

After the Vietnam War, we purged ourselves of

everything that had to do with irregular warfare or

insurgency, because it had to do with how we lost that

war. In hindsight, that was a bad decision.

Perhaps we could learn from the medical diplomacy of

Vietnam as detailed by Wilensky3:

Almost 40 million encounters between American

military physicians and Vietnamese civilians occurred

from 1963 to 1971 in the Medical Civic Action

Program (MEDCAP) alone during the Vietnam conflict.

...Aside from the humanitarian reasons for the various

civilian medical aid programs, Spurgeon Neel thought

that medical services were properly used for political

gain. MEDCAP was a tactical employment of medical

capability to “try and influence the people we were

there trying to help.”...Neel also felt that another reason

for the programs was that they improved the image of

the United States.

Medical Civic Action Program events (MEDCAPs) are

being conducted sporadically throughout Iraq by small

unit engagements, but, outside of the Erbil region,

there is no apparent concerted effort to use MEDCAPs

in counterinsurgency operations to win the hearts and

minds of the Iraqi populace. The Zaytun Division of

the Republic of Korea Army in the Erbil region is a

prime example of medical diplomacy. The Korean

hospital, in cooperation with Korean civil affairs,

treats approximately 120 Iraqi (Kurdish) patients 4

days per week. This accounts for more than 90% of

their outpatient workload. The civil affairs unit screens

the local Iraqis needing care, provides them a “ticket”

which entitles them to acute and chronic care in the

Korean hospital. The Koreans provide a monthly, fairlike event which, in addition to Tae Kwon Do and

magic show demonstrations, includes health screening

and education. The events have had no security issues.

The hospital leadership attributes the medical care

provided to the local populace as a key element in the

security successes enjoyed in the northern part of Iraq.

It is impossible to satisfy everyone. However, using

medical diplomacy as a tool in the counterinsurgency

fight is an alternative to significantly restricting access

The Complexity of Moving Patients in Today’s Maturing Counterinsurgency Environment:

Whom, When, and How
October – December 2008 49

THE ARMY MEDICAL DEPARTMENT JOURNAL

118 118

127

132

125 124 126

109

123

105

111

103 104 102

110

90 93

87

52%

45% 44% 43% 43% 46% 48% 46% 46% 46%

40%

45%

38% 40%

37% 38% 37% 40%

33% 34% 32%

0

20

40

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140

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10%

20%

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Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08

Number of Beds Monthly Bedfill Average Bedfill Trend Line

Figure 5. Percentage average daily inpatient bed fill at US military facilities in the Iraq theater of operations,

November 2006 through July 2008, based on total of 274 operational available beds.* Data as of 4 August 2008. Note:

Inpatients consist of US, Iraqi military, and others eligible under the medical rules of eligibility.

*Available operational beds decreased to 254 on 17 July 2008

Figure 6. Comparison of US and Iraqi patients (actual numbers and percentages) occupying inpatient beds at US

military facilities in the Iraq theater of operations from December 2006 and July 2008. Data as of 4 August 2008.

18 24 25 29 28 28 24 25 26 25 24 22 22 20 21 28 28

89

85

92 90 92 85 90

76

88

71 74 71 71 81

59

53

50

25%

29%

25%

15%

20% 20% 22% 22% 23%

19%

23% 21%

24% 22% 21% 21%

18%

24%

30% 33%

66% 65% 67%

75% 72% 72%

68%

74%

69% 71%

70%

72%

68% 67%

69% 68% 74%

65% 58% 57%

0

20

40

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120

140

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08

Number of Iraqi pts. Number of US pts. US IRAQI Iraqi Patients US Patients US Av erage Iraqi Av erage
50 www.cs.amedd.army.mil/references_publications.aspx

to care. A balance must be struck between the

acceptable CF medical footprint—the ability, through

security, to provide care to the local populace while

ensuring excess capacity is maintained for that

expected surge in CF casualties—with the ability to

ensure the Government of Iraq is caring for its citizens.

This paradigm shift in the medical diplomacy line of

operation in support of the counterinsurgency fight

would certainly involve medical regulating operations

and a variance of historical DoD/US policy on medical

rules of eligibility. Perhaps then the next street the

command sergeant major and his unit patrols will not

be littered with improvised explosive devices.

CONCLUSION

The inextricable link between medical regulating

operations and the medical rules of eligibility is more

than the medical regulating operations officer. In an

operational environment as vast as Iraq involving host

nation civilians, Iraqi military personnel, Iraqi

dignitaries, and a host of other potential patients, the

complex mission of executing medical regulating

operations while adhering to MROE is an extremely

dynamic undertaking. The theater MRO always

expects—but never knows—what will be contained in

that next call or that next email:

There are conjoined twins in an Iraqi hospital that the

King of Saudi Arabia has accepted. If the Saudis cannot

get them moved, can we move them into our facility

and then arrange for transportation to Saudi Arabia?

REFERENCES

1. Jones SG, Hilborne LH, Anthony CR, et al. Securing

Health Lessons from Nation-Building Missions. Santa

Monica, CA: RAND Corporation; 2006.

2. Nagl JA, Petraeus DH, Amos JF. The US ArmyMarine Corps Counterinsurgency Field Manual.

Chicago, IL: University of Chicago Press; 2007.

3. Wilensky RJ. Military Medicine to Win Hearts and

Minds: Aid to Civilian in the Vietnam War. Lubbock,

TX: Texas Tech University Press; 2004.

AUTHOR

At the time this article was written, LTC Richardson

was the Iraq Theater of Operations Medical Regulating

Officer, Task Force 62 Medical Brigade, Baghdad, Iraq.

Figure 7. Admissions to US military medical facilities January through July 2008, broken down by cause for

admission. The trend for battle injuries is clearly down, while the admission rate for nonbattle injuries has

remained relatively constant.

411 422 412

377

295

185 187

206

265

179 165

187

166

203

661

702

527 533

490

633

665

0

100

200

300

400

500

600

700

800

1 2 3 4 5 6 7

Jan 2008 Feb 2008 Mar 2008 Apr 2008 May 2008 Jun 2008 Jul 2008

Monthly Average

Battle Injury 327

Nonbattle Injury 196

Disease 602

Battle Injury Nonbattle Injury Disease

The Complexity of Moving Patients in Today’s Maturing Counterinsurgency Environment:

Whom, When, and How
October – December 2008 51

Planning guidance to staff:

Strive to synchronize a sustainable healthcare system

defined by measurable outcomes, innovation, and

performance excellence in pursuit of perfecting combat

medicine.

COL Patrick Sargent, Commander,

Task Force 62 Medical Brigade

When the Task Force 62 Medical Brigade (TF62

MED) assumed control of the theater medical

command mission in 2007, it was clear from the 98%

patient survivability rate that previous medical task

forces had been successful at providing medical care.

Understandably, in the support of extensive combat

operations, there had been little systematic planning

for more than one year at a time. Also, a systemized

healthcare delivery network that used evidence-based

standards and knowledge management to qualify and

improve patient outcomes had not yet been developed.

Considered the “tip of the spear” for healthcare

delivery, TF62 MED launched a campaign plan to

build a sustainable healthcare system. This system had,

as its foundation, standards-based healthcare delivery

infused with a relentless focus on evidence-based

combat health care and performance excellence, two of

the commander’s top 10 priorities. The success of this

campaign would be the template for future deployable

medical systems, and would ensure a codified standards-based continuum of care delivery system.

HEALTHCARE SYSTEM ASSESSMENT

A major long-term investment associated with

healthcare excellence is gained by creating and

sustaining an assessment system focused on healthcare

outcomes. An effective healthcare system depends on

the measurement and analysis of performance. We

developed the healthcare systematic assessment model

(Figure 1) to assess and manage clinical synchronization at the tactical, operational, and strategic levels

to keep our combat healthcare system on track towards

the 2 supporting conditions relative to our near-term

objectives: aggressive force health protection and

conservation of combat power.

The 3 core competencies delineated in Figure 1 that

supported our healthcare system were: process

management, work force, and work systems. Process

management allowed us to assess and benchmark

processes in our Warrior healthcare delivery system

using quality outcome metrics such as those with the

ventilator associated “care bundle”* to evaluate patient

outcomes. Ongoing assessment of surveillance metrics

such as disease and nonbattle injury rates and

reportable medical events reports provided critical data

points that allowed adjustments in force health

protection strategies. We analyzed the workforce by

examining workforce capacity, defined as our ability

to ensure sufficient staff to accomplish our work

processes and successfully deliver patient care. Work

force capability was defined as our ability to

accomplish our work processes through the knowledge, skills, and competencies of our staff. We

assessed work force capacity, for example, by using

workload metrics such as the number of surgical cases,

surgical hours, bed occupancy rates, and nursing care

hours. We built a metrics workbook for each facility

that allowed us to analyze each facility’s progress, as

well as compare and contrast data among facilities.

These metrics, when compared to work force metrics

such as numbers and skill mix of staff, allowed us to

optimize workload to work force ratios. One of the

ways we assessed work force capability was to track

staff competency metrics, such as credentialing,

privileging, and licensure. We continuously assessed

work system design using key work process metrics to

evaluate strategies for redesign of systems and

processes to make them safer for our patients. We used

risk management metrics, such as incident reporting,

trending and analysis, to systematically assess our key

work processes. Decisions about the 3 core competencies (process management, work force, work

systems) guided brigade strategies. The decisions

involved defining, protecting, and capitalizing on our

Clinical Quality Management in a Mature

Combat Environment

COL Susz Clark, AN, USA

MSG(P) Richard Brewer, USA

*Mandated by the Office of The Surgeon General/US Army

Medical Command Policy Memo 07-011, dated April 26,

2007.
52 www.cs.amedd.army.mil/references_publications.aspx

Clinical Quality Management in a Mature Combat Environment

critical health service support capabilities and systems

in order to be a sustainable healthcare system.

PATIENT SAFETY: THE FIRST STEP

An initial, early assessment of units in theater at the

time revealed that there was no standardized approach

to patient safety and clinical risk mitigation.

Subsequently, the task force developed and

implemented a task force-wide patient safety program

to decrease variation of patient safety practices,

improve measurement reliability, and promote patient

safety best practices within the system. Incident

reporting which summarized both error occurrence as

well as near-miss reporting (where the error is

identified prior to impacting the patient) was tracked at

the direct reporting unit level for summary and

analysis across the task force on a monthly, quarterly,

and annual basis. Direct reporting units remained

responsible for corrective action and error prevention

training based on the incident report findings at each

unit, while task force-wide trends identified generalized training needs. Incident reporting analyses lead

to the development and implementation of standardized blood administration, moderate sedation delivery

and inpatient medication administration guidelines,

and a sharps safety training package for use throughout

the task force.

IMPLEMENTING QUALITY IN DEPLOYED HEALTHCARE

Today’s Army healthcare system continues to

exemplify the highest quality of patient care, both in

the United States (CONUS) and forward deployed.

Although providing the same consistency of healthcare

in an austere deployed environment has its challenges,

the expectation to provide a standard-based healthcare

system remained our goal. Since the inception of

mobile combat hospitals to treat the sick and wounded,

the concept has remained the same: provide a standard

Figure 1. The healthcare systematic assessment model developed by TF62 MED to assess and manage clinical

synchronization at the tactical, operational, and strategic levels.
October – December 2008 53

THE ARMY MEDICAL DEPARTMENT JOURNAL

of care based on the experience and training of the

clinical staff deployed from CONUS-based medical

facilities. This doctrinal concept has shown resilience,

but it lacked a process to validate and codify best

practices within the mobile combat hospitals.

Historically, deployable hospitals are not required to

withstand the rigors of a Joint Commission*

inspection. Higher headquarters have historically

provided various degrees of oversight and instituted

clinical polices to maintain standards of care. To

ensure a standards-based healthcare system, we

leveraged proven clinical practice guidelines and most

of the Joint Commission’s nationally established

standards of care to validate medical units rotating into

theater. Prior unit inspections focused on availability

of clinical policies and standard operating procedures.

In order to adequately assess the components of the

healthcare systematic assessment model, we had to go

beyond paper policies to look at the processes and

systems driving healthcare delivery at the frontline of

care delivery—the unit. To do so, we focused on the

patient and devised the concept of the quality

healthcare assistance visit (QHAV) that used patient

and system tracer methodology to evaluate clinical

processes.

In the early stages of development, the staff created a

graphic model (Figure 2) to visually portray the

diverse patient systems that compelled the validation

process and drove standards-based care delivery.

The model depicts the patient as the “center-ofgravity” for all healthcare delivery processes, from

point-of-injury through level III hospital care and

theater evacuation, with an emphasis on quantifying

and qualifying patient outcomes. Using the Joint

Commission functions to define patient care and

support processes, we developed a 120-item QHAV

checklist (Figure 3) to use with tracer methodology in

order to evaluate each of our level III hospitals.

Patient and system tracer methodology allowed the

QHAV team to follow, observe, and evaluate a

patient’s care throughout the healthcare process. The

patient tracer process started from the moment a

patient entered a level I (aid station) thru level III

(hospital) activity, and continued throughout his/her

stay or until discharge or evacuation from the Iraq

theater of operations. This process ensured all

healthcare functional areas were synchronized to

provide the best outcome for the patient. Furthermore,

it gave the QHAV team the opportunity to assess

policies and procedures and provide recommendations

for performance improvement.

We used this process to evaluate 7 geographically

dispersed level III hospitals twice, once at 30 days

after transfer of authority (initial arrival) to ensure

appropriate standards and processes were codified and

in use. They were evaluated a second time 120 days

prior to their redeployment to ensure standards had

been maintained for handoff during the unit’s

transition. The model and the QHAV checklist

provided the direct reporting unit commanders and

their staffs priority focus areas to consider in their

respective unit’s organizational risk assessment. The

concept allowed a continuous improvement process

during the unit’s tour of duty and identified numerous

best practices that were disseminated throughout the

task force. In addition, and most importantly, it

ensured a standards-based healthcare system that was

validated and codified.

The end state was a comprehensive evaluation of

systems that were patient-centric and allowed for an

overarching collaborative approach to resolve clinical

issues that had inundated the rotations of previous

medical brigades. Undoubtedly, the ability to apply

Joint Commission standards in an austere environment

is limited by conditions on the ground and resources

available. Though there are numerous differences

between the environments of care in CONUS and Iraq,

we directly challenged the false assumption that we

initially heard, “we can’t do that quality improvement

stuff in a combat zone.” However, the belief still exists

that we can expect and should hold ourselves to a US

standard of care—one founded on proven guidelines,

practices, and patient safety.

STANDARDS-BASED HEALTHCARE DELIVERY: NURSING

After visiting several units, we found early-on that the

medication management system required some

reengineering specific to medication administration.

Concurrently, medication administration errors were

consistently in the top 3 errors reported via our

incident reporting system. During the QHAVs, we

observed that nurses, used to electronic medication

*Joint Commission on Accreditation of Healthcare

Organizations, One Renaissance Blvd, Oakbrook Terrace,

Illinois 60181
54 www.cs.amedd.army.mil/references_publications.aspx

dispensers in CONUS-based medical treatment

facilities, had problems completing the 10 rights of

medication administration without the electronic

systems and a clear delineation of an alternate method

of administering medications. In addition, long

hallways at several of the facilities increased the

distance between the patient and the nurses’ station,

where the medications were stored, which increased

the chance of error. During a QHAV, we discovered a

best practice in use at one of our facilities: mobile

medication carts. Nurses formerly used medication

carts to deliver medications, but these were outmoded

by implementation of electronic delivery devices. The

medication carts could be stocked with medications at

the nurses’ station, and then rolled to the patient,

thereby decreasing the steps required, literally and

figuratively, for medication administration. To

minimize medication administration errors among the

new nurses, we revised an old adage, “new nurses

learning old tricks.” The medication carts, along with a

standardized medication administration policy that

served as an operator’s manual for the carts, were

disseminated throughout the task force to promote

patient safety and decrease medication errors.

STANDARDS-BASED HEALTHCARE DELIVERY:

EQUIPMENT

The patient and system tracer methodology identified a

staff that was unfamiliar with the type of dated

equipment being employed in theater. Similarly, the

procedures to request and standardize equipment were

not well-established, causing further delays in

obtaining modern equipment. This required staff

coordination between the clinical operations staff and

S4 (logistics) to develop a process that allowed a

seamless and transparent platform by which units

could order equipment. First, units had to establish a

competency checklist relevant to their equipment. This

provided a codified system by which staff could

Clinical Quality Management in a Mature Combat Environment

Figure 2. The graphic model adopted by TF62 MED to visually portray the diverse patient systems that compelled

the validation process and drove standards-based care delivery.

O

u

t

c

o

m

e

s
October – December 2008 55

THE ARMY MEDICAL DEPARTMENT JOURNAL

demonstrate their competency on a

particular piece of equipment. Next, the

Deputy Commander for Clinical Services

established a Medical Equipment Standardization and Validation Board consisting of clinical hospital leaders and

equipment proponents. Through a virtual

meeting room; clinical staff reviewed,

approved, and standardized equipment

requested by units. Likewise, it allowed

them to look for redundancies or like

items that had been previously approved.

This systematic approach allowed the task

force to purchase approximately 1,340

items, valued at approximately $15.7

million. Of note, the QHAV program’s

focus on evidence-based practice

identified forward surgical team

equipment modifications in the type of

refrigerators and beds necessary to

support current clinical practice guidelines and standards of patient care.

STANDARDS-BASED HEALTHCARE

DELIVERY: DOCUMENTATION

Documentation is a critical component of the delivery

of healthcare, not only within Iraq but throughout the

care continuum to the level IV medical centers in

CONUS. The QHAV team recognized early that,

although the Army had an electronic medical record

(EMR), there were enormous gaps in knowledge about

and use of the system. The medical staff was not

familiar with various mandatory form fields to be

completed. Conversely, the medical staff complained

of a lack of fields needed to complete their

documentation. Technical problems beleaguered the

system to the point that medical documentation was

either lost or delayed, causing breaks in the

chronological order of treatment. TF62 MED Clinical

Operations and Health Information Systems had to

collaborate to institute changes that were requested by

the units. Working with medical communications for

combat casualty care (MC4) system consultants, this

team educated staff on the EMR/MC4 systems use.

Furthermore, working in conjunction with physicians

and nurses, the team drove an upgrade to the EMR,

adding more fields to support clinical notes.

Improvements in connectivity, access, and medical

record audits increased visibility and use of the EMR,

not only in Iraq, but also in our level IV medical

centers back home. In the previous 2 years there were

approximately 23,000 inpatient and 1,840,000

pharmacy, laboratory, and radiology (PLX) EMR

encounters. At the time this article was written (July

2008), the 62nd Medical Brigade had entered

approximately 17,250 inpatient and 2,115,00 (PLX)

encounters since it assumed authority for the theater

medical mission (August 2007). This extraordinary

increase was reflective of the institution of

standardized detailed medical records documentation

through medical automation systems within the theater

and across the continuum of care.

CONCLUSION

The expectation of our patients is “we train as we

fight,” honing those clinical skills that will result in

flawless delivery of healthcare. Warfighters withstand

unit, battalion, and brigade inspections which

constantly evaluate tactics, and work toward

improving and synchronizing operations with the goal

of accomplishing the mission and bringing the Soldiers

home safely. Those tactics, techniques and procedures

(TTPs) get codified and standardized, and in turn

become an Army standard. Those TTPs are learned

through experiencing harsh realities, from the

Figure 3. Excerpt from the integrated quality healthcare assistance

visit team checklist.

Team # Team Member Date of Tracer Attending Staff

Member

Admission

Diagnosis

Initials of Patient

Selected/Last 4

SSN

Unit Date/Time

Admitted

1 2 3 4

5 6 7 8

9 10 11 12

Score 2 = fully

compliant

1 = partially

compliant

0 = not in

compliance

NA = not

applicable

What CPGs are used for providing resuscitative

services?

PC 9.30

What would you do if you became aware of an

ethical issue concerning a patient? (Consider

interdisciplinary meeting with family, contact

Ethics Committee)

RI 1.10

What is your process for performing IV moderate

sedation?

PC 13.20

What are your two patient identifiers? NPSG

If a patient needs to be restrained for medical

reasons, how frequently do orders need to be

written? (every 24 hours)

PC 12.140

INTEGRATED SECURITY TEAM CHECKLIST

1. Go to the front desk, introduce team and ask to speak with the head nurse of NCOIC.

2. Introduce team to the head nurse and explain the purpose of your visit—an integrated patient tracer visit.

3. Ask for a brief description of the unit (types of patients, average daily census, acuity, staffing complement).

Sequence of Care Received

Priority Questions for Physician Team Member

Enter Appropriate Score Below
56 www.cs.amedd.army.mil/references_publications.aspx

shedding of US blood and loss of our Soldiers’ lives.

We recommend deployable medical units adopt the

same concept and ensure that codified, evidence-based

standards that cover the rigors of a Joint Commission

inspection be the foundation for deployed healthcare

delivery.

Present and future deployable medical units should

build their capabilities on codified standards developed

from organizations that have tried and tested clinical

processes. Degradation of capabilities is apparent as

units bring a variety of their own policies and

procedures to the fight. Too many units stagnate

initially, as they go through the growing pains of

trying to implement their standards, only to find out

that the previous unit had anguished through the same

process, and ultimately resorted back to an objective

set of standards. The perspective frequently

encountered in a deployed environment is one that is

distorted: US standards do not or can not apply and

modifications, if you will, are acceptable. It is our

belief that this perspective adversely affects how we

train and evaluate our deployable medical units. It

requires significant change and renewed focus on

current, US standards-based healthcare. As an example, Annex Q* describes TF62 MED policies and

procedures relevant to all Iraq theater of operations

healthcare facilities and units. It has elements of

performance and performance measurements, along

with National Patient Safety Goals†to help assess the

performance of an organization. To ensure a

continuous improvement process, periodic semiannual

reviews of systems will appraise action plans and

mission success.

Future organizational inspection programs and training

exercises should focus not only on the command and

control aspects, but also on the clinical doctrine

through an established, deployable, US standardsbased inspection system. The system should define

common policies and procedures specific to

deployable organizational equipment, facilities,

staffing, scope of practice, environment of care, and

logistics. The mindset of current exercises focuses on

trauma-heavy patient play, mass casualties, treatment,

and evacuation. All of these are relevant, however,

upon further review, none of those particular areas

have an associated, codified, standards-based ideology,

nor do they reflect the majority of challenges faced by

healthcare facilities in a mature operational

environment. When reviewing and questioning the

processes used by units, the normal response is

subjective—“that’s how we do it back home.” Again,

relying on the their clinical experience learned within

CONUS facilities, physicians, nurses, medics, and

administrators apply those often nonstandard clinical

practices associated with a robust medical system.

Unfortunately, in a deployed environment, services,

equipment, staffing, and logistical constraints dictate a

different approach as to how we deliver healthcare.

However, US standards and principles should be

employed through specific policies and procedures

tailored for deployable medical units. Leaders

implementing these standards will encounter initial

resistance, but healthcare professionals quickly

recognize the benefits of delivering US quality

standards-based healthcare wherever in the world their

nation sends them.

AUTHORS

At the time this article was written, COL Clark was

Deputy Commander, Nursing, and Chief, Clinical

Operations, Task Force 62 Medical Brigade, Baghdad,

Iraq.

At the time this article was written, MSG(P) Brewer

was Sergeant Major, Clinical Operations, Task Force 62

Medical Brigade, Baghdad, Iraq.

Clinical Quality Management in a Mature Combat Environment

*Annex Q is the Medical Services Annex to the TF62 MED

Operations Order 08-02 (internal military document not

readily accessible by the general public).

†Starting in 2003, the Joint Commission annually releases a

number of National Patient Safety Goals, and directs all

accredited healthcare organizations to implement those

goals. Although they are termed as goals, they are

mandatory practice changes modeled after best-practices

throughout the world. The goals, ranging from very simple

to very complex, address a variety of safety issues that

confront hospitals on a daily basis. Available at: http://

www.jointcommission.org/patientsafety/national

patientsafetygoals/
October – December 2008 57

We will not be effective and relevant in the 21st century

unless we become much more agile but with the capacity

for a long-term, sustained level of conflict. Being relevant

means having a campaign-quality Army with joint

expeditionary capability. It must be an Army not trained

for a single event like a track athlete, but talented across

a broad spectrum like a decathlete.1(p4-6)

General Peter J. Schoomaker

INTRODUCTION

Although there were lonely voices arguing that the

Army must focus on counterinsurgency in the wake of

the Cold War, the sad fact is that the Army was

unprepared to fight the insurgency in Iraq when it

began in the late summer of 2003. The story of how

the Army found itself less than ready to fight an

insurgency goes back to the Army’s unwillingness to

internalize and build upon the lessons of Vietnam.2If

the Army Medical Department (AMEDD) does not

want to follow suit and repeat history, the AMEDD

must internalize and build upon the lessons learned in

Iraq to update doctrine, continue its transformation,

and modularize the medical force structure by

developing highly trained medical capability teams. In

Iraq, counterinsurgency operations are playing an

essential role in shaping the strategic, operational, and

tactical environment, and securing peace in Iraq.

Combat healthcare is proving to be an important

“weapon system” in its own right, and a

counterinsurgency combat multiplier across the Iraq

theater of operations. Therefore, the complexity of

combat healthcare in a counterinsurgency environment

demands an agile and campaign quality AMEDD with

joint expeditionary capability; a capacity for rapid

change and flexibility in how medical units are trained,

deployed, and employed in theater; as well as changes

in combat healthcare clinical work systems and

processes.

The purpose of this article is to propose the AMEDD

develop and implement a modular, interoperable, joint

expeditionary combat healthcare model, the medical

capability team (MCT), as the “clinical microsystem”

for combat healthcare delivery that promotes the best

patient outcomes in a counterinsurgency environment.

STRUCTURING THE BRIGADE COMBAT TEAM CONCEPT

FOR HEALTHCARE DELIVERY

As described in Army Field Manual 1,

1

the Army

restructured from a division-based to a brigade-based

Medical Capability Team: The Clinical

Microsystem for Combat Healthcare Delivery

in Counterinsurgency Operations

COL Susz Clark, AN, USA

MAJ Jon K. Van Steenvort, MS, USA

ABSTRACT

Today’s operational environment in the support of counterinsurgency operations requires greater tactical and operational

flexibility and diverse medical capabilities. The skills and organizations required for full spectrum medical operations

are different from those of the past. Combat healthcare demands agility and the capacity for rapid change in clinical

systems and processes to better support the counterinsurgency environment. This article proposes the Army Medical

Department (AMEDD) develop and implement the medical capability team (MCT) for combat healthcare delivery. It

discusses using the concept of the brigade combat team to develop medical capability teams as the unit of effectiveness

to transform frontline care; provides a theoretical overview of the MCT as a “clinical microsystem”; discusses MCT

leadership, training, and organizational support, and the deployment and employment of the MCT in a counterinsurgency environment. Additionally, this article proposes that the AMEDD initiate the development of an AMEDD

Combat Training Center of Excellence to train and validate the MCTs. The complexity of combat healthcare demands

an agile and campaign quality AMEDD with joint expeditionary capability in order to promote the best patient outcomes

in a counterinsurgency environment.
58 www.cs.amedd.army.mil/references_publications.aspx

Medical Capability Team: The Clinical Microsystem for Combat Healthcare Delivery in

Counterinsurgency Operations

*Table of Organization and Equipment: Defines the structure and equipment for a military organization or unit.

†Predesignates qualified Active Duty health professionals serving in Table of Distribution and Allowance units to fill

Active Duty and early deploying and forward deployed units of Forces Command, Western Command, and the medical

commands outside of the United States upon mobilization or upon the execution of a contingency operation.3

force—the modular force—in order to meet the vision

of a campaign quality Army with joint expeditionary

capability. This modular organization simplifies providing force packages (eg, brigade combat team) that are

strategically flexible, meet operational requirements,

and increase tactical independence. The brigade combat team enhances integration with Army, joint, interagency, and multinational forces. This organizational

transformation has made the operational Army more

powerful and responsive, as demonstrated in Afghanistan and Iraq, allowing the Army to sustain deployment of brigade combat teams for over 5 years. Having

an enlarged force pool of available maneuver brigadebased forces enables the Army to generate forces in a

predictable rotation and give Soldiers and units more

time between deployments. Further, this modular force

stabilization allows higher quality training and better

support to combat commanders.1(p4-7)

The AMEDD should initiate a modular organizational

transformation to become campaign quality (operationally sustaining) with joint expeditionary capability to be more agile, relevant, and flexible. This

modular concept creates a large pool of medical force

packages that enable the AMEDD to meet operational

requirements across the full-spectrum of operations,

from combat to stability operations. This enlarged

force pool will also give AMEDD personnel and

TO&E* units greater predictability and more dwell

time between deployments. It demands a change in the

AMEDD Professional Filler System†by assigning

those personnel to a specific MCT. More importantly,

this modular AMEDD force will allow the opportunity

for higher quality individual and team training, thus

providing better support to the operational force—the

Warfighter.

Today’s operational environment in the support of

counterinsurgency operations requires greater tactical

and operational flexibility and diverse medical

capabilities. The skills and organizations required for

full spectrum medical operations are different from

those of the past. Combat healthcare demands agility

and the capacity for rapid change in clinical systems

and processes to better support the counterinsurgency

environment.

THE MCT AS THE FRONTLINE CLINICAL MICROSYSTEM

IN COUNTERINSURGENCY OPERATIONS

The concept of clinical microsystems is based on the

science of chaos theory and complexity science.4 Both

sciences postulate that even the most seemingly

disordered systems have hidden ordered processes; the

whole of the systems is greater than the sum of its

processes, and that complex systems are selforganizing and highly adaptive. Chaos theory and

complexity science reject the notion that systems are

composed of repairable, replaceable parts that can be

separated and analyzed.5 These theories describe

systems as dynamic, that is, systems whose state

evolves with time and are highly sensitive to initial

conditions. Behavior appears chaotic, but these

systems are actually deterministic; future dynamics are

fully defined by their initial conditions, with no

random elements involved.5James Quinn states that

system redesign must begin at the “smallest replicable

unit as early as possible in the design process.”6

Based on this theory, the MCT is the “smallest

replicable unit,” or the unit of effectiveness, designed

to align AMEDD strategy with clinical capability and

combat healthcare delivery. The MCT is modeled after

the brigade combat team concept in an effort to

modularize force structure into medical force packages

that are patient-centered and team-driven. An MCT

can be defined as a modular, interoperable, highlytrained medical operational unit of effectiveness that is

task-organized with specific medical capabilities and

equipped to perform a patient-focused mission under

the direction of the MCT leader in combat. The MCT

is the locus between the AMEDD vision and combat

healthcare delivery, serving as a catalyst for change at

the frontline care interface that links the AMEDD’s

core clinical competencies with the healthcare needs of

Soldiers, Marines, Sailors, and Airmen. The MCTs are

small, interdependent groups of professionals who

regularly work and train together in order to develop

into highly proficient specialized medical teams that

provide combat healthcare to a specific group of

patients. As a clinical microsystem, MCTs have

unique clinical aims, linked processes, shared

information environments and performance outcomes.

MCTs are embedded in the “macrosystem,” the

combat support hospital (CSH) where, as a type of
October – December 2008 59

THE ARMY MEDICAL DEPARTMENT JOURNAL

complex adaptive system, they must do the work, meet

patient and staff needs, and maintain themselves as a

clinical unit of effectiveness. Emergence theory

advocates environments that encourage people to

organize themselves around common problems in

order to seek creative solutions.5 Central to every

microsystem is the patient. MCTs are organized

around the common problem sets associated with

combat healthcare delivery for resuscitative, surgical,

and critical care patients. The team possesses the

appropriate clinical competencies to resolve combat

healthcare delivery problem sets associated with their

specific group of patients. For example, the

resuscitative MCT includes, at a minimum, an

emergency medicine physician (AOC* 62A),

emergency medicine nurse (AOC 66HM5), and

specially trained health care specialist (MOS†68W).

The microsystem is the place where clinical quality

management, efficiency, and innovation are made, and

staff morale and patient satisfaction begin. Finding

time to improve care can be difficult, but the only way

to improve and maintain quality and safety is by

blending analysis, measuring and redesigning into the

regular patterns and the daily habits of front-line

clinicians and staff.

At the foundation of the MCT concept is the

importance of sourcing combat healthcare delivery the

way clinicians provide care—as a team. Traditionally,

health professionals’ training and socialization

emphasizes individual skills, education, and

achievement that leads to difficulty, when deployed,

with collaboration and the development of teamwork

competencies. The AMEDD’s sourcing of clinical

capability is unit-centric (ie, CSH) and AOC/MOSdriven, and runs counterintuitive to what clinicians

bring to the fight in combat: patient-centered, teamdriven care. There is growing evidence that the focus

on individual skill development and individual

accountability and achievement that results from

existing models of health professional training, and

which is continually reinforced by human resource

management practices within healthcare systems, is

not consistent with the competencies required for

effective teamwork.7 Teamwork is essential in the

provision of healthcare. The division of labor among

medical, nursing, and medics means that no single

staff member can deliver a complete episode of

healthcare. In healthcare, where patient outcomes are

dependent on effective interdisciplinary teamwork,

there is a need for better preparation of health

professionals in teamwork. Many studies have

identified teamwork as a requirement for high quality,

safe care.7

The MCT is the unit of effectiveness that provides an

innovative means to perfect combat medicine by

aligning AMEDD strategies of how we deliver care

with the AMEDD imperatives of quality, safe, “worldclass” care by producing patterns of critical results,

such as patient and risk outcomes.

KEY SUCCESS FACTOR TO THE MCT: THE MCT LEADER

The Joint Commission’s series of articles,

“Microsystems in Health Care” identifies 9 success

characteristics of high-performing microsystems.8

These characteristics paralleled those described in the

study by the Institute of Medicine9 with the difference

being leadership emerged as a key success factor at the

microsystem level and resonated throughout the other

eight characteristics.4

In a study by Leggat7 which examined critical teamwork competencies for health service managers, the

number one individual characteristic for a team that

most contributed to the success of the team and

effective teamwork was leadership. The term “leader”

is a word that arises from the root words laitho or

laithan meaning way, journey, or to travel. Thus, MCT

leadership is less who a person is or what they do as a

leader, but more of how they influence the team’s

journey as the team adapts to environments of care.10

The leader provides constancy of purpose to create a

team environment that centers on the patient, promotes

team autonomy and accountability, embraces process

improvement, and harnesses data and technology to

develop performance patterns and outcomes. The

following paragraphs discuss the top 3 MCT leadership imperatives we believe are crucial for high-performing, quality teams.

KNOWLEDGE MANAGEMENT

Weick observed that systems can not be improved

until the “performance of the factors preventing failure

are noticed.”11 Leaders must notice and “make sense”

of these factors. After making sense of what’s been

noticed, leaders must take action. MCT leaders must

be knowledgeable on the different management and

process management models for success in chaotic and

*Area of Concentration

†Military Occupational Specialty
60 www.cs.amedd.army.mil/references_publications.aspx

complex systems within a macrosystem (eg, CSH)

where nonlinear problems and processes exist. Since

traditional statistical tools are generally insufficient to

capture the richness of information in healthcare systems infused by the complexity that humans introduce

into a system, MCT leaders must be able to create

context for statistical data for use by the MCT. For example, flowcharts that use boxes to capture the

dynamics of a process do not clearly articulate the importance of the relationships among the boxes where

“intracare gaps” can occur; for example, during patient

care handoffs between MCTs (eg, resuscitative MCT

to a surgical MCT) or during medical evacuation

(MEDEVAC) transports between different echelons of

care. Leaders should be aware of new management

theories such as clockware and swarmware which

offer the MCT leader an intellectual diagram for

outlining general goals and boundaries for team

improvement.5 Clockware defines those boundaries

delineated by tactics, techniques, and procedures

(TTPs) to which a team must adhere for standardsbased care. For example, blood administration is an

example of clockware in that it requires adherence to

regulations and policies enforcing safe patient care to

prevent errors. Traditional clinical quality management

benchmarks work well to measure this type of process.

Leaders use swarmware theory when creativity and

innovation are required to produce solutions outside

the boundaries of TTPs. For example, enabling an

MCT to redesign the MEDEVAC patient transfer

process for efficiency and safety to prevent patient

delays would use traditional metrics to evaluate the

process (eg, turnaround time), but realize some

variables that impact patient outcomes during that

process might not be so easily quantified. When used

together to produce both tight and loose parameters,

clockware and swarmware theories encourage agile,

adaptive team responses to a variety of scenarios.

CREATING SYNERGY

Leaders can strongly influence the way work gets done

in an MCT microsystem by understanding process

management and using specific processes to make

things happen. Complexity science delineates “strange

attractors” in nature such as the phenomena of eddies

in rivers that cause new flow patterns.5 MCT leaders

inherently are strange attractors who create boundaries

or restraints from which patterns in systems evolve. In

order to do so, the MCT leaders possess characteristics

such as an ability to facilitate a common team

language to avoid confusion and promote team

effectiveness. Over time they create shared definitions.

For example, each team member should understand

what constitutes, for the team, a successful patient

outcome as delineated by palliative versus aggressive

treatment of a patient.12 Leaders leverage team

communication venues as an invention platform where

the voltage of new ideas creates team synergy for

process redesign and improvement. Leaders are able to

structure the shared information then connect it to

plans for action. Therefore, MCT leaders must be

adept at facilitating reciprocal relationships between

other microsystems and linking the MCT to the

macrosystem in order to mitigate intracare gaps among

different microsystems. They must facilitate

collaboration and a common vocabulary with other

microsystems to manage overlapping shared processes,

such as patient admissions and discharges, or

management of supplies and equipment used by the

team.

CENTERING

The MCT leader must be a virtuoso in “mindful

watchfulness,” an ability to constantly and actively

attend to and focus the team on the patient as the

team’s center-of-gravity. Leaders must be able to

orchestrate a team interdisciplinary approach that

provides care synchronicity for good patient outcomes

and mitigates a competing focus on disciplinarycentered care (ie, physician, nursing). Leaders identify

and help the team address other strange attractors, such

as team member characteristics, technology,

environment, and process design that either accelerate

or decelerate the team’s ability to provide patientfocused care. MCT leaders use team stress or conflict

in a “forged by fire” method to achieve team

congruence and catalyze change. They make

individual and team values actionable and accountable.

Finally, effective quality leaders recognize the

complexity that humans introduce into systems.

Leaders create a team culture that promotes flexibility

of roles and understanding and respecting each others’

roles with respect to professional scopes and standards

of practice.10 Each team member should feel they are a

member of an elite team and have confidence in each

other’s competence. Leaders must create venues, over

Medical Capability Team: The Clinical Microsystem for Combat Healthcare Delivery in

Counterinsurgency Operations
October – December 2008 61

THE ARMY MEDICAL DEPARTMENT JOURNAL

time, to allow the team to reflect on what is working

and what is not in order to create change and patient

care improvements.

BUILDING AN MCT: TRAINING, MANNING AND

ORGANIZATIONAL SUPPORT

Although microsystems work at the microinterface of

frontline care, they can produce results at the macroorganizational level. As microsystems, the MCTs

provide more agility and responsiveness to adaptation

and can more quickly provide lessons learned at the

microlevel frontline of care. The lessons learned at the

microlevel, aggregated at the macrosystem level, identify organizational best practices and provide

coherence throughout the macrosystem as a learning

organization. The MCTs require organizational support from a macrosystem (eg, CSH) in the form of

“resources to enhance and legitimize the work of the

microsystem.”4

Particularly important is the need for ongoing team

training for the MCTs. Team training must be

resourced appropriately to ensure the MCTs develop

team work systems and work processes over time in

support of patient-centered care. Current

predeployment training and validation exercises (eg,

mission readiness exercise) conducted for echelonabove-division (EAD) medical units are only at the

macrolevel and do not address the microsystem level.

Therefore, the AMEDD should initiate the development of an AMEDD Combat Training Center of

Excellence that focuses on the training and validation

of these MCTs. The Center would ensure that the

individuals and the team are highly proficient in their

specialty, are ready to accomplish their mission prior

to deployment, and will integrate well into their larger

unit. As described, the MCT is the unit of

effectiveness designed to align AMEDD strategy and

core clinical competencies with capability and combat

healthcare delivery. The MCT is patient-centered and

team-driven, and therefore should be trained and

validated by an AMEDD Combat Training Center to

ensure that they are trained on teamwork competencies

across the mature theater continuum. The properly

trained and prepared MCT will then deploy as a highly

proficient, specialized medical team that provides

quality combat healthcare. These MCTs are the

building blocks that form the CSH. The quality of the

CSH can be no better than the care produced by the

MCTs that deliver patient-centered combat healthcare.

Moreover, there is a problem with current sourcing of

medical units and degradation of critical medical team

capability and capacity in the areas of treatment,

trauma, behavioral health and critical care. In

particular, the current manning and qualification of

medical units in Army Regulation 220-1

13 does not

accurately identify the critical medical manning and

qualifications required for EAD medical forces.

Therefore, Task Force 62 Medical Brigade in Iraq has

recommended an update to Army Regulation 220-1 to

the US Army Medical Command to track critical

medical teams and qualification criteria to ensure the

deployment of highly trained medical teams. To this

end, the AMEDD should develop and implement the

MCT process in order to ensure that units are trained

and validated prior to deployment into theater.

THE MCT: DEPLOYING IN A COUNTERINSURGENCY

ENVIRONMENT

The maturation of the combat theater in Iraq has

provided optimal conditions for the medical task force

to make major improvements in health system-wide

quality and management practices in the

counterinsurgency environment. The medical task

force has taken advantage of this unique time in

history to place a concerted focus on institutionalizing

our combat healthcare support system. The medical

task force is implementing an initiative using the CSH

modified table of organization and equipment as a

sourcing platform to develop MCTs as part of a

deployment manning document to support level II+

and level III operational requirements across the Iraq

theater of operations. The medical task force is

focusing on the capabilities required and assigning

specific medical areas of concentration to respective

MCTs—treatment, ancillary, surgical, critical care,

specialty care, and resuscitative—based on the

functional area in order to optimize staffing for fullspectrum operations (normal state to mass casualty

events). To make the AMEDD more agile, relevant,

and flexible, a smaller modular organizational

transformation is needed to better support the MCT

concept and identify additional specialty personnel

skill identifiers in order to facilitate task-organizing

personnel to respective MCTs. As a result, the

AMEDD can optimize clinical capability while

decreasing the clinical capacity required. Additionally,

the MCTs should rotate as a unit team rather than

having only a portion rotate into combat theater for

180 days, when others serve for 12 to 15 months.
62 www.cs.amedd.army.mil/references_publications.aspx

CONCLUSION

The condition of the Army today can only be understood

when one considers where we have been and where we

are going ...The changes in the world have made us

realize that to ultimately be successful in the Global War

on Terror, we must transform our capabilities.1(p4-1)

Francis J. Harvey

Today’s operational environment in supporting

counterinsurgency operations requires greater tactical

and operational flexibility and diverse medical

capabilities. The skills and organizations required for

full spectrum medical operations are different from

those of the past. Combat healthcare demands agility

and the capacity for rapid change in clinical systems

and processes. This discussion proposes that the

AMEDD build upon the lessons learned in Iraq to

modularize the medical force structure and develop

highly trained, medical capability teams to be more

agile, relevant, and flexible. The AMEDD must

develop the capacity for rapid change and flexibility in

how medical units are led, trained, and employed in

theater. Teamwork is an essential component of the

combat healthcare delivery system. This article

submits that the AMEDD develop and implement

medical capability teams as the frontline clinical

microsystem for care delivery and initiate the

development of an AMEDD Combat Training Center

of Excellence to train and validate the MCTs.

Moreover, the complexity of combat healthcare

demands a responsive and campaign quality

(operationally sustaining) AMEDD with joint

expeditionary capability. The MCT, at the frontline of

healthcare delivery, can provide the agility and

responsiveness necessary for patient-centered, teamdriven care that promotes the best patient outcomes in

a counterinsurgency environment.

REFERENCES

1. Field Manual 1: The Army. Washington, DC: US

Dept of the Army; 14 June 2005.

2. Nagl JA, Petraeus DH, Amos JF. The US ArmyMarine Corps Counterinsurgency Field Manual.

Chicago, IL: University of Chicago Press; 2007:xii.

3. Medical Corps Professional Development Guide. Fort

Sam Houston, TX: US Army Medical Department

Center and School; March 2002:27.

4. Nelson EC, et al. Microsystems in healthcare: part 1.

Learning from high-performing frontline clinical

units. Jt Comm J Qual Patient Saf. 2002;28:472-493.

5. Benson H. JHQ 168 – Chaos and complexity:

applications for healthcare quality and patient safety.

J Healthc Qual. 2005;27(5):4-10.

6. Quinn JB. Intelligent Enterprise. New York: Simon

& Schuster Adult Publishing Group; 1992. Cited by:

Kosnik LK, Espinosa JA. Microsystems in

healthcare: part 7. The microsystem as a platform for

merging strategic planning and operations. Jt Comm J

Qual Patient Saf. 2003;29:452-459.

7. Leggat SG. Effective healthcare teams require effecttive team members: defining teamwork competencies. BMC Health Serv Res. 2007;7(17):1-10.

8. The Joint Commission published a 9 part series of

articles under the title Microsystems in Health Care

in the publication Joint Commission Journal on

Quality and Safety, which appeared as follows: 2002

Volume 28–Part 1 (Sep): 2003 Volume 29–Part 2

(Jan); Part 3 (Apr); Part 4 (May); Part 5 (Jun); Part 6

(Aug); Part 7 (Sep); Part 8 (Oct); Part 9 (Nov).

9. Committee on the Quality of Healthcare in America,

Institute of Medicine. Crossing the Quality Chasm.

Washington, DC: National Academy Press; 2001.

10. Batalden PB, Nelson EC, Mohr JJ, Godfrey MM,

Huber TP, Kosnik L, Ashling K. Microsystems in

health care: part 5. How leaders are leading. Jt Comm

J Qual Patient Saf. 2003;29:297-308.

11. Wieck KE. The reduction of medical errors through

mindful interdependence. In: Rosenthal MM,

Sutcliffe KM, eds. Medical Error: What Do We

Know? What Do We Do?. New York: John Wiley

and sons; 2002:177-199.

12. Gardebring S. A Report by the Academic Health

Center Task Force on Interdisciplinary Health Team

Development. Minneapolis MN: University of

Minnesota; 1996. Available at: http://www.ahc.umn.

edu/tf/ihtd.

13. Army Regulation 220-1: Unit Status Reporting.

Washington, DC: US Dept of the Army; December

19, 2006.

AUTHORS

At the time this article was written, COL Clark was

Deputy Commander, Nursing, and Chief, Clinical

Operations, Task Force 62 Medical Brigade, Baghdad,

Iraq.

At the time this article was written, MAJ Van Steenvort

was the Future Plans Officer (S5), Task Force 62

Medical Brigade, Baghdad, Iraq.

Medical Capability Team: The Clinical Microsystem for Combat Healthcare Delivery in

Counterinsurgency Operations
October – December 2008 63

THE DEPLOYED ELECTRONIC MEDICAL RECORD

One of the principal reasons America’s armed forces

are successful in warfare is the confidence every

service member has in the military healthcare system.

Soldiers, Marines, Sailors, and Airmen know they

have the best medical system available if they are

injured. This knowledge translates as a combat

multiplier on more than the immediate battlefield; it

also affects recruiting, retention, and Family support.

With a 97.5% survival rate for all casualties arriving at

our deployed combat support hospitals (CSH), the

military healthcare system is providing the highest

survival rate of any war in history. This remarkable

statistic reflects highly on the quality of our medical

professionals: combat medics, doctors, nurses,

therapists, and the supporting specialists and

technicians. In addition to record levels of quality care,

the Department of Defense (DoD) medical system also

has the most robust electronic medical documentation

system ever created for military applications.

Ensuring that quality documentation is created and

maintained is incumbent on every leader in the Army

Medical Department (AMEDD) and the other

components of the military healthcare system (MHS).

The purpose of this article is to review the current state

of electronic medical documentation and outline some

of the challenges experienced in the Iraq theater of

operations. The discussion consists of 2 elements: first,

an evaluation of the development of health information

systems (HIS) and a survey of how the stage was set

for the existing situation; next, a synopsis of the

current HIS challenges and the significance of these

limitations.

DEVELOPMENT OF HEALTH INFORMATION SYSTEMS

During the Gulf War in 1991, electronic medical

documentation did not exist. Follow-on care for

Veterans was dependent on the accuracy and

maintenance of paper records. Oftentimes, medical

documentation at the point of injury and initial care

could not be obtained or re-created. The problems with

documentation continuity and availability resulted in

DoD initiatives in the research of electronic medical

documentation throughout the 1990s.

Operation Iraqi Freedom (OIF) provided the

opportunity to implement the first deployed electronic

medical record (EMR). The Defense Health

Information Management System (DHIMS) developed

software and programs for the individual services. The

Army’s implementation of the DHIMS toolset is called

Medical Communication for Combat Casualty Care

(MC4).

Deployed medical leadership faces numerous

challenges and responsibilities across the battle space,

with the most important being the provision of care

and its subsequent electronic documentation. The

continuity of this care must be complete from the point

of injury through long-term care with the Department

of Veterans Affairs (VA). The importance of initial

documentation cannot be overstated. Incomplete

The Deployed Electronic Medical Record

MAJ Leslie E. Smith, MS, USA

ABSTRACT

This article reviews the current state of the electronic medical record in the deployed environment, with a discussion of

challenges faced in the course of mission execution. Focus discussion includes current system architecture, system

integration, interoperability, networking, and security concerns. The Department of Defense electronic medical

documentation system does function, and records care from the point of injury through enduring care within the

Veterans Health Administration. However, there is a high cost in dollars and man-hours, which should be aggressively

addressed and improved.

NOTE: The October-December 2006 issue of the Army Medical Department Journal contains a special section of 6 articles

addressing electronic medical records within the Department of Defense in general, and Army medicine in particular.

Those articles are complementary to the information presented by MAJ Smith in this article. That issue of the AMEDD

Journal is available online at http://www.cs.amedd.army.mil/dasqadownload.aspx?policyid=160.

The Editors
64 www.cs.amedd.army.mil/references_publications.aspx

documentation that only becomes detailed upon a

casualty’s arrival at MHS hospitals is akin to writing a

book and skipping the first several chapters.

Some of the most challenging and complex injuries

seen during OIF are the result of blast trauma. There

have been hundreds of amputees and cases of mild

traumatic brain injury. Providers caring for these

injuries not only need to know the first few chapters of

previous care delivered to these Soldiers, they also

need to know the most detailed story that can be

written. Imagine yourself as the recipient of this care:

how important would it be for you to know your

provider is making decisions based upon the details

that were electronically documented at your point of

injury?

From a top-down view, the current state of our

electronic medical record system can be described as

separate, stove-piped systems and applications across

the spectrum of care. Many of these systems are small

and standalone, while a few are larger but still limited

in their scope and range. Some of the systems interface

with each other and others are completely

disconnected. The large systems include DHIMS,

Armed Forces Health Longitudinal Technology Application (AHLTA1

), and the Veteran’s Health

Information Systems and Technology Architecture

(VistA), while the smaller ones are independent

initiatives that are focused on a certain specialty of

care.

Working with and supporting a nonhomogeneous electronic medical record system can be confusing;

however, by reflecting on the recent history of

information technology, the current situation is better

understood. The trend influencing the current state is

the incredible rate with which information technology

has improved in capability, as well as its rapid permeation throughout culture and business processes.

Fifteen years ago, desktop computers in work areas

and in homes were the exception, Microsoft was just

starting to work in networking technology, and the

internet was infrequently accessed by the average

military professional. During this time, the DoD began

the development of an electronic medical documentation solution for deployed forces.

The current state of our EMR is a product of these

efforts and limits. While significant progress has been

made in the DoD EMR, there is still much room for

improvement. Yingling asserted the following:

To prepare forces for war, the general must visualize

the conditions of future combat. To raise military forces

properly, the general must visualize the quality and

quantity of forces needed in the next war. To arm and

equip military forces properly, the general must

visualize the materiel requirements of future

engagements. To train military forces properly, the

general must visualize the human demands on future

battlefields, and replicate those conditions in peacetime

exercises.2

The same principles leaders apply to success in

warfare can be applied to a successful EMR—

visualization of future conditions, quality and quantity

of forces, required material, and an assessment of

human demands.

The challenges to the EMR have been rooted in the

simultaneous development of multiple systems that

were not centrally managed and coordinated. The

multiple systems are a result of separate initiatives

started early in the information technology

development curve, with each having a separate scope

and goal. The garrison/peacetime AHLTA focuses on

fixed facility care to DoD health care beneficiaries.

The VA’s VistA has many merits, but was designed

and is used by a department outside of DoD, and the

multiple tools developed by DHIMS are designed for

use in a deployed theater. Larger HIS tools, along with

many smaller, independent HIS tools, must be integrated into a single portfolio of interoperable systems

that generate a high quality, longitudinal EMR. While

many initiatives have demonstrated success from their

respective vantage points, a strategic review of the

direction, capability, and cost of the DoD EMR is

needed.

CURRENT HEALTH INFORMATION SYSTEM CHALLENGES

Within the medical task force, providers use multiple

systems and experience first hand the challenges

associated with implementing electronic

documentation. This experience is unique because the

documentation of care starts only from the position of

the deployed force. Further, the deployed force

healthcare documentation must fully navigate the

entire myriad of automated systems, all the way back

to the Clinical Data Repository.

The Deployed Electronic Medical Record
October – December 2008 65

THE ARMY MEDICAL DEPARTMENT JOURNAL

The challenges of successfully documenting care in

the EMR start with provider training and preparation

to electronically document patient encounters. The

principal interfaces used are DHIMS tools: AHLTATheater (AHLTA-T) used to document outpatient care,

and the Theater Medical Information Program

Composite Health Care System Cache (TC2), used to

document inpatient care. MC4 fields these systems to

the Army with training available in the United States

through one of 3 regional offices. Despite the

requirement to electronically document care, training

is not mandatory for deployment, rather it is only

recommended. Furthermore, no proficiency standard

exists for users. One of the primary complaints by

deploying providers is their unfamiliarity with MC4;

they feel that the predeployment training they received

has been inadequate in many areas. To address this,

the AMEDD Center and School has recently taken

responsibility for developing MC4 sustainment

training, to include defining tasks, conditions, and

standards.

The millions of dollars spent on the separate EMR

programs and the expectation for continued expenditures demand conscientious leaders to strategically

review the current state and engineer a plan for the

future. The current plan is engineered around technology solutions anchored in the past that are not

easily adaptable to emerging requirements. For example, the MC4 distributed server design has a

separate AHLTA-T server at all clinics and CSHs.

Additionally, there are separate inpatient TC2 servers

at all level III CSHs. These separate servers are

effectively isolated islands of care documentation.

This distributed server design presents many

challenges. The most significant is maintenance and

security. A high level of daily, weekly, and quarterly

maintenance is required on each server and

approximately 1,000 MC4 laptops. The maintenance

support plan for MC4 computers relies on non-MOS*

specific unit level administrators assigned by the

medical unit. This is usually a Soldier with a strong

computer background. The unit level administrators

receive training and are expected to perform essential

backups and daily maintenance required for successful

EMR transmission. Given the approximately one

thousand MC4 computers across the Iraq theater of

operation (ITO), there are a thousand points of

potential failure. Within the divisions, the second tier

of support falls upon the battalion S6 (communications

and information technology) sections that are not part

of the AMEDD and have little or no healthcare

management knowledge. The top level of support for

MC4 is a contractor support structure distributed

throughout the ITO. These MC4 contractors work

diligently to maintain a complex system that has many

technical flaws.

An additional challenge of the distributed server

design is that the speed of technology advances

outpace the speed of DHIMS and MC4 upgrades.

Strict information assurance (IA) requirements

demand secure strategic networks. Since the

deployment of MC4 in 2003, the operating system has

been out of date and has consequently become an

information assurance risk. Deployed with Microsoft

NT as the operating system in 2003 when Windows

2000 was the standard, the current version of MC4

includes the Windows 2000 operating system, while

Windows XP is the standard. The next release of MC4

will have the XP operating system, however the

question remains as to whether this release will occur

before the next version of Windows becomes the new

standard. The point is that information technology

development is a dynamic environment, compounded

by the pitfalls and challenges of IA security

requirements. Our EMR platform must be able to

adapt to the fluid IA landscape.

Changing the distributed server design model can

eliminate or significantly minimize the maintenance

and security requirements. A web-based interface

connecting to a remote server is a proven model that is

not only secure, but is also independent of deployed

server and client hardware requirements. Web-based

interfaces to remote servers provide many functions

across numerous other disciplines and, in some cases,

are successfully used as part of the DoD solution.

Examples include the Theater Medical Data Store

(TMDS), and Corporate Dental Application. Webbased applications are not only an industry standard,

but comply with IA requirements and do not require

the heavy maintenance cost in dollars and man-hours

that is part of the current distributed server design. The

comparison of the distributed server solution and the

proposed web-based or thin client solution further

makes the case for a strategic review of how to

proceed for future HIS design and development.

*Military Occupational Specialty However, challenges exist, such as the theater network
66 www.cs.amedd.army.mil/references_publications.aspx

infrastructure available in theater is not always robust

enough to support extensive web traffic. Also, joint

requirements call for an HIS that can function on ships

with extremely limited bandwidth.

The next generation of health information systems

should have a combination of both standalone

capability and web-based flexibility. Additionally, the

future solution must require minimum user

maintenance as well as have the ability to keep up with

changing security standards. The development of such

a solution is a challenging endeavor, but one that must

be pursued. Solutions include a more robust AHLTAMobile device coupled with the continued use of very

small aperture terminal systems, and the possibility of

thin clients connected over a local area network.

Perhaps the most significant challenge in assessing the

viability of the theater EMR has been the measurement

of reliability. Between September and December 2007,

Task Force 62 performed 18 audits of 1,284 AHLTAT encounters across the ITO. The goal of the audits

was to test the reliability of AHLTA-T encounters

reaching and being accessible in TMDS. The study

revealed a 93% reliability rate for a first time reference

to TMDS for encounter results. Most missing

encounters were recoverable within DHIMS,

ultimately showing a reliability rate of 99% for

subsequent encounter references. As of 27 July 2008, 4

encounters remain missing.

There are several potential causes of this problem.

Lack of regular maintenance (daily, weekly, monthly

on each MC4 computer) could have contributed to

some of these errors. Another potential cause of the 4

remaining missing encounters (and the one proposed

by the DHIMS and MC4 technical experts) is that an

MC4 configuration altered to adhere to IA security

requirements can cause encounters to be lost. These

modifications include updating the antivirus program,

installing common access card software, and updating

the Microsoft Office application software. Another

potential cause for these errors is the instability of

AHLTA-T software that has been described by

DHIMS technicians as “not fault tolerant.” A future

release of AHLTA-T will include an expeditionary

framework design that is expected to be more fault

tolerant and eliminate most of these transmission

errors.

One of the principal complaints from providers across

numerous deployments has been the interface

challenges of TC2. The consensus is that the archaic

text interface is not conducive to documenting care. A

graphical user interface is currently under development

within DHIMS that will provide a familiar Windows

interactive environment. This upgrade, scheduled for

release in calendar year 2008, should facilitate some

easing of electronic medical documentation

procedures.

Efforts to improve and expand the interoperability of

the numerous health information systems must

continue. The recent merge of the joint patient tracking

application and TMDS is a good step. As DHIMS

continues to develop solutions, focus should be on a

single login. Many of the different health information

systems address a niche medical need, and are not

strategically integrated in the portfolio. Under the

current design, a typical provider seeking to properly

deliver care must log onto multiple systems, and

sometimes multiple computers. Each of these requires

a separate account login and a separate action to

activate the application. There are some tie-ins.

However, the constant is that full delivery of care, and

subsequent documentation, is complicated; not

intuitive, user friendly, nor convenient; and in

desperate need of further integration.

A byproduct of these discontinuous systems is the

challenge of providing data queries for command

decision support, which results in great frustration

among the leaders of military healthcare. In general,

these systems offer limited query tools. Further, with

the separation inherent in the current design, the ability

to mine data across systems is problematic at best, and

in some scenarios impossible. In addition to the

myriad of separate systems, CSH staffers find the tools

and functionality often lacking and insufficient for

their needs. This results in workaround solutions, such

as the development of Microsoft Access Databases and

Excel spreadsheets that are used to track pertinent

patient data. The impact is that data gathered locally

are not completely captured in the EMR, and are not

real-time. There are copies of these work flow data

tools in DHIMS, and there are plans to incorporate

them into future releases of DHIMS products.

The end result of the disparate medical systems used to

document care, combined with the less than 100%

The Deployed Electronic Medical Record
October – December 2008 67

THE ARMY MEDICAL DEPARTMENT JOURNAL

reliability of AHLTA-T, is an envelope containing

paper copies of a Soldier’s medical record that is sent

with the Soldier when he or she is evacuated from

theater. Paper records moving with the patient is an

indication of how much work remains in the

improvement of our EMR.

Separate HIS solutions exist as a result of the lack of

overarching corporate direction and encompassing

guidance driving all health information systems. These

solutions are good ideas that do serve a legitimate

medical need, however, without proper coordination,

prioritization, governance, and integration with a

larger HIS strategic plan, navigating these systems

causes frustration as well as man-hour and monetary

expense inefficiencies. The 62nd Medical Brigade

Chief of Clinical Operations, COL Susz Clark, said it

best as she described our EMR, “The way we

document care is not the way we deliver care.”

Understanding how care is delivered in theater must be

the driving force behind the development of health

information systems. The DHIMS organization,

responsible for the development of deployed systems,

has been very responsive to feedback and input from

the 62nd Medical Brigade, and has taken steps to

improve the immediate product as well as implement

changes that will affect future releases.

THE ROAD AHEAD

The complexity of DoD health information systems is

extensive. The only way the AMEDD can successfully

address these concerns is to communicate through

direct human interaction and involvement. The theater

needs can only be fully assessed from the perspective

of the deployed force—the functional users. The

leadership of DHIMS and MC4 should remain in

theater assessing the application of their tools while

interacting with the Soldiers who use these systems.

As important as the logical data connections are to the

use of these tools, so are the human connections that

must take place for top decision makers to fully

communicate with the forward deployed providers.

The above discussion points out the challenges with

health information systems that healthcare personnel

experience in the course of mission execution intheater—the ultimate test for the utility of an HIS.

There are times during an operation when it is

appropriate to pull back, regroup, and evaluate the

potential for a new plan. The leadership of DoD and

AMEDD should assess our current HIS solutions from

the perspective of the deployed force. The current

design is neither cost effective nor manpower efficient.

Furthermore, it does not fully satisfy the current

documentation requirements. Just as generals must

visualize the conditions for future combat, so too must

the evolving technology landscape be visualized and

adaptive changes made.

The ultimate goal of military healthcare system

documentation must be a top quality electronic

medical record that facilitates care of the Soldier from

the point of injury through enduring care within the

Veterans Health Administration.

REFERENCES

1. Moody R, Freeman D. The new name of the military

electronic medical record. Army Med Dept J.

October-December 2006:40-41.

2. Yingling P. A failure of generalship. Armed Forces J.

May 2007. Available at: http://www.armedforcesjour

nal.com/2007/05/2635198.

AUTHOR

When this article was written MAJ Smith was the

Health Information Systems Officer, 62nd Medical

Brigade (Task Force 62), Baghdad, Iraq.
68 www.cs.amedd.army.mil/references_publications.aspx

US Army medical units have supported Operation

Iraqi Freedom (OIF) for more than 5 years. US forces

have transitioned from conducting full spectrum operations to primarily counterinsurgency operations. As the

situation improved with regard to stable positioning,

security, and the improvement of infrastructure within

our bases, there was, unfortunately, little standardization of the various aspects of health-care support,

including medical equipment, beyond that which the

individual units had implemented.1 Each newly arrived

unit essentially reinvented the approach to executing

the mission that their predecessor had followed during

their tour. With maturation of the theater of operations,

the environment became more conducive to efforts to

standardize both equipment and supplies. The Task

Force 62 Medical Brigade Headquarters had great

success in standardization efforts and made substantial

progress in the development of a standardized

equipment guideline. The keys to success in this

endeavor include command emphasis and a combined

effort between the clinical leadership and logisticians

working synergistically to achieve the same end state:

standardization of medical materiel.

Counterinsurgency operations in the Iraq theater

demonstrated the lethality and destructiveness of the

improvised explosive devices, explosively formed

projectiles, and indirect fire. The resulting casualties

stimulated the reengineering of tactical combat

casualty care. OIF represents the first protracted, largescale, armed conflict since the advent of civilian

trauma systems. Collaborative efforts among the joint

military forces of the United States initiated

development of a theater trauma system in May 2004.

The implementation of a theater trauma system

demonstrated numerous opportunities to improve the

outcome of Soldiers wounded on the battlefield. As of

the end of July 2008, there had been 30,490 service

members wounded in action.2 The covenant of the Iraq

theater medical task force is to provide the highest

level and quality of healthcare to patients that transit

the continuum of care in Iraq. The key to this is to

ensure that the theater has the right clinician, at the

right place, with the right equipment to preserve life

and prevent suffering.

Medical units deployed in support of the initial phase

of OIF with standardized MTO&E* medical

assemblages. The assemblages include standardized

unit sets, including nonexpendable, durable, and

expendable medical supplies and equipment. The

medical assemblages were designed to provide

treatment primarily to service members in generally

good health conducting offensive or defensive

operations. The baseline service medical assemblages

and equipment items are not ideally suited to optimally

support the bulk of the current patient caseload within

theater. With the increasingly stable security situation,

operations in Iraq gradually changed to mostly

stability operations, with the focus being on

counterinsurgency operations. Units providing medical

treatment and hospitalization developed new

equipment requirements as their missions changed.

The requirement to treat contractors and Iraqis, from

infants to the elderly, drove equipment needs beyond

what standard medical assemblages could provide.

Units ordered what they required to support their

healthcare mission, but there was no task force level

effort to standardize equipment requirements across

the medical task force. Individual and piecemeal

service and unit replacement efforts, while bringing

needed and enhanced medical care capabilities,

brought some new medical equipment items into the

theater with incomplete or partial logistical support

tails. This resulted in equipment being nonmission

capable for significant periods of time due to lack of

maintenance and equipment repair parts.

Based on the Task Force 62 Medical Brigade

Commander’s guidance upon assuming the medical

Medical Equipment Standardization in a

Maturing Combat Theater

LTC Bruce Syvinski, MS, USA

CPT Jason Hughes, MS, USA

*Modified Table of Organization and Equipment: Defines the structure and equipment for a military organization or unit,

adapted to the special circumstances of that unit.
October – December 2008 69

task force mission, the Task Force Deputy Commander

for Clinical Services (DCCS) and the S4 (logistics)

section developed a plan to implement a monthly task

force medical equipment validation and standardization board (MEVSB) involving both the DCCS and

medical logistics personnel of our direct reporting

units. Army Regulation 40-61 states

...materiel standardization can support clinical efforts

for utilization management and development of

outcome-based pathways and protocols.3

Establishment of the board would improve other

aspects of healthcare standardization within the task

force. The MEVSB serves as a medical equipment

standardization tool for the medical task force

commander. As the name implies, the board both

validates the unit’s requirement and establishes a

standardized materiel solution (ie, manufacturer,

model). The board is guided by the following

principles:

 Equipment should support a capability which is

appropriate to the mission and role in theater.

 Equipment should represent a clear advantage to

the patient and/or the units we support.

 Equipment should be sustainable within theater

without creating overwhelming support problems.

 Equipment should be procured to be usable by

subsequent rotations, not to support a one-time

special skill.

 Equipment should be standardized within theater

to the extent possible.

Task force subordinate units submit a letter of justification (LOJ), to justify an equipment requirement to

(1) replace unserviceable/uneconomically repairable

equipment, (2) replace lost equipment, or (3) replace

an existing shortage. The condition code, which is

used to identify the degree of serviceability,

condition, and completeness in terms of readiness for

issue and use, must be verified by the unit biomedical

maintenance officer. That documentation becomes

part of the LOJ process. Upon receipt of the letter of

justification, the task force headquarters staffs the

request with the clinical operations, operations (S3),

and logistics (S4) sections. The staffing is focused on

several considerations, including: clinical

justification, currently used equipment (if applicable),

maintainability, sustainability, required training, and

standardization. Detail on each of the considerations

is shown in the graphic (right).

Requests for equipment not previously approved by

the MEVSB will be prepared for presentation at the

next scheduled board. Minutes are recorded for each of

the board proceedings. Once equipment requests have

been validated, the requesting unit is provided with a

written document authorizing them to order the

equipment through their supporting class VIII supply

support activity. To date, 65 types of equipment have

been standardized within the task force. The US

Central Command (CENTCOM) Surgeon further

improved standardization efforts with the recent visit

of an assessment review team of clinical equipment

subject matter experts.

The Army utilizes a team known as the technology

assessment and requirements analysis team. In keeping

with this concept, the CENTCOM Surgeon requested a

joint technology assessment for the purpose of

establishing a standardized theater medical equipment

formulary. The Joint Medical Technology Assessment

Review Team (JMTART) was commissioned by

CENTCOM to apply commonly accepted practices

that each service medical logistics agency uses to

support their US based medical treatment facilities in

upgrading medical technology. The JMTART

provided a valuable external perspective to assist the

theater with medical equipment standardization. The

JMTART visited all 9 level III medical treatment

facilities in the CENTCOM area of responsibility in

June and July 2008, and presented their recommendations in August 2008.

Task Force 62 standardization efforts, in conjunction

with those of the JMTART, have validated modern

equipment that is supportable and will both reap

financial savings and streamline future medical task

force standardization efforts. Standardization and

follow-on life cycle management must continue in the

Medical Equipment Request Considerations

Justification Why is this particular equipment

required?

On Hand within the Task Force Is this equipment already in

theater?

Maintainability Who is qualified or will maintain

the equipment?

Sustainability How will the equipment be

sustained (repair parts)?

Training Required What level of training is required

to optimally use the equipment?

Standardized Is there a standard for the

equipment?
70 www.cs.amedd.army.mil/references_publications.aspx

theater to sustain the US standard healthcare that our

service members and DoD civilians deserve. Future

medical task force headquarters must employ medical

equipment standardization efforts early in their

deployment as a means to both manage the quality of

healthcare delivered, and stay on the relevant and

capable edge of the technology curve. Commanders,

clinicians, and senior leaders should understand the

tools they have available to ensure medical equipment

life-cycle management and standardization to maintain

the fleet of state-of-the-art medical equipment in a

maturing combat theater of operations.

REFERENCES

1. Syvinski B, Elliott J. Combat casualty care on the

technology curve: medical equipment standardization

in a maturing combat theater. Mil Med Technol.

2008;5:34-37. Available at: http://www.mmtkmi.com/article.cfm?DocID=2499.

2. Office of the Secretary of Defense Statistical

Information Analysis Division page. DoD Personnel

and Procurement Statistics Web site. Military

casualty information.. Available at: http://

siadapp.dmdc.osd.mil/personnel/CASUALTY/

castop.htm. Accessed August 17, 2008.

3. Army Regulation 40-61: Medical Logistics Policies.

Washington, DC: US Dept of the Army; January 28,

2005:12.

AUTHORS

At the time this article was written, LTC Syvinski was

the Task Force 62 Medical Brigade Logistics Officer

(S4), Baghdad, Iraq.

At the time this article was written, CPT Hughes was

the Task Force 62 Medical Brigade Deputy Logistics

Officer (S4), Baghdad, Iraq.

Medical Equipment Standardization in a Maturing Combat Theater
October – December 2008 71

We all approach the subject of ethics differently. For

every individual there is an interpretation of what is

right and what is wrong; we all come from different

backgrounds and different belief systems. However, in

order for an organization, any organization, to be

successful, it must rely on a set of core values and

beliefs that are adopted corporately and shared

individually. This is particularly true in the United

States Army—the Army requires predictability. As

junior Soldiers and leaders, we are taught early the

importance of being “in the right place, at the right

time, in the right uniform.” The knowledge that those

serving to our left and right are known quantities is an

essential key to our Army’s operations, in peace and in

war. This predictability extends to our ethics and

values; knowing your peers share and embrace the

same ethical standard is crucial to the maintenance of

good order and discipline within the Army, the Army

Medical Department, and deployed units.

The Commander, Task Force 62 Medical Brigade

(TF62 MED), identified a requirement for a training

model to address ethical lapses within the task force.

The purpose of this model was to explain, in plain

language, some of the common ethical failures that

subjected Soldiers to disciplinary action under the

Uniform Code of Military Justice,* including perhaps

even prison, and always put at risk careers, marriages,

freedom, and sometimes even lives. As shown in

Figure 1, the task force experienced a high level,

relative to unit strength, of officer and senior noncommissioned officer misconduct. Incidents of adultery,

inappropriate relationships, and the use of alcohol and

pornography in violation of General Order Number 1†

were frequent. In a single TF62 MED unit, every

officer was relieved. The acts of misconduct and the

resulting punishments were rank indifferent. TF62

MED initiated UCMJ action against Soldiers of every

rank, from colonel to private. The question became:

Why?

The task force commander directed an examination of

the misconduct occurring across the task force. He

believed that understanding the reasoning and

methodology behind ethical failures and misconduct

could lead to a training module which would explain

to every Soldier currently in, or entering, TF62 MED

how to avoid common mistakes. Certain predictable

behavior leads to certain predictable results—

examining the UCMJ case files of those who had

already failed could provide insight into how to

mitigate future acts of indiscipline across the task

force.

Applied Ethics in a Combat Theater of

Operations

MAJ Frederick C. Jackson, MS, USA

Figure 1. TF 62 MED UCMJ legal actions pertaining to

alleged senior enlisted (E8, E9) and officer misconduct

during deployment (August 2007 through July 2008).

General Officer Article 15 Proceedin gs (n=8)

Investigations (n=48)

General Officer Me moranda of Reprimand (n=23)

*The Uniform Code of Military Justice (UCMJ), a federal law,1is the judicial code which pertains to members of the

United States military. Under the UCMJ, military personnel can be charged, tried, and convicted of a range of crimes,

including both common-law crimes (eg, arson) and military-specific crimes (eg, desertion).

†US Army 5th Corps General Order Number 1 (03/19/2003).
72 www.cs.amedd.army.mil/references_publications.aspx

An ethical value system is crucial to helping Army

Medical Department personnel avoid some of the

ethical “landmines” they will encounter while

deployed in support of Operation Iraqi Freedom. Acts

of indiscipline usually result in punitive action, but

they also have the secondary effect of invaluable time

lost to mission performance, as investigating officers

are pulled from operational duties, units face the

disruptions of investigations under Army Regulation

15-6,

2

and good order and discipline, trust ,and

camaraderie are damaged. The effects of undisciplined

acts are wide ranging.

The chain-teaching* module, Applied Ethical Framework, a part of TF62 MED’s overall combat health

support system, the model of which is shown as Figure

2, was the result of the Commander’s desire to address

acts of indiscipline across the task force. The applied

ethical framework covers 7 ethical training modules,

and includes several case studies of actual failures on

the part of Soldiers and leaders. We designed the

applied ethical framework training approach from the

perspective that: the teaching would be accessible to

all ranks; it would take less than 50 minutes to deliver;

it would be visually interesting; and the overall tone of

the brief was to aid in critical thinking, but not scold

the Soldiers.

The 7 modules of the Applied Ethical Framework

training package were core ethics, the patient-centric

task force module, financial stewardship, ambassadorship, personal courage and integrity, behavior in

accordance with Army Regulation 600-20 ,

3

sexual

harassment, and inappropriate relationships.

The remainder of this article describes the Applied

Ethical Framework training package and its purpose in

providing assistance to Soldiers in building,

maintaining, and remaining within a sound and proven

ethical framework.

THE CORE ETHICS MODULE

The ethical framework is a basic enabler of success for

the TF62 MED combat healthcare support system. It is

vital, therefore than each individual’s values support

actions which maintain that ethical framework. TF62

MED bases its ethical framework on the idea of

Family, leadership, ambassadorship and growth

(F.L.A.G.) (see Figure 3), which represent the Army

values in action. Part of the TF62 MED Commander’s

continuous operational focus was the inculcation of

F.L.A.G. across the task force footprint.

If the Army values and F.L.A.G. each describe what

we should do, then the core module must address some

reasons why we vary from sound ethical practices and

commit acts of indiscipline. The focus of the applied

ethical framework was to reach 2 types of Soldiers:

1. Soldiers who just do not know the regulations

and policies. We wanted these Soldiers to know

that the Army has a regulation for everything;

find a supervisor or leader and ask.

2. Soldiers who just do not understand the letter or

the spirit of the regulation. Again, we wanted

them to know to ask a leader; alternatively, they

could ask an equal opportunity or inspector

general representative—someone will have the

answer to the question.

Unfortunately, we also identified the third type of

Soldier: the Soldier who will not comply. This was the

smart Soldier; the Soldier for whom Army regulations

and command policies did not apply. We often

encountered this individual. The case files of the

Multi-National Corps-Iraq Judge Advocate General

are filled with the stories of those Soldiers who would

not comply. What these Soldiers fail to understand is

that the Army has been in Iraq for awhile; every type

of misconduct has been seen, recognized, and

subjected to the Uniform Code of Military Justice.

What we were able to pull from the case files were the

specific patterns of behavior that resulted in acts of

indiscipline.

Just about every investigation, Article 15†proceeding,

or courts-martial centered on one of 3 things: power,

money, and/or sex. We are Soldiers, but we are also

*Chain-teach is a method of unit training in which designated unit members first receive the training, after which it is

their responsibility to train another level of personnel, who in turn will continue training others. The training continues

in a pyramid fashion until all personnel requiring such training have received it.

†Nonjudicial punishment (NJP) refers to certain limited punishments which can be awarded for minor disciplinary

offenses by a commanding officer or officer in charge to members of his/her command. Article 15 of the Uniform Code

of Military Justice, and Part V of the Manual for Courts-Martial,

4

constitute the basic law concerning NJP procedures.

The legal protection afforded an individual subject to NJP proceedings is more complete than is the case for

nonpunitive measures, but, by design, is less extensive than for courts-martial.

Applied Ethics in a Combat Theater of Operations
October – December 2008 73

THE ARMY MEDICAL DEPARTMENT JOURNAL

human. By not maintaining the appropriate boundaries,

we subject ourselves to the temptations of power,

money, and/or sex. Under the UCMJ, we cannot be

punished for temptation, however, succumbing to

temptation, committing the act of indiscipline, is

punishable under the UCMJ. We needed a

methodology of identifying and mitigating

“improvised ethical decision-making.”

The TF62 MED Commander insisted that every

decision made by his subordinate commanders would

be able to withstand inspector general inquiry, equal

opportunity questioning, and congressional and

civilian authority oversight. In short, he insisted on

transparency as the key to organizational integrity.

With transparency in mind, we laid out the steps to

E

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Management Fiscal Stewardship Medical IM/IT MHS Acquisition, Research/Dev elopment,Inf rastructure

Customer and Stakeholder Perspective

Optimize Return to Duty &

Conserv e Combat Power

Maximize Well Present f or

Duty & Reduce DNBI

Improv ed Health Status,

Public Conf idence, Increased

Capability and Capacity

Warrior Healthcare

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Medical Civil-Military

Operations

Hospitalization, Surgery ,

Diagnostic & Specialty Care Prev entiv e Medicine Systems Detainee Healthcare System

Primary & Dental Care

Sy stems Veterinary Care Sy stems Pro-MEET, Cooperativ eMedical Engagements

Trauma & Chronic Care

CPGs

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Facilitate Improv ed Access to

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Facilitate Timely Iraqi Patient Transf ers/

Discharges f rom US to Iraqi Facilities

Internal Processes and Systems

Learning and Growth

Clinical Quality Management Electronic Clinical

Documentation Dev elop Adaptiv e Leaders Continuing Education &Training

Organizational Assessment Comprehensiv e Risk

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Health Facilities Planning &

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Agile Joint/Multinational C2

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Protect the Health of

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Enhance GOI Credibility by

Supporting Self-reliant Iraqi

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Provide World-Class

Warrior Healthcare to US

& Coalition Forces

Figure 2. The Task Force 62 Medical Brigade model for development and execution of the Combat Healthcare Support

System. The model was conceived and designed to optimize healthcare support in the mature combat theater while

operating in a counterinsurgency environment.
74 www.cs.amedd.army.mil/references_publications.aspx

achieve ethical failure points following

the simple mantra, “it is what it is.”

Ethical violations begin at the top of a

slippery slope. A pattern of behavior

and thought leads to conclusions not in

line with Army regulations and policies.

We found that an individual starts

acting based on “thinking (assuming) or

feeling.” These individuals were not

well grounded in the standards,

regulations, and policies that govern our

organization. Instead, they operated on

“gut” feelings. Next, we saw a tendency

to “situationalize” ethics; we saw

statements such as “we are at war” or

“we are in Iraq.” The individuals

convinced themselves that Army

standards of behavior no longer applied

outside of the continental United States

(CONUS) garrison environment, when,

in fact, those very Army standards of

behavior were designed to help us

maintain discipline in combat and under

combat conditions. “Self-justification”

was another frequently observed

b e ha vi or . S ol die rs c o n vi nc ed

themselves, usually in instances of

inappropriate relationships, that

somehow it was “OK.” Over and over, in case after

case, these type behaviors appeared: thinking or

feeling, situationalized ethics, and self justification.

We saw these as the steps leading to the triggering

of improvised ethical decision-making.

The teaching of applied ethical framework stressed

to Soldiers the importance of setting limits as

represented in Figure 4, of conducting an honest

self-assessment and establishing strong boundaries

to guide themselves. By remaining within a strong

ethical framework, Soldiers would be able to avoid

those actions which violated Army regulations and

policies. We stressed the role of perceptions as a

vital component of the strong ethical framework. As

individuals, we cannot control peer or group

perceptions. However, our actions play an important

role in shaping group and peer perceptions. By

having a strong ethical framework, one which did

not “edge up” against or shortcut Army regulations

and policies, we ensure that our peers have the

correct perceptions of our actions. The applied

ethical framework addressed the role of honest

Applied Ethics in a Combat Theater of Operations

Army Regulations

and Policies

Army Regulations

and Policies

Figure 4. Illustration of the limits of Army regulations and

policies which form the boundaries of the Soldier’s ethical

framework, preventing incidents of misconduct, or perceptions thereof.

Figure 3. Reproduction of the in-theater poster displaying the tenets of

the F.L.A.G. institutional philosophy developed by the TF62 Medical

Brigade as the foundation for the combat healthcare support system.

I will never leave a fallen comrade

We not only fight for the Constitution and our Democracy,

We fight for each other.

Families take care of each other and treat one another

with dignity and respect.

You enlist Soldiers, Sailors, Airmen, and Marines, but

reenlist Families.

I will never accept defeat

No one is more professional than I.

Lead from the front with personal and organizational

integrity.

Leadership is a TEAM sport-counsel, coach, and mentor.

I will always place the

mission first

Duty, Honor, Country!

Your character must honor our nation, your service, unit

and Family.

Ethical conduct and medical diplomacy are force

multipliers.

I will never quit

Know your job, do your best, and develop your abilities to

the utmost.

Always seek to improve your physical and spiritual fitness.

We are a learning organization and must maintain a

perpetual quest for knowledge.

S O HE L P M E G O D !

Family, Leadership,

Ambassadorship, and

Growth

“Your life is not important except for

the impact it has on anoth er life”

Jackie Robinson
October – December 2008 75

THE ARMY MEDICAL DEPARTMENT JOURNAL

identification of personal limitations, self knowledge,

establishing blocks against temptation, and

commitment to a strong ethical framework as key to

avoiding improvised ethical decision-making.

Finally, Soldiers are taught ownership as part of the

core module; ownership of Army values and

ownership of personal responsibility. The TF62 MED

Commander often stated that we are “entitled to our

own opinions, but not our own set of facts.” Ultimately

as Soldiers, Army regulations and the Uniform Code

of Military Justice determines what is right and what is

wrong. We must ensure that our behavior, actual and

perceived, is above reproach.

A PATIENT-CENTRIC TASK FORCE MODULE

The medical task force in the theatre of operations is a

“patient-centric organization.” But what does that

mean? It means the patient—military, civilian, and

detainee—is the sole reason we are there. Our core

business is to meet the medical needs of our patients

on the battlefield. As such, each member of the

medical task force was assigned the individual

responsibility to act as patient advocates; the applied

ethical framework taught that we demonstrate patient

advocacy in a number of ways.

We start with patient privacy. Soldiers were taught to

ask “how much do I really need to reveal” about a

patient. One of the greatest barriers to care is the

perception that some treatments or procedures are

embarrassing. Mental health and the need to maintain

a resilient force is one such category of care we strive

to destigmatize. In their training as medical

professionals, Soldiers were taught that they are the

guardians of patient privacy, and that patient privacy is

not only a right, it is a law. We stress that commanders

have a limited right to know, especially when an issue

may impact the overall health of their commands, but

that Soldiers need to be vigilant, and, when erring, to

err on the side of patient rights.

Next, Soldiers are taught to view patients as

customers—not robots. Soldiers are taught to always

aim to be the best; that we measured our care against

evidence-based standards and best healthcare practices

as codified by tactics, techniques, and procedures in

CONUS-based medical treatment facilities. The

applied ethical framework defined this as the quality of

care we deliver. The TF62 MED Commander

committed the task force to building a combat

healthcare support system which would validate our

stated mission of providing world class healthcare.

Key to world class healthcare was the recognition of

the dignity of human life. Soldiers learn to treat each

life as unique and precious.

Soldiers receive instructions on detainee care. The

instructions were blunt and to the point: when

detainees are under our care, then they are patients,

period. The medical task force does not support 2

standards of medical ethics; one for our guys and one

for those guys. Our medical ethic is not situational,

and as such, the delivery of detainee care is no

different from the care we provide our Soldiers,

Marines, Sailors, and Airmen.

FINANCIAL STEWARDSHIP MODULE

The facts surrounding financial impropriety are usually

very simple. Most instances of financial impropriety

involve small dollar amounts, and represent a misuse

of government resources for purposes the individual

could have easily met with his or her own means.

Some financial improprieties were even approved by

superiors. Nonetheless, Soldiers are expected to use

their own judgment and should not rely solely on the

judgment of their superiors when it comes to ethical

conduct. Ethics are an individual responsibility.

As custodians of the taxpayer dollar, Soldiers are

taught to conserve the nation’s financial strength. Part

of this process is the establishment of sound financial

controls, or placing a policing mechanism upfront in

that process. In the Iraq theater of operations, we

utilize bulk funding—actual US cash—to meet

operational needs. This access to cash could represent

a temptation, but it is a temptation Soldiers avoid by

actively seeking to be kept accountable.

We teach Soldiers that our nation spends some $80

billion a year prosecuting the Global War on Terror. A

large part of that money ends up in Iraq. Part of

conserving the financial strength requires asking

simple questions:

 Does this purchase further my deployed mission?

 Can I defer this purchase?

 Is there a cheaper option?

Our nation will spend what it takes to win the Global

War on Terror, but it should not be forced to pay for

our personal desires. The resources we have are not

infinite, nor are they for personal use.
76 www.cs.amedd.army.mil/references_publications.aspx

AMBASSADORSHIP MODULE

This module stresses that all Soldiers will behave as

ambassadors for their unit, the Army Medical

Department, the Army, and our nation.

Soldiers are taught that the enemy is intelligent and an

opportunist. He understands that he will not defeat us

conventionally, the likelihood of Al Qaeda and associated militias rolling tanks down the streets of New

York City approaches zero. The enemy knows this, so

how does he plan to defeat us?

He seeks to defeat us strategically through

informational operations. The enemy loves propaganda

and spreads it at every opportunity. Creating negative

propaganda about our forces does 5 things for the

enemy:

1. It allows him to destroy our international

legitimacy.

2. It allows him to erode our domestic support.

3. It allows him to win the “hearts and minds” of

local nationals.

4. It allows him to cause us to doubt our mission.

5. It allows him to win support to his side.

The enemy spreads his propaganda through technology

and tried-and-true methods from the printing press to

simple word of mouth. Every time we commit some

unethical act, we give the enemy a strategic win. Even

the perception of impropriety injures our cause. As

Winston Churchill observed, “A lie gets halfway

around the world before the truth has a chance to get

its pants on.”5

Ambassadorship is one of our responses. Ambassadorship is how we conduct ourselves and how we

perform. Ultimately, ambassadorship is the story we

tell through our actions. A key and essential part of

how we demonstrate ambassadorship is in the

treatment of our patients—fairly—in compliance with

accepted medical standards.

Any maltreatment of patients is an “unforced error”

that gives the enemy a strategic win.

PERSONAL COURAGE AND INTEGRITY MODULE

The applied ethical framework package teaches the

importance of personal courage and integrity. The

intent is to make every Soldier a stakeholder in the

process of sound behavior. Soldiers are encouraged to

display personal courage and integrity by reporting

ethical lapses and failures, without fear of retribution.

The training module stresses to Soldiers that if the

ethical framework is what you know to be right, then

personal courage and integrity is what you do with that

knowledge. People will often “act out” against

perceived injustices; provided they do not personally

have to take responsibility. The training stresses a

simple rule of thumb:

If you do not have the courage of your

convictions, it is because you do not have

convictions.

Personal courage is doing what is right and correcting

what is wrong, no matter the cost. Personal courage is

not dependent on who you hang around with, what

your position is or where you are. Personal courage is

the ability to take ownership of what is right. Personal

courage keeps the Army strong. As an organization,

we are respected because what we do is open to

inspection, always. We do not hide. The Army has

many management controls, and Soldiers were

encouraged to use those controls.

ARMY COMMAND POLICY BASED BEHAVIOR MODULE

Army Regulation 600-20 3addresses our most important resource, our people. It tells us

...military discipline is founded upon self-discipline,

respect for properly constituted authority, and the

embracing of the professional Army ethic with its

supporting individual values.3(p21)

That excerpt clearly explains the Army’s concept for

good order and discipline. Again, the Army has

regulations for everything. Commanders do not have

to make up our values, our ethics, or good order and

discipline as we go along. Nine times out ten, the lack

of military courtesy—familiarity—and Soldier conduct

is what starts the ball rolling towards unethical

behavior. Military authority must be exercised

promptly, firmly, courteously, and fairly.

Army Regulation 600-20 provides a prohibition on

relationships between Soldiers of different ranks. The

trend in theater for Soldiers deviating from those

prohibitions shows the following: “Compromise or

appear to compromise,” “actual or perceived,”

“involve or appear to involve,” “actual or clearly

Applied Ethics in a Combat Theater of Operations
October – December 2008 77

THE ARMY MEDICAL DEPARTMENT JOURNAL

predictable.” Perceptions of our actions, which are

often heard on the “rumor mill,” are just as important

as the actions themselves. Leaders must ensure that

perceptions and realities line up.

Leaders maintain good order and discipline in several

ways:

 They address all problems when raised, and do so

directly and promptly.

 They understand that there is no “grace period”

for compliance with Army regulations.

 They know that perception is as injurious to good

order and discipline as actual acts.

 They deal with issues before they become

problems.

 Leadership is an action verb, not a position or

title.

Leaders must constantly act to ensure good order and

discipline are maintained within their units.

SEXUAL HARASSMENT MODULE

When a command responds to complaints of sexual

harassment, the leaders often hear that Soldiers,

whether they are victims, witnesses, or perpetrators,

thought the acts were “all a joke.” With sexual

harassment, the closer an individual gets to the line,

the easier it is for actions to be viewed by an impartial

observer as sexual harassment. Sexual harassment is a

violation of Army Regulation 600-20. Like many of

the issues discussed above, being a perpetrator of

sexual harassment can land a Soldier in the “danger

zone” of an improvised ethical decision.

What gets a Soldier into the realm of sexual

harassment is a repeated pattern of behavior that

targets the same person or groups of persons, again

and again. The Army breaks sexual harassment into 3

categories. Verbal and nonverbal patterns often build

into some sort of physical act of harassment. The

maltreatment of Soldiers (which is what sexual

harassment really is) will never be tolerated. Army

policy seeks to handle cases, especially unintentional

cases, of sexual harassment at the lowest level

possible. These are the informal approaches. Using the

direct (talking), indirect (letter writing), or third party

approach (having a peer speak on one’s behalf) will

usually do the job. But if the behavior continues, or if

there is an identifiable pattern, it should be reported to

the chain of command.

The key is that the behavior stops immediately. There

is no grace period.

INAPPROPRIATE RELATIONSHIP MODULE

Inappropriate relationships are perhaps the most

corrosive form of ethical violations we saw.

Inappropriate relationships between Soldiers of

different ranks, Soldiers who were married, and

Soldiers in positions of authority and trust did grave

damage to the good order and discipline of units where

these relationships took place.

Each inappropriate relationship basically follows the

same depressing pattern. The applied ethical

framework identified 10 key indicators, shown in

Figure 5, that an inappropriate relationship was

incipient or already ongoing. These indicators

consistently repeated themselves. They were known

patterns within units, they were revealed during

investigations or mentioned during rebuttals to Article

Figure 5. The 10 key indicators of the potential for, or

existence of, an inappropriate relationship, as described

by the TF62 MED ethical framework training package.

Earn an Article 15 Procedure for Adultery/Fraternization!

Classic Behaviors

1. Opposite gendered "workout partners" or "smoking buddies"

2. Constantly "hanging around" the work area of the other person

3. Sending or receiving emails and instant message chats of a

familiar or suggestive nature

4. Spending time alone away from one's assigned place of duty

5. Hiding: attempts to wipe clean computer hard drives, meeting

"off-site," unexplained absences during the duty day

6. Displaying casual familiarity in the workplace either through

verbal or body language: using first or nicknames, touching,

“back rubs," or leaning closely in a way that violates normally

established personal space

7. Having conversations that are intimate (sensitive, personal,

not necessarily sexual) which end when others come near

8. Visiting the quarters of Soldiers of the opposite gender alone

9. Finding that special person who is a "really good listener who

understands what I'm going through"

10. It is common for one to use intimacy to get sex, while the other

uses sex to get intimacy.

Though there are many other signs not listed here, the

cumulative effect of engaging in these predictive behaviors

normally leads to inappropriate relationships.
78 www.cs.amedd.army.mil/references_publications.aspx

15 procedures or requests for leniency. Inappropriate

relationships occurred across all ranks and grades, but

they all followed the same inevitable pattern.

The chain of command should try to stop individuals

from going down this path. There should be some

initial counseling. If the Soldier understands and

complies, then the desired result is reached. If not, the

commander should issue a “no contact order.” If the

Soldier understands and complies, the final step is

avoided.

Most inappropriate relationships do not come to light

until near the end of the tour. There have even been

cases of redeploying Soldiers returned to Baghdad,

from Kuwait, to face disciplinary action. Most cases of

inappropriate relationships are brought to light in the

course of unrelated investigations or events. Again,

this is the pattern, over and over.

CONCLUSION

Our training stresses that the problem is not

temptation. The problem, such as inappropriate

relationships, comes from succumbing to temptation.

Soldiers failed when they allowed personal wants to

overcome their oaths, their Army values, and external

commitments. We have temptations. Applied ethics

requires indentifying those temptations up front and

mitigating them. Army regulations make no

allowances for passive ethical failures.

There are all kinds of temptations in a theater of

operations. No one has ever been punished for being

tempted. What is punishable is succumbing to that

temptation. Everyone has ethical failure points. Some

of those points are where temptation overcomes our

defenses. Each individual needs to conduct an honest

self-assessment and identify his or her specific

temptations and failure points. Then, establish fences

between them and the failures. Change what you do,

where you go, or with whom you associate. Maintain

an ethical situational awareness and be on the constant

lookout for temptations that could end your career,

destroy your honor and family life, or even place you

in prison.

Control your individual ethical framework. An

individual’s behavior is what shapes the perceptions of

unit leadership and peers. Ultimately, for Soldiers,

Army regulations and the Uniform Code of Military

Justice determine “what is right and what is wrong.”

We must ensure that our behavior, actual and

perceived, is above reproach.

Ethics is an activity. The values and ethics we profess

are also what we must continue to practice and use

daily. We do this by grounding ourselves in the letter

and spirit of Army regulations and policies. Army

regulations address not just the action, but also the

perceptions of those actions. We must ensure that we

use a strong ethical framework which will ensure

perceptions of others are in line with your actions.

Finally, although deployed, our ethics are based upon

who we are, not where we are.

Set Your Ethical Bar High!

Make Sure You Clear It—Every Time!

ACKNOWLEDGEMENT

I thank COL David Budinger, Task Force 62 Deputy

Commanding Officer, and LTC Katherine Chiapulis

for their collaboration and assistance in the design and

implementation of the Applied Ethical Framework

training module discussed in this article.

REFERENCES

1. 64 Stat. 109, 10 USC, ch 47.

2. Army Regulation 15-6: Policies for Investigating

Officers and Boards of Officers. Washington, DC:

US Dept of the Army; October 2, 2006.

3. Army Regulation 600-20: Army Command Policy.

Washington, DC: US Dept of the Army; March 18,

2008.

4. Manual for Courts-Martial, United States (2008

Edition). Washington, DC; Joint Service Committee

on Military Justice, US Dept of Defense; February

21, 2008. Available at: http://www.apd.army.mil/

pdffiles/mcm.pdf.

5. Humes JC, Nixon RM. The Wit and Wisdom of

Winston Churchill. New York: HarperCollins

Publishers; 1995.

AUTHOR

When this article was written, MAJ Jackson was the

Commander, Headquarters Company, Task Force 62

Medical Brigade, Baghdad, Iraq.

Applied Ethics in a Combat Theater of Operations
October – December 2008 79

INTRODUCTION

Military healthcare in a deployed environment

parallels many of the same characteristics Keating1

used to describe civilian healthcare organizations:

turbulent environments, constrained resources,

expensive modernization requirements, and everchanging customer expectations, just to name a few.

However, even more overwhelming is the 100% to

200% turnover in personnel every year due to unit

rotations; cumbersome, bureaucratic acquisition

regulations; and a politically charged climate, not to

mention the very real and dangerous environment that

is pervasive throughout Iraq. Medical forces represented merely 4% of the total forces in Operation Iraqi

Freedom (OIF) in 2004 2and there is acute political

pressure to reduce the military force numbers and the

medical footprint in general.

In testimony to the House Appropriations Committee

in April 2007, ADM William Fallon, Commander of

the US Central Command said

Our MILCON [military construction] program is

critical to continued combat operations and posturing

forces for the future...These initiatives provide critical

operational, safety, health, and quality of life support to

our service members serving in Operations Iraqi

Freedom in Iraq and Enduring Freedom in

Afghanistan.3

The MILCON provides the resources that commanders

in Iraq required to achieve their operational priorities

and enable consolidation of the military presence in

Iraq.3 Military operations in a counterinsurgency

environment present unique challenges to medical

personnel. Like logistic support, medical or health

service support to counterinsurgency operations is

often accomplished from bases or forward operating

bases that provide relatively secure locations.4

Placement of medical facilities, hospitals in particular,

is extremely important in that geography, time and

distance, troop population densities, and the medical

regulating within the combat health support system in

the Iraq theater of operations (ITO). It is this “diversity

of phenomena that can arise though the interaction of

simple components” that tends to make the

interactions of hospitals and other medical units

complex. In other words, “the whole is more than the

sum of the parts.”5

Health Facilities Planning: Determining

Infrastructure Requirements for Form and

Function from Clinical and Operational

Capabilities

MAJ Don Chapman, MS, USA

LTC Kristen L. Palaschak, AN, USA

ABSTRACT

This article describes the practical application of documenting the operational concept and scope of services for military

combat hospitals providing joint health service support during Operation Iraqi Freedom. Due to the rapid changes that

take place in healthcare in general, and, in particular, in a large, rapidly maturing military theater of operations, a clear

operational concept and accurate scope of services is essential for hospital commanders and medical planners. A highly

structured, yet flexible collaborative approach to health facility requirements development begins with a clinical concept

of operations (CONOPS). Initial, up-front investment of time in the requirements process, and subsequent reviews and

revisions result in a definitive description of the clinical and operational requirements. Those requirements in turn

become the authoritative source for space, building systems, equipment, functional arrangements, and financial

justification. A recent case study highlights the utility of the CONOPS document in translating the necessary clinical

capabilities and capacities into facility space and building systems required to support them in a very tight schedule

driven process normally not associated with the military construction program and in particular medical projects.
80 www.cs.amedd.army.mil/references_publications.aspx

A clinical concept of operations (CONOPS) is a tool

that can aid investigation and understanding of the key

capabilities, scope of services, and interactions within

a medical treatment facility (MTF). The CONOPS is a

foundational document which helps direct the design

development of a health facility project. It is a forward

looking document articulating to the design

consultants a word picture of the future facility and

scope of services to be provided in the new or

remodeled space. The narrative is the format to “write

the story” of how an area operates. The narrative

should allow the reader to “walk” through the new

area and “see” the operation in action. It should

contain and describe the integration of each of the

following functional elements, all in support of the

services offered:

In effect, the CONOPS helps to simplify the

complexity that surrounds day-to-day operations of a

hospital organization. Also, it provides substance and

unity in the planning between multidisciplinary

functional areas that cannot be just assumed by the

medical planner, clinician, engineer, or logistician.

BACKGROUND

Bases and construction in the ITO are governed by US

Central Command Regulation 415-1,

6

also called “The

Sand Book.” Bases within the ITO are categorized as

contingency bases, and are defined as “sites to support

immediate contingency operations that are temporary

in nature.”6 There are 3 subcategories outlined in The

Sand Book:

Contingency Operation Bases (COB): Its purpose is

typically a command and control hub and/or regional

logistics hub; characterized by advanced infrastructure

for facilities and communications for the expected

duration of the operation.

Contingency Operation Sites (COS): Capable of

providing local and regional operations, security, and/

or humanitarian assistance relief. The site size and

capabilities are scalable to support rotation of forces or

prolonged contingency operations. Characterized by

limited infrastructure and may be dependent on

contracted services.

Contingency Operation Locations (COL): Capable of

quick response to operations, security, civic assistance,

or humanitarian assistance relief. A COL will be

dependent upon COS or COB for logistical support;

characterized by stark infrastructure primarily

dependent on contracted services or field facilities.

Contingency base camp support construction is

characterized as being either initial, temporary, or

semipermanent:

Initial: Initial standard includes expeditionary (unit

organic and military service provided equipment and

systems) up to initial facilities designed and

constructed on an expedient basis and characterized as

austere requiring minimal engineer effort. Initial

standard is intended for immediate operational units

for a limited time (less than 6 months) and may require

replacement by more substantial and durable facilities

subject to Central Command (CENTCOM) approval if

exceeding the initial standard.

Temporary: Temporary standard increases efficiency

of sustained operations for use up to 24 months.

Temporary standards provide a wider selection of

minimum facilities, thereby increasing the efficiency,

safety, durability, morale, and health standards of

personnel on operations.

Semipermanent: Designed and constructed with

finishes, materials, and systems selected for moderate

energy efficiency, maintenance, and life-cycle cost

with a life expectancy of more than 2 years, but less

than 25 years.

Over time, military medical units have for the most

part gradually transitioned from the large semimobile

deployable medical system (DEPMEDS) comprised of

expandable tactical shelters and frame tents into

buildings of opportunity or modular trailer facilities.

While deliberate planning by the Multi-National

Force-Iraq Surgeon and Medical Command occurred

for key hospitals, much of this transition occurred in

an ad hoc basis, with each medical unit left to fend for

itself, sometimes with the assistance of the base camp

mayor’s cell. The gradual shift into slightly more

durable, cleanable, and maintainable facilities helped

mitigate the exposure to the harsh environmental

Health Facilities Planning: Determining Infrastructure Requirements for

Form and Function from Clinical and Operational Capabilities

mission population served

scope of services manpower

equipment supply

traffic patterns procedural policies

adjacencies
October – December 2008 81

THE ARMY MEDICAL DEPARTMENT JOURNAL

conditions that challenge maintenance efforts, shorten

medical equipment lifecycles, stress infection control

programs of any hospital over the extended length of

theater operations. Additionally, infrastructure

requirements have increased due to the introduction of

new equipment as outlined by Syvinski and Elliott,

...through the collective efforts of the Military Health

System-Forward and use of state-of-the-art technology,

conditions are set for a continual increase in hostile

survivability as seen from 78.3% in 1991 to 90% in

2007.2

The new equipment introductions have been based on

the actual healthcare requirements of the population

being supported, and the skill sets of the assigned

clinical staff.

In August 2007, on the heels of the transition of

authority ceremony when Task Force 62 Medical

Brigade took over the command and control of all

echelons-above-division medical forces in Iraq, an

opportunity to replace the last remaining DEPMEDS

hospital presented itself. After identifying the obvious

need to replace the dilapidated deployable hospital on

the base, the COB Speicher received funds from a

cancelled military construction project. However, time

was of the essence as the project was already a couple

of months behind schedule compared to the other

fiscal year 2007 projects. Also, the required

documentation which describes the proposed project,

the operational requirement, the current situation, and

the impact if not provided had not been completed at

that point.

The hospital logistics officer and the utilities warrant

officer measured every room, tent, vestibule, and ISO*

expandable tactical shelter that comprised the hospital

at that time. They submitted this as the requirement for

the new hospital. While intuitively, a one-for-one

replacement seems like an acceptable solution to most

people, the logic and the assumptions upon which it is

based are flawed. By replacing “like in kind” space

requirements, the hospital would lock in the existing

inefficiencies, functional inadequacies, and other

deficiencies challenging healthcare delivery today. The

total space requirement initially identified just by

measuring interior dimensions was just over 30,000 sq

ft. However after validating the space requirements

derived from the CONOPS using Department of

Defense space planning criteria, the total space

required before design alternatives were considered

jumped to 60,000 sq ft. Inadequate space criteria

combined with the fact that interior dimensions

represent net rather than gross square feet, the space

requirement dramatically underestimated the full space

requirements by 30,000 sq ft, with the net to gross

ratio alone representing 20,000 sq ft.

Through cooperative discussions with a focus on

reaching the goals of the project, a decision was

proposed by the Army Corps of Engineers

TransAtlantic Program Center to incorporate two

6,000 sq ft options that, if exercised, would bring the

project up to a total maximum 42,000 gross sq ft. The

remainder of the shortfall, or nearly 18,000 sq ft,

would be addressed by reusing the 2 existing hardstand

buildings, reusing a few specific DEPMEDS

containers, and eliminating or trimming some scope

through a deliberate process that considered design

alternatives discussed later. At the 35% design review,

it was decided to plan and design the full 42,000

square foot project documented in the space program

for design derived from the CONOPS. This decision

making process was successful because the brigade

health facility planner and the hospital leadership had a

very good understanding of the clinical and other

functional requirements due to a well documented

CONOPS. The CONOPS guided the entire design

process and was referred to frequently when certain

design decisions were necessary.

DRAFTING THE CLINICAL CONCEPT OF OPERATIONS

The next 2 days were spent with the officer and

noncommissioned officer-in-charge of each section

within the hospital, conducting intensive interviews

and documenting the relevant information. These

discussions provided insight into the existing hospital

(system) in place and already operating. This is

important because we were not designing a new

hospital, but replacing an existing facility.

Transforming, replacing, modernizing, or relocating an

existing system (or in this case a facility) is vastly

different than starting from scratch.7 There are existing

contextual issues requiring consideration, such as

current conditions, staff, equipment, policies,

procedures, and what the desired end state mission and

capabilities are at project completion. These contextual

issues constrain the number of potential solutions

*International Organization for Standardization available, but often there is still room for small,
82 www.cs.amedd.army.mil/references_publications.aspx

incremental improvements, as well as large scale

changes within the scope of the project. These

opportunities can only be gleaned by first documenting

what is currently done, and then what can and should

be improved.

Determining the operational, clinical, quality, or

capability shortfalls is absolutely necessary in order to

improve operations. It requires great tact and judgment

to determine what gaps should be addressed by the

project. The facility is only one aspect or component in

a complex system of systems comprised of people,

technology, policies, procedures, information

technology, logistics, maintenance, and command and

control systems. Care must be taken not to look for

deficiencies that do not exist or are inconsequential in

the grand scheme. Judgment must be exercised in

trying to resolve larger problems where facility

constraints thought to be the problem are really only

symptoms rather than the source of the malady. The

clinical CONOPS serves as an excellent tool. It is

designed to guide discussion through a series of

questions that tease out the necessary information. It

also documents other issues that may be invisible to

hospital leadership and staff due to the complexity of

the environment, allowing those issues to be brought

to their attention later as necessary.

While formats vary, the important point to remember

about the CONOPS is that it serves to document the

vision for the future facility and the scope of services

to be provided in the new or remodeled space. It

should be noted that the CONOPS is not a description

of the physical facility. Although drawing pictures

may help the staff develop the narrative, a preferred

floor plan is not part of the document. The format is

designed for the clinical, administrative, and logistical

staff to document their operational requirements and

explain how they envision the operation of the

hospital. An example CONOPS format is provided as

a potential template that can be modified for a specific

situation. The template is a series of questions that,

when answered, can be reformatted and edited into a

standalone narrative describing in fairly specific detail

the intended scope of services, procedures, and

adjacencies, and desired improvements upon the

conclusion of the project.

COMPONENTS OF A CONCEPT OF OPERATIONS

Mission. Restate the current (unclassified) mission

statement for the medical treatment facility and every

section within the facility in general terms. This is

usually straightforward for the overall facility, but

often requires some thought for individual sections.

Official missions of the organization includes type of

patients, level of care, and any other mission

requirements impacting the operation or ongoing

design of the renovated facility.

Population Served. This identifies the served

population, or to whom the MTF provides healthcare

services, and can be broken out by percentages for

each category. In a deployed environment there is less

of a focus on whether the patient is Active Duty,

Reservist, dependent, or retiree, and more on whether

they are a US service member, coalition force, US

government civilian, local national, contractor,

detainee, or others. It should include gender ratios and

ages of the served population. Also, this section

identifies any projections of increases or decreases in

the supported population due to base closures,

consolidations, or openings.

Scope of Services. The scope of services section is

probably the single most important part of the

document. If careful consideration and detail are not

included in this section, it is very likely that the facility

which is designed and built will not properly support

the full medical mission requirements. This section

also provides appropriate boundaries on the scope of

the project to prevent including capabilities and

requirements that are not appropriate or exceed the

resources of the MTF. The scope of services

statements should not only discuss services currently

provided, but also those services which have command

endorsement and are not currently provided, and

identify if the problem is due to equipment, space, and/

or personnel.

Manpower. Current Army Medical Department facility master planning relies on manpower as one key

input variable in determining the appropriate size and

shape of a facility. By aligning the facility to personnel

requirements, and aligning positions to mission and

capabilities, the resources closely follow. Facility

planners will not program space for services where

staffing does not exist, or is not forecasted. Additional

considerations requiring discussion include

identification of borrowed military manpower

positions, volunteers, students, research, and any other

unique types of personnel. Organizational structure

Health Facilities Planning: Determining Infrastructure Requirements for

Form and Function from Clinical and Operational Capabilities
October – December 2008 83

THE ARMY MEDICAL DEPARTMENT JOURNAL

and/or product line affiliations should be discussed

within this paragraph. Attach a manning document to

supplement the information provided.

Equipment Issues. The Space and Equipment

Programming System provides a comprehensive roomby-room equipment list drawn from a current database.

There might be specific equipment requirements to

meet patients’ needs in the future. Briefly describe

those requirements and any training needed to use the

equipment. If the MTF is currently incapable of

providing a full range of services due to a lack of

equipment, it should be documented. If a draft

equipment room content list has been developed,

reference it here, or reference and include it as an

attachment. Remember, if the effort is a renovation

project, frequently the equipment must be moved and

used in the swing space.

Supply. Considerations of changing supply requirements

necessary for patient care treatment and procedures are

documented in this section. Office and administrative

supplies are discussed. This paragraph also outlines

changes in types of supplies being used (eg, disposable

versus reusable) that will affect storage space and

restocking procedures. New equipment and/or new

services may significantly drive logistical

requirements and, in turn, resource requirements.

Identify who (by position) within the section is

responsible for supplies.

Traffic Patterns. Only after the previous paragraphs

have been fairly well developed can this section be

tackled effectively. At this point, detailed descriptions

of traffic flow for patients, staff, materials and

supplies, and waste management is required. After

identifying the high traffic areas and choke-points,

determine if any processes can be modified to avoid

cross-traffic and/or constricted areas (laboratory,

radiology, check-in, pharmacy waiting, etc). Describe

how “way finding” should be handled in each area (eg,

signage package, color schemes). Answer these same

questions for transition (swing) space if applicable.

Procedural. Given current operations, describe what

works well within the department and should be

continued. Consider what is dysfunctional to prevent

those habits from continuing in the new footprint.

Provide examples of what workarounds had to be

developed in order for the staff to accomplish their

jobs, and for the MTF to fulfill its mission. Discuss

different ways of performing the current operation that

would improve services to the primary customer, the

patient. While tactical standing operating procedures

may be useful in completing this section, avoid using

them verbatim, especially if those procedures already

have been modified, or will require modification to

work in a fixed facility.

Adjacencies. Adjacencies describe the physical

location of spaces to one another. There are at least 4

types of adjacencies that should be discussed in this

section: department; functional area; room to

functional area; and room-to-room. First, identify

which departments should be next to each other (eg,

radiology and emergency care). Next discuss

functional areas that should be adjacent (eg,

immunization to primary care). Then, determine what

rooms should be aligned with functional areas (eg,

isolation room near the reception and waiting spaces or

dental chairs to x-ray). Finally, associate rooms that

have adjacency requirements such as toilets next to

ultrasound and treatment rooms.

Composing a detailed clinical CONOPS for anything

larger than a very small aid station can be an

overwhelming task. The collection of information can

take days or even weeks, and very likely will require

follow-up questions and clarifications. As such, the

CONOPS should be considered a “living document,”

requiring periodic updating as more facts become

available and assumptions are validated. It is likely

that the scope of the project may grow and contract

over time depending upon mission, cost, schedule, and

other influences.

Therefore, it is recommended that the hospital initially

complete the CONOPS development process as

thoroughly and quickly as possible to document the

preliminary description of the facility project’s goals.

The draft should then be reviewed by both hospital

personnel and the health facility planner. This allows

the health facility planner to continue with the

remaining planning processes while the hospital

completes another iteration of the CONOPS

development. Each time the document is advanced,

goals can be reformulated, priorities can be developed

and the scope of the project adjusted.8If constraints in

terms of approved scope or funding require

elimination of space, then alternative strategies can be

developed to address those items as separate projects

as necessary.
84 www.cs.amedd.army.mil/references_publications.aspx

Attempting to complete a CONOPS in a single draft

without moving through the steps in the facility

planning process will likely result in project delays,

suboptimization, wasted time and money (particularly

when faced with cost constraints), and in some cases

may lead to early project failure.8 All too frequently

hospital leadership defines the problem as needing a

better building, usually qualified with an expansion in

space, which constrains the definition of the problem

and the potential solutions too early. To mitigate this,

the CONOPS serves as an organized and detailed

methodology to identify and explain the project goals

(provision of clinical capabilities) that should be

addressed in the statement of work for the facility

project.

THE SPACE PROGRAM FOR DESIGN

The next step of the overall facility planning process is

development of a program for design (PFD). The PFD

is a room by room, department by department listing

of space requirements for the entire facility. The PFD

is tied directly to and derived from the CONOPS. The

PFD translates the clinical and operational capabilities,

personnel, and other functional requirements outlined

in the CONOPS into space requirements for the

architect to develop a workable solution or design.

Unfortunately, throughout the ITO,

construction projects, including those for

medical purposes, are completed every day

with very little consideration of the clinical

and procedural implications.

Engineers and clinicians jump straight to the

solution by drawing what they think they

want without really defining the problem

statement or goals of the project. Many

projects are to correct deficiencies from

previous projects, likely due to poor upfront

planning and requirements development.

This becomes a vicious cycle and in the end

drives up costs, increases frustration, and

reduces overall efficiency of the entire

healthcare system. The environment in

which medical organizations operate within

the ITO is tumultuous. Unit and individual

rotations, enemy actions, constraints on permanent

construction, and varying methods and priorities of

medical and nonmedical leadership make medical

projects extremely difficult. The CONOPS provides a

historical record of the decisions taken to develop the

project and generally stabilizes the overall project

development process.

Finally, the CONOPS serves to validate the PFD as

well as provide justification to operational and medical

planners, military leadership, and resource managers.

When decision makers are faced with tough decisions

on project scope, the CONOPS informs and enables

them about alternative scenarios to satisfy the

operational and clinical space requirements. When a

CONOPS does not exist, this becomes a risky guessing

game with unpredictable results that are difficult to

anticipate, let alone mitigate. Late adjustments to a

project without a CONOPS, which leaves the decision

makers uninformed, could mean delaying or even

jeopardizing the project’s viability.

CASE STUDY: DEPMEDS HOSPITAL REPLACEMENT AT

CONTINGENCY OPERATIONS BASE SPEICHER

Existing Conditions

The existing level III hospital at COB Speicher

consisted of a mixture of expeditionary structures

(DEPMEDS ISO containers, and TEMPER [Figure

1]), and existing single story, hardstand buildings

occupied by the hospital. Some improvements have

been made to the MTF (CT*scanner added,

microbiology added to the laboratory), but generally

the DEPMEDS ISOs and TEMPER had exceeded their

service lives and require replacement. Figure 2 is an

aerial view of that hospital showing how DEPMEDS

Health Facilities Planning: Determining Infrastructure Requirements for

Form and Function from Clinical and Operational Capabilities

*Computerized Axial Tomography

Figure 1. TEMPER (Tent, Extended Modular Personnel)
October – December 2008 85

THE ARMY MEDICAL DEPARTMENT JOURNAL

and TEMPER layout on the site between the 2 existing

hardstand buildings. The site identified for the new

facility would be to the left of the area illustrated in the

figure.

Power generation is provided by a combination of

prime power, commercial, and military generators.

Both 220V 50Hz and 110V 60Hz power are

maintained in the building due to large quantities of

DEPMED ISO and medical equipment requiring 110V

power. The harsh environment and heavy electrical

loads from the hospital exceed the available power

capacity and there are frequent power failures. These

are quickly resolved through a triple-redundant mix of

commercial and military generators, but the resources

and effort to maintain that redundancy are significant

and unsustainable.

Inherent deficiencies in the DEPMEDS are inadequate

dust control, noise abatement, and lack of privacy,

elements unacceptable in any hospital. Two building

methodologies were discussed in detail during the

design charette.* The first was the common precedent

of the trailer hospital. While quick and cheap, it was

judged as inferior to that of a preengineered building

(PEB), similar to the one recently constructed at

Logistics Support Area Anaconda, near Balad. A PEB

is a large, temporary metal building with an interior

that can be configured to suit the application.

The PEB was determined to be the best

value for the money and would overcome

many of the shortcomings experienced by

both expeditionary and trailer hospitals.

This type of construction would provide

cleanable surfaces, reducing infection

rates and improving outcomes. It would

also reduce exposure to excessive noise

levels for the patients and staff, an

environmental factor which has also been

shown to lead to more favorable

outcomes, such as less pain medication

and faster recovery rates. It would provide

a more robust infrastructure to support

improved healthcare capabilities and

extend lifecycle management of the stateof-the-art medical equipment in a maturing combat theater of operations.

Timeline

Day 1

Arrived, Contingency Operating Base Speicher

Meeting with Speicher Facility Engineer Team

Meeting with Corps of Engineers

Tour of hospital

Day 2

Conducted individual meetings with the 18 sections

that comprise the hospital

Day 3

Completed interviews and follow-up with key staff

Consolidated key capabilities identified during

interviews into a single document

Integrated and validated functional relationships

into adjacencies

Developed the space program for design based

upon the clinical capabilities

Preparation and coordination

The design process began with an initial meeting at

COB Speicher with the Corps of Engineers design

team from the TransAtlantic Program Center to

conduct the design charette. This meeting was useful

in understanding the purpose and scope of the project

and constraints due to funding and schedule. An early

idea of the design team was to select a recently

completed hospital project and duplicate that facility at

this location. However in an article on a systems-based

*A final, intensive effort to finish a project before a

deadline. Source: Random House Unabridged Dictionary.

New York, NY: Random House, Inc; 2006.

Figure 2. Aerial view of the hospital at COB Speicher prior to

construction of the replacement preengineered buildings.
86 www.cs.amedd.army.mil/references_publications.aspx

methodology for analyzing organizational structure

and performance improvement within healthcare,

Keating posits

Every organization in the health sector, from small

clinic to national health service, can be viewed as a

complex system, integrating people and technology

through relationships to achieve desired purposes.1

Therefore, while intuitively this sounds like a very

practical idea, for those who are not familiar with

medical projects, as well as medical personnel who are

not familiar with facility requirements, it is fraught

with assumptions and potential disappointment.

The underlying assumptions and key criteria driving

the appeal of cookie-cutter medical facilities is that

whatever is built is an improvement to what is

currently there. Just because a solution worked in one

context does not mean that it will transfer to a new

location, organization, and situation with different

personnel, equipment, financial resources, and

operational environment, and produce the same

outcome. Due to the characteristics that differentiate

complex systems from simple systems, it follows that

solutions for complex problems should not be

duplicated by making assumptions that oversimplify

the system.7 Therefore, replicating a preexisting design

or performing a site adaptation is not always the best

solution.

The technical and administrative coordination and

points of collaboration were discussed and a tentative

plan and a sequence of events were outlined to refine

the project scope and gather the key data required to

properly plan the project. This concluded the initial

preparatory and coordination portion. The next phase

involved data gathering and analysis requirements,

beginning with a tour and orientation to the existing

hospital complex. At the conclusion of the tour of both

the existing hospital and a terrain walk of the proposed

future site adjacent to the hospital, final administrative

coordination occurred with both the base facility

engineer and Corps of Engineer program manager.

Scope of the project, cost planning factors, and the

overall programmed amount of the project were

tentatively established, with mechanisms in place to

revisit as knowledge of the project requirements were

defined and justified.

Preparation of the CONOPS: The Value It Provides

After establishing a tentative plan to finalize the scope

of the project for the design team, interviews with the

hospital staff were conducted. Pertinent information

was captured from the 399th Combat Support Hospital

(CSH) staff from each of their 18 sections. Notes taken

from these interviews were transcribed into the initial

draft of the CONOPS. The following day, each section

was provided the opportunity to review and amend

their section. Key data points such as recommended

staffing positions and surgical, inpatient, outpatient,

and ancillary workload data were obtained for the

previous year to validate capacities. That data was

used to properly size areas within the hospital, such as

waiting rooms, number of exam rooms, and number of

beds. Laboratory, pharmacy, radiological workload,

and other key data points were obtained in order to

determine the right mix of services and project

capacity.

In fact, the data gathered, coupled with historical bed

census, resulted in the decrease of 4 intermediate care

inpatient beds. This was not an arbitrary reduction, but

a fully informed and staffed decision because of the

transparency and visibility which allowed planners,

leadership, and clinicians to feel comfortable with the

decision. Another example of an informed decision

resulted later in the actual design of the facility when it

became apparent that some scope reduction was

required. Dental services were initially included within

the footprint of the acute care clinic. However,

collaboration with the dental company leadership

revealed a greater need to consolidate dental assets

rather than locate a couple of chairs within the

hospital. While there was not room within the scope of

this project, a deliberate decision was made to develop

the requirements and justification for a separate,

standalone dental clinic to provide the necessary

capacity and efficiencies for dental care needed on

COB Speicher. This would not have been possible

without the later insight that the CONOPS provided.

An added value is that continuity has already been

realized as the 399th CSH has been replaced by the

325th CSH, which was subsequently replaced by the

345th CSH. At least one more CSH will rotate into

COB Speicher before the facility is complete. The

turnover (400%) of personnel by the hospital and the

garrison is quite high by any standard. The CONOPS

Health Facilities Planning: Determining Infrastructure Requirements for

Form and Function from Clinical and Operational Capabilities
October – December 2008 87

THE ARMY MEDICAL DEPARTMENT JOURNAL

provides a written continuity of decisions on the

medical services offered within the hospital, and has

reduced the number of total changes in scope normally

associated with poorly defined projects, or projects

where turnover in leadership results in shifts in

mission and vision of the organization.

SUMMARY AND CONCLUSION

The clinical CONOPS is a foundational document

which helps direct the design and development of a

health facility project. It is a forward-looking

document articulating to the design consultants a word

picture of the future facility and scope of services to be

provided in the new or remodeled space. The narrative

is the format to write the story about the operations. It

serves to validate the project as well as provide

justification to operational and medical planners,

military leadership, and resource managers. When

faced with resource constraints, the CONOPS allows

informed decisions and enables alternative scenarios to

satisfy the operational and clinical space requirements.

While drafting the CONOPS appears, on the surface,

to be a formidable task to complete, it really involves

answering questions about everyday procedures,

processes, equipment, and functions carried out by the

staff members of the hospital. In other words, the

hospital staff has to explain what they do to take care

of patients now, and how they would like to provide

improved care in the future. Since the value of the

hospital and its cumulative contribution to the health

service support plan in support of contingency

operations is more than the sum of its parts,

documenting the activities carried out and the

improvements envisioned exists as a critical task to be

completed in the early stages of any facility

improvement project.

REFERENCES

1. Keating CB. A systems-based methodology for structural analysis of health care operations. J Manag Med.

2000;14:179-198.

2. Syvinski B, Elliott J. Combat casualty care on the technology curve: medical equipment standardization in a

maturing combat theater. Mil Med Technol. 2008;5:34-37. Available at: http://www.mmt-kmi.com/article.cfm?

DocID=2499.

3. Fallon WJ. Statement of Admiral William J. Fallon, US Navy, Commander US Central Command Before the House

Appropriations Committee Subcommittee on Military Construction on Military Construction in US Central

Command. April 17, 2007. Available at: http://www.dod.mil/dodgc/olc/docs/testFallon070417.pdf.

4. Field Manual 3-24: Counterinsurgency. Washington, DC: US Dept of the Army; December 15, 2006:p3-2.

5. Flood RL, Carson ER. Dealing with Complexity: An Introduction to the Theory and Application of Systems Science.

2nd ed. New York: Plenum Press; 1993:31.

6. US Central Command Regulation 415-1: Construction and Base Camp Development in the USACENTCOM Area of

Responsibility “The Sandbook”. Tampa, Florida: Headquarters, US Central Command; December 17, 2007. Note:

Access to this document is restricted.

7. Keating CB, Fernandez A, Jacobs D, Kauffmann P. A methodology for analysis of complex sociotechnical processes.

Bus Process Manag J. 2001;7:33-50.

8. Gibson JE, Scherer WT, Gibson WF. How To Do Systems Analysis. Hoboken, New Jersey: John Wiley & Sons, Inc;

1991:33-34.

AUTHORS

At the time this article was written, MAJ Chapman was the Health Facility Engineer, 62nd Medical Brigade (Task

Force 62), Camp Victory, Baghdad, Iraq.

LTC Palaschak is Chief, Clinical/Technical Service, US Army Health Facilities Planning Agency, Falls Church,

Virginia.
88 www.cs.amedd.army.mil/references_publications.aspx

INTRODUCTION

In September 2007, Task Force 261 Multifunctional

Medical Battalion, headquartered at Joint Base Balad,

assumed command and control of the 561st and the

257th Medical Companies (Dental Services), as part of

their larger mission to provide synchronized, worldclass, echelon-above-brigade combat team (EABCT)

healthcare across the Iraq theater of operations. The

257th Medical Company from Fort Bragg was

immediately replaced by the Reserve Component’s

307th Medical Company. The 673rd Medical

Company from Ft. Lewis replaced the 561st Medical

Company in December 2007. In addition to the 2

dental companies, Task Force 261’s task organization

included 5 area support medical companies, each with

an organic dental corps officer and enlisted dental

technician, 2 ground ambulance companies, 4

optometry detachments, one forward surgical and one

head and neck surgical team, and the headquarters

detachment.

Each dental company was given a geographic area of

responsibility, with one company primarily operating

in northern Iraq, responsible for the operation of dental

clinics at 6 locations, with a “flagship” clinic at Joint

Base Balad, and the other in southern Iraq, with 6

(later 7) clinics, including a flagship facility at Camp

Liberty, Victory Base Complex, Baghdad (Figure 1).

Both companies maintained a command post at Joint

Base Balad, and worked together to meet the task

force’s vision of “Dedicated to Establishing a

Professional Healthcare System.”

One dental company was given administrative control

of a 3-person optometry detachment at one location, a

testament to the increasing “plug-and-play” nature of

the Army Medical Department.

STARTING POINT

Previously deployed dental companies and battalion

task forces performed pioneering work, initiating the

transition from generator powered, mobile facilities

using deployable field equipment, to fixed clinics with

plumbing, prime power, and durable equipment. By

September 2007, Multinational Corps-Iraq’s medical

brigade task force had established a comprehensive

and enduring dental care footprint, with EABCT dental

care located at 12 enduring forward operating bases

(FOBs.) Construction had been completed at the

flagship locations for each dental company. Camp

Liberty’s clinic was equipped with 8 dental chairs,

sterilization, laboratory, and digital radiography,

including panographic capability. Joint Base Balad’s

clinic was nearly operational, opening with 8

functioning dental operatories, later increasing

capacity to 18 operatories, and also had sterilization,

Expanding a Professional Dental Care

System: Experiences of Task Force 261

Multifunctional Medical Battalion During

Operation Iraqi Freedom 07-09

LTC(P) Frank L. Christopher, MC, USA LTC Craig G. Patterson, DC, USA

SGM Gregory M. Smith, USA CW4 Mark A. Smith, MS, USA

CPT James W. Cobb, DC, USA CPT Jennifer A. Pollard, MS, USA

ABSTRACT

During Operation Iraqi Freedom 07-09, Task Force 261 Multifunctional Medical Battalion managed an extensive dental

care system stretching throughout the Iraq theater of operations. We illustrate several of the unique challenges faced by

Task Force 261’s headquarters and its dental and area support companies, and describe the remedies emplaced by the

Task Force. Personnel structure, the evacuation chain, supply and facility management, dental civil-military operations,

detainee care, information technology applications, and public health initiatives are discussed in detail.
October – December 2008 89

laboratory, and digital plane and panographic

capabilities. Other clinic locations varied from

modular buildings to hardened preconflict buildings,

most still working on field compressors and generatorbased power.

PROVIDER VARIABILITY

Dental companies are staffed with Dental Corps

providers based upon their station and component.

Active component companies are predominately

resourced through the Professional Filler System

(PROFIS),* which rotates providers from US Army

Medical Command facilities for 6 to 15 months, and in

which specialty substitutions may be made. For

example, a comprehensive dentist billet may be filled

by an endodontist for 6 months, then replaced with a

prosthodontist. Active Duty companies originating

from US Army Europe are staffed with dentists who

deploy for the duration of the unit’s deployment,

usually 12 or 15 months. Reserve component

companies rotate their entire provider set every 90

days, also with specialty substitutions permitted.

Area support medical company dental officers

deploy for the entire duration of the unit’s

deployment, typically 12 or 15 months.

The new PROFIS policy, released in January 2008,

limits active duty PROFIS provider deployments.

It was greeted with mixed emotion by those

officers already in theater. While a positive step

forward to decrease deployment time for PROFIS

providers, a great deal of inequity seemed to apply

as dental officers served 6 months or 15 months,

depending on what day one arrived in theater.

Many of the 15-month providers will have seen

numerous dental officers rotate in and out of

theater because their deployment date was posted

after the cutoff date.

The end result is a great deal of personnel

turbulence, with a resulting requirement to closely

manage specialty care dentists, placing them at the

highest volume facilities to maximize their

efficiency and reduce evacuations, yet ensuring

continuity of care as deployments occur.

SYNCHRONIZATION WITH AREA SUPPORT MEDICAL

COMPANIES

The 5 area support medical companies (ASMCs)

within Task Force 261 were responsible for providing

level II medical care at key troop concentration areas,

in addition to level I care at outlying areas. Each

ASMC deployed to Iraq with both a Dental Corps

officer and a dental specialist. At Joint Base Balad and

Camp Liberty, the ASMC dentist and specialist

integrated into the staff of the flagship clinics. The

same arrangement was made at one other high volume

location. At the 2 other ASMCs, where there was

significant geographic dispersion between the

ASMC’s clinic and the dental company’s clinic,

ASMC dental personnel maintained a single-chair

capacity within the level II medical clinic. At all

locations, a senior dental officer was identified by

Task Force 261 (TF261) to supervise and synchronize

care, maximizing efficiency of available personnel and

dentists, and providing professional developmental

opportunities for junior personnel.

Task Force

261MMB

Area Support

Medical Company

(5)

Medical Company

Dental Services

Northern Iraq

Medical Company

Dental Services

Southern Iraq

Flagship

Dental Clinic

Dental Clinic

(6)

Flagship

Dental Clinic

Dental Clinic

(5)

Dental O fficer

Dental Specialist

Staffing Profile (total):

Area Support Medical Co mpanies:

5 Dental Corp s Officers

5 Dental Spe cialists

Dental Services Co mpanies:

28 Dental Corps Officers

56 Dental Specialists (including hygienists and laboratory specialists)

Figure 1. Dental support organization of the Task Force 261

Multifunctional Medical Battalion (September 2007).

*PROFIS predesignates qualified Active Duty health professionals serving in Table of Distribution and Allowance†units to

fill Active Duty and early deploying and forward deployed units of Forces Command, Western Command, and the

medical commands outside of the continental United States upon mobilization or upon the execution of a contingency

operation.1

†Prescribes the organizational structure, personnel and equipment authorizations, and requirements of a military unit to

perform a specific mission for which there is no appropriate table of organization and equipment (the document which

defines the structure and equipment for a military organization or unit).
90 www.cs.amedd.army.mil/references_publications.aspx

HUB-AND-SPOKE MODEL OF SPECIALTY DENTAL CARE

One of the major goals of TF261’s dental elements

was to build upon the success of preceding units to

minimize the number of Soldiers evacuated out of

theater for specialty or complex dental care. The

simplest and most successful strategy was to emplace

specialty care dentists at each of the 2 company

flagship clinics, ensuring that as providers rotated in

and out of theater, specialty care access was

maintained at each facility. This occasionally resulted

in a requirement to balance specialists among

companies. The next challenge was to market this

change, the availability of specialty care at the 2 hub

locations, to dental officers across Iraq, including at

the brigade combat team level, to sister services, and

to coalition forces. This process was aided by the

theater dental consultant and the 62nd Medical

Brigade’s senior dental noncommissioned officer

(NCO) who updated and distributed the theater dental

provider list to each dental officer in theater. Finally,

coordination for patient movement, housing, treatment,

and return to home forward operating base (FOB) was

required (Figure 2).

Patients seen at any outlying clinic were referred to the

flagship clinic within the geographic responsibility of

one of the 2 dental companies. The receiving clinic,

through a single screening and coordinating provider,

arranged housing and care with the appropriate

specialty provider. It is the responsibility of the

referring clinic, the patient’s unit, and the patient to

ensure that dental records, including radiographs (if

available) are available at the specialty care

appointment.

If one flagship clinic lacked a particular specialty, it

would use a comprehensive dentist to screen the

patient, and, if needed, refer to the other flagship

clinic. These occurrences were exceptionally rare

during TF261’s deployment to Iraq.

Utilization of the hub-and-spoke model, with close

cooperation between referring and accepting dental

officers, dramatically improved access to specialty

dental care across Iraq, and virtually eliminated

evacuations out of theater.

DEVELOPMENT OF THE DENTAL FACILITY ADVISORY

BOARD

Upon completion of the initial battlefield surveys of

TF261 dental facilities, it became evident to the

leadership that there was a requirement to provide

dynamic oversight of the conversion from field to

fixed facilities and equipment, and to ensure that

dental officers and specialists were integrated into the

decision-making cycle when planning new

construction or renovation of dental clinics. Most

of the existing facilities had been established in

pre-war buildings, modular buildings, or

deployable medical systems containers, leading

to inefficiencies in design, ergonomics, and

patient flow.

The Dental Facility Advisory Board (DFAB) was

chartered to guide the “way ahead” as clinics

were renovated or constructed, providing

engineers and FOB mayor cells with

recommendations to maximize the efficient use

of space, ensure sufficient dental chairs and

operatories to support the current and future

installation population, and provide technical

input, including unique compressor, sterilizer,

plumbing, and medical gas requirements.

The DFAB consisted of the senior dental

company commander (acting also as Theater

Dental Consultant), the junior dental company

commander, the deputy commander for clinical

Figure 2. The hub and spoke organization established by Task

Force 261 to provide specialty dental care across the Iraq

theater of operations.

Expanding a Professional Dental Care System:

Experiences of Task Force 261 Multifunctional Medical Battalion During Operation Iraqi Freedom 07-09
October – December 2008 91

THE ARMY MEDICAL DEPARTMENT JOURNAL

services for each dental company, the battalion senior

dental NCO, the battalion medical maintenance officer

(also serving as facilities manager) and senior NCO,

and the battalion medical supply officer and senior

NCO. Meeting first in January 2008 and monthly

thereafter, the DFAB continuously researched

anticipated troop shifts and developed comprehensive

scopes of work for each dental clinic in the task force

footprint. As an example, work on a new design for a 6

chair clinic at Contingency Operating Base (COB)

Endurance to meet projected population shifts in the

coming year had already been started. This clinic

design was later accepted by the DFAB as the

blueprint for a standardized medium-size clinic design

which could be later used, expanded, or contracted at

different locations to support the current and future

population at risk. The DFAB will continue to work

closely with installation mayor cells and TF261

facility engineers and planners to provide information

and clinical relevance to future dental facility

construction projects.

THE CORPORATE DENTAL

APPLICATION

Like our predecessor, we

continued using the Corporate

Dental Application (CDA), a

comprehensive workload and

readiness reporting system

developed by the US Army

Dental Command (DENCOM)

and used throughout the Army

Dental Care System. The

application is internet based and

user friendly. In the fairly

mature environment of Iraq,

sufficient bandwidth is present

to support CDA at all care

locations. Additionally, the

DENCOM CDA team is

available to provide end-user support for the

application.

Upon assuming the mission, TF261 recognized that a

significant portion of dental professional time and

resources were being used in the care of contracted

personnel, a potentially reimbursable expense. At the

time, contractors were not included in CDA’s patient

care categories, instead being lumped together under

the “other” category, which included detainees and

other miscellaneous groups. Working through the

DENCOM’s chief information officer, we were able to

get a modification to the CDA that separated

individual patient categories for US and foreign contractors (Figure 3). This allowed our dental commanders to better track expenditure of dental resources

throughout the theater of operation, and provided

situational awareness of the time and cost associated

with contractor care.

The central management of EABCT dental care under

one task force allowed better data collection and

decision-making. Prior to our arrival in theater, dental

provider location in the CDA database was somewhat

unorganized. Some area support and dental company

providers were reporting their data under the generic

“Southwest Asia Dental Clinic,” with separate

duplicate entries under their respective units. These

inaccuracies were compounded by the constant

turnaround of personnel rotating at 90- and 180-days,

which made it difficult to pull and compile accurate

workload data for each provider or each individual

location. Together with the DENCOM CDA staff, the

theater dental leadership conducted an education and

quality management campaign, ensuring all providers

were correctly mapped to their individual units. Task

force dental personnel then used an internal tracking

matrix to link their workload to their respective

satellite location. This data allowed the Task Force

commander to easily identify workload trends and

3500

3000

2500

2000

1500

1000

500

0

SEP OCT NOV DEC JAN FEB MAR APR MAY JUN

Figure 3. Category of patients seen at Task Force 261 Dental Clinics, Sep 2007–

Jun 2008. Data extracted from US Dental Command Corporate Dental

Application.
92 www.cs.amedd.army.mil/references_publications.aspx

make required staffing decisions (Figure 4).

An added benefit to using CDA is the

ability to calculate the relative dollar value

of care rendered, based on the current

dental terminology codes built into the

database. Each dental procedure is assigned

a weighted value, with a value of 1.00

being equivalent to 100 dollars. This allows

commanders to see the relative dollar value

of services rendered with each workload

rollup (Figure 5).

CHALLENGES OF IN-THEATER DIGITAL

DENTAL RADIOGRAPHY

The ability for dental providers to view,

use, retrieve, and transmit radiographic

images for clinical practice is understood as the

standard of care when evaluating and examining

patients. Department of Defense Instruction 6490.03 2

states:

To the extent feasible, deployment health data will be

collected and maintained in DoD-approved automated

health information management systems. Information

shall be shared as broadly as possible (except where

limited by law, policy, or security classification), and

any data produced as a result of the assigned

responsibilities shall be visible, accessible, and

understandable to the rest of the Department as

appropriate....

During the Task Force’s initial assessment of our

dental clinical informatics infrastructure, the inability

to upload and store digital dental radiographs to the

Corporate Dental System (CDS) for review through

CDA emerged as one of the primary concerns for

providers. As the Iraq theater has matured, many

Soldiers have served multiple deployments, and have

had extensive dental care in-theater. All dental

radiographic images had previously been stored on the

local hard drives of imaging systems used at the

individual clinics. As each unit or clinic team

transitioned in and out of theater, the images were

carried home on unit equipment, or remained stored on

media residing in the clinic. Further, as hard drives

filled and storage space diminished, thousands of

images were deleted.

There are currently no means to send dental

radiographs stored at each theater facility to the

Army’s repository at Fort Sam Houston, Texas.

However, the Digital Enterprise Viewing and

Acquisition Application (DEVAA), the DENCOM

corporate solution in the sustaining base, has the

capability to accomplish this task. TF261 began

necessary coordination with the DENCOM

DEVAA Sustainment Manager to determine the

system and network requirements to make this

initiative a reality.

As TF261 and the Theater Dental Consultant began

aggressive cooperation with the Multinational

Corps-Iraq (MNC-I) information assurance network

engineers to implement DEVAA at their dental

clinics, it became clear that this was a project best

developed in coordination with the sister services,

as the capability to transmit locally archived

imagery to each services’ repository is crucial, as

all components share these medical resources in the

Figure 4. Monthly workload (raw numbers) at Task Force 261 Dental

Facilities, Sep 2007–Jun 2008.

APR

JUN

MAY

MAR

FEB

JAN

DEC

NOV

OCT

SEP

0 5000 10000 15000 20000

Figure 5. Relative value of the workload at Task Force 261

Dental Facilities, Sep 2007–Jun 2008.

$1,600,000

$1,400,000

$1,200,000

$1,000,000

$800,000

$600,000

$400,000

$200,000

$0

$1,800,000

SEP OCT NOV DEC JAN FEB MAR APR MAY JUN

Expanding a Professional Dental Care System:

Experiences of Task Force 261 Multifunctional Medical Battalion During Operation Iraqi Freedom 07-09
October – December 2008 93

THE ARMY MEDICAL DEPARTMENT JOURNAL

Iraq theater of operations. TF261 garnered support

from the Task Force 62 Medical Brigade, and

developed a series of briefings and information papers

for the MNC-I Health Information Systems Officer,

who then worked with the CENTCOM medical chief

information officer to sponsor this initiative. At the

June 2008 Theater Functional Working Group

meeting, the cochairs requested that the integrated

requirements design, joint capabilities integration

development systems staff conduct a capabilities based

analysis (CBA) for digital dental imaging in theater.

This CBA covers an analysis of the functional area,

needs, and recommended solutions for theater digital

imaging.

It is the hope of TF261 that this grassroots effort will

ultimately result in a solution for the current capability

gap that exists in joint service dental digital imaging.

STANDARDIZATION OF DENTAL SUPPLY CHAINS AND

SUPPLY MANAGEMENT

Even before TF261 assumed its mission in Iraq, the

Theater Dental Consultant and dental company

commanders had determined that the class VIII supply

system then in place was far too cumbersome to

facilitate effective supply chain management and stock

levels. It had become standard practice for individual

clinics to order as much of an item as possible, and

stockpile materials for later use. Additionally, many

providers would order specific supplies and durable

equipment to accommodate their particular treatment

peculiarities. When the provider rotated out of the area

or redeployed, a new provider would start the process

again, leaving unused, excess supplies on the shelves

to expire. At the time TF261 began to provide dental

care, over 9,000 individual lines of supply were

available to the dental companies, an amount far too

unwieldy for the medical logistics units to stock at the

theater’s central class VIII warehouse.

These practices had become commonplace and were

counterproductive in effectively establishing logistical

support. The medical logistics system works on the

principle that the more an item is ordered, the more

available it must be for the customer, and it is

stockpiled at theater and strategic logistics depots. An

individual line item must be ordered at least 6 times in

one year for that item to be carried in warehouses as a

routinely stocked item. When an item is not ordered

with that frequency, it is dropped from the routine

supply channels, and the customer must initiate a new

item request, starting a 3-month process of approvals

and verification, a frustration to providers.

Clearly, a more effective and less cumbersome dental

class VIII supply system had to be established. The

standardization of class VIII dental supplies across all

facilities became a top priority for the Task Force. The

first step was to establish standard operating

procedures for the management of dental supply

rooms, with several goals in mind. First, supply

discipline had to be established as a commander’s

priority, to be measured and periodically reviewed.

Second, minimize the total number of dental lines of

supply available, eliminating infrequently used

equipment and standardizing operative and

interventional equipment sets. Third, effectively

manage each facility’s supply room, establish 30-day

benchmark stock levels, turn in existing excess for

redistribution, and identify what shelf level will trigger

a reorder. Fourth, maximize proactive ordering

efficiency by leveraging existing technology and

systems, specifically the Defense Medical Logistics

Standard Support Customer Assistance Module

(DCAM), as a management tool to identify, assess,

track, and facilitate the proper flow of supplies across

the theater. Fifth, maximize use of government assets

and prevent fraud, waste, and abuse. Sixth, provide the

customer with the best logistical support possible

through training, follow-up on identified concerns, and

reliable communication. Finally, establish and

maintain effective managerial control and provide

checks and balances at the company level. This policy

was gradually implemented at TF261 facilities, and

introduced into the entire theater by the Theater Dental

Consultant for implementation across the theater,

including Navy and Air Force dental assets.

The second goal was achieved by the development of a

standardized list of close to 300 class VIII items,

carved out of over 9,000 line items available. This

standardized supply list encompassed all critical areas

of treatment, and included sterilization, hygiene, and

subspecialty requirements. The list was developed and

refined by a committee of dentists from both dental

companies, supply specialists, and medical logisticians

in TF261, as well as the 56th Multifunctional Medical

Battalion Task Force.

The medical logistics specialists at both TF261 dental

companies are engaged and using DCAM to the
94 www.cs.amedd.army.mil/references_publications.aspx

fullest, processing more than 190 requisitions per

month. Clinic representatives across the theater submit

orders as needed via email or telephone to their

company’s medical logistics specialist, who enter the

order into the DCAM system using codes that allow

direct shipment to the customer’s installation. This

employment of centralized management imposes a

high level of command supply discipline, and

decreases the incidence of waste and excess. Early in

2008, the 2 dental companies turned in a cumulative

total of more than $480,000 in excess material, which

was redistributed throughout the theater.

At the time of inception, the central medical class VIII

warehouse had the items requested by the 2 TF261

dental companies available only 7% of the time. This

extremely low demand accommodation rate was

significantly below the Department of the Army’s goal

of 60%.Within 4 months, the accommodation rate had

escalated to an average of 58% for the 2 companies.

Finally, by stocking the smaller list of line items on the

shelf, the order-to-receipt time was decreased from an

original 30-60 days to 6-9 days. Further program

success is evident in an all time high customer demand

satisfaction rate, which has improved from 18% to

over 90% since the program’s inception.

PROVISION OF DENTAL CARE TO THE DETAINEE

POPULATION

TF261’s dental companies were also tasked to

augment the split-based combat support hospital

charged with providing healthcare to detainees housed

at theater internment facilities. The detainee

population presents unique challenges to the dental

officers and technicians assigned to these locations,

and require unique compassion and patience.

US Army doctrine, specifically Special Text 4-02.46,

Medical Support to Detainee Operations,* provides

guidance for the provision of dental care to the

detainee population. In accordance with these policies,

detainees are entitled to operational dental care,

defined as emergency and essential dental care, which

is inclusive of restoration, minor oral surgery,

endodontic, periodontic, and prosthodontic procedures,

as well as prophylaxis.

An initial dental screening examination is performed

on all detainees and made part of the dental record.

However, this screening is typically performed by a

physician extender, not a dental officer. Currently,

TF261’s dental personnel detailed to detainee care are

developing a procedure by which all detainees are

screened by a dentist. Detainees are also periodically

screened, and may be referred for additional dental

care based on consults from other providers or by a

detainee presenting at sick call. Inpatients may also

generate dental consults.

The language barrier is often the most challenging

aspect of providing detainee care. Despite the presence

of translators, the inability to communicate directly

with the patient hinders the history development,

examination, and treatment phases of the encounter.

Both the language barrier and the Army uniform may

be detrimental towards the establishment of patient

confidence. It is our experience that the screening

examination represents the first visit to a dentist for

many of the detainees. As the whole experience is

foreign to them, exceptional patience is required on the

provider’s part, and frequently extraordinary

selflessness and compassion must be displayed to

reassure the patient that the dental care system is there

to provide for them, regardless of the actions leading

to their internment.

Such limited exposure to dental care means that the

detainee population has tremendous need. The

population’s general dental health can best be

characterized as exceptionally poor. Badly infected,

broken teeth, large caries burdens, and unrelenting

periodontal disease are endemic.

The overwhelming need for comprehensive dental care

makes the screening process essential. This process is

hindered by the logistics of detainee movement.

Detainees must be accompanied by guards, and, as a

security precaution, only a fixed number of detainees

are allowed in the entire facility complex at any one

time. Dental instruments must be inaccessible to

detainees, and the detainees cannot have easy access to

exits.

The number of detainees requiring dental care can

easily exceed the allowable number of detainees in the

facility, and this in turn can quickly lead to a large

backlog. As a result, the dental officer must triage

patients appropriately, with the majority of the care

provided being emergent or urgent in nature. On some

Expanding a Professional Dental Care System:

Experiences of Task Force 261 Multifunctional Medical Battalion During Operation Iraqi Freedom 07-09

*Internal Army document, not readily accessible by the

general public.
October – December 2008 95

THE ARMY MEDICAL DEPARTMENT JOURNAL

occasions, detainees will request to attend dental sick

call, only to refuse treatment when they get there—a

trip into the treatment facility is seen as a social event,

a break in the monotony of confined living in the

internment center. These aspects, in combination,

present a challenge to the dental providers in getting

the care to the population with the greatest need.

Functionally, the restrictions of movement, the

tremendous demand for care, and the language

restrictions hinder accomplishment of the goal of

providing essential dental care to the entire detainee

population. There remains a significant mismatch

between supply and demand. As such, detainees who,

under ideal conditions with unlimited resources would

receive more definitive and complex procedures,

typically undergo simple extraction to prevent pain

and suffering, and mitigate the need for complicated

follow-up care. TF261, together with other theater

dental assets, continues to strive to meet the goal of

providing the same level of essential dental care to the

detainee population, inclusive of endodontic,

periodontic, prosthodontic, and prophylactic care, as

that provided to coalition forces. To do so will require

an influx of personnel, equipment, and a supporting

guard force at our detainee care facilities.

Treating all detainees with dignity and respect is a

critical tenet of the overall dental care plan. Detainees

should know that they will receive quality care at our

theater internment facilities, receive the

pharmaceuticals required to relieve pain and treat

infection, and have the right to informed consent, and

to refuse treatment.

PUBLIC HEALTH AND PREVENTIVE MEDICINE INITIATIVE

SUPPORT

Soft drinks, sports drinks, and energy drinks are

offered in abundance in all dining facilities (DFACs)

and post exchanges across theater. These drinks are

free to the Soldiers at the DFACs, and readily

available at every turn. Heat, long hours, the

operational tempo, and numerous other activities

encourage consumption of high quantities of these

cariogenic beverages. The high number of

deployments and infrequent dental care during

deployment are without question merging, resulting in

a significant increase in the caries and treatment-need

backlogs that are occurring at redeployment clinics.

The need for effective preventive measures to counter

the assault has led the Army to seek solutions. The

Office of The Surgeon General, the Army Center for

Health Promotion and Preventive Medicine, and the

Army Dental Command used input from dental units

in both Iraq and Afghanistan to request and receive

approval from the Army G-4 to procure xylitol gum

for mass distribution in theater DFACs.

Xylitol gum use has been proven to be extremely

effective in reducing caries by 30-85%. First put into

Meals, Ready to Eat (MRE) in 2004,3 with a maturing

theater and infrequent MRE use it was decided that the

gum should be available in DFACs. Fielded in summer

2008, the xylitol gum campaign has been supported

and advertised by each TF261 clinic through direct

contact with the local DFACs. The Task Force has

been able to assist in the distribution of promotion

materials, flyers, and posters in the local dental clinics

and dining facilities to increase use. Additionally, the

timing of the gum’s fielding coincided with the first

Medical Brigade Health Fair, supported by TF261

dental assets.

The Medical Brigade’s premier health fair was held in

April at the Al Faw Palace (Multi-National Corps-Iraq

(MNC-I) Headquarters) in Baghdad. The dental booth

was supported by TF261 dental assets, including

dentists, hygienists, and dental assistants, who talked

with key leaders about dental topics and issues in

theater. A whole host of educational, thoughtprovoking materials were presented and discussed.

Free samples of toothbrushes, toothpaste, floss, and

xylitol gum were distributed. Hygiene demonstrations

were provided along with static displays. The dental

section was voted the favorite by participants of the

health fair. From the dental perspective, a key feature

of the second health fair was the importance of support

for the xylitol gum initiative. The significance of

having key leaders working at MNC-I aware of the

xylitol campaign and other ongoing dental care issues

will no doubt pay dividends as this and other

initiatives move forward.

ESTABLISHING A PARTNERSHIP WITH OUR IRAQI

COLLEAGUES

One of the critical missions of TF261 was to work

together with the 62nd Medical Brigade and MNC-I to

assist our Iraqi colleagues, both in the Ministry of

Defense and the Ministry of Health, to develop selfsupporting systems to provide comprehensive

healthcare to the Iraqi populace.
96 www.cs.amedd.army.mil/references_publications.aspx

Expanding a Professional Dental Care System:

Experiences of Task Force 261 Multifunctional Medical Battalion During Operation Iraqi Freedom 07-09

TF261’s staff included Dr Khalid,* a native Iraqi

dentist, trained in the United Kingdom, who, in

conjunction with an appointed master sergeant,

coordinated all of TF261’s partnerships with our Iraqi

counterparts. Early in the deployment, Dr Khalid made

contact with the senior dental officers in the Iraqi

Ground Forces Command (IGFC), the Iraqi Air Force,

and the Ministry of Health. Within 6 weeks of

assuming the mission in-theater, the TF261 conducted

the first in a series of continuing dental education

(CDE) programs at the Medical Brigade Headquarters,

Victory Base Complex in Baghdad with lectures on

forensic odontology and bony pathology of the

craniofacial skeleton. For the remainder of TF261’s

deployment to Iraq, additional CDE events were

presented every 6 to 8 weeks, led by the dental

companies, with events in Baghdad, Tallil, and Balad.

Each event experienced increased participation from

our Iraqi colleagues. Eventually, CDE events were

planned by the Ministries, with lectures developed and

given by Iraqi dental officers, and included other

Coalition Forces, including Romanian, Polish, Australian, and British dental officers and specialists.

The professional interaction between members of the

Task Force and the Iraqi Ground Forces Command

were recognized by the IGFC Command Surgeon,

Brigadier General (Dr) Jowad Madhi, as the epitome

of cooperation between Coalition and Iraqi forces.

Brigadier General Madhi and Dr Khalid later worked

together to develop numerous other programs within

the larger Task Force, including combat lifesaver

training, development of a ground ambulance and

emergency medical response system, and

standardization of battalion-level aid stations, all using

the interpersonal networks first established by the

dental leadership.

CONCLUSION

Through the coordinated and synchronized effort of a

variety of subject matter experts at company and

battalion level, TF261 Multifunctional Medical

Battalion was successful in improving the delivery of

dental care across the Iraq theater of operations, using

multiple strategies to systemize and standardize

personnel utilization, equipment supply and storage,

the evacuation chain, information technology

solutions, and preventive medicine efforts. Care was

also optimized for the detainee population, and our

Iraqi colleagues became part of the combined dental

care effort throughout Iraq. Consolidating dental assets

under one headquarters allowed effective and seamless

command and control of all efforts, allowed

development of a true dental care system, and ensured

mission completion.

REFERENCES

1. Medical Corps Professional Development Guide. Fort

Sam Houston, TX: US Army Medical Department

Center and School; March 2002:27.

2. Department of Defense Instruction 6490.03:

Deployment Health. Washington, DC: US Dept of

Defense; August 11, 2006:3.

3. Scott AE Jr. Xylitol chewing gum: a recommended

addition to the MRE package. Army Med Dept J.

January-March 2006:56-58.

AUTHORS

When this article was written, the coauthors were

assigned as follows:

LTC(P) Christopher was Commander, Task Force 261

Multifunctional Medical Battalion (Fort Bragg, NC)

deployed to Joint Base Balad, Iraq.

LTC Patterson was (and is) Commander, 673rd Medical

Company (Dental Services) (Fort Lewis, WA) deployed

to Joint Base Balad, Iraq.

SGM Smith was Senior Clinical Operations NCO, Task

Force 261 Multifunctional Medical Battalion (Fort

Bragg, NC) deployed to Joint Base Balad, Iraq.

CW4 Smith was Chief, Medical Logistics, Task Force

261 Multifunctional Medical Battalion (Fort Bragg,

NC) deployed to Joint Base Balad, Iraq.

CPT Cobb was assigned to the 464th Medical Company

(Dental Services) (Landstuhl, Germany) and was

deployed as Officer-in-Charge, Theater Internment

Facility Dental Clinic, Camp Bucca, Iraq.

CPT Pollard was a Battle Captain, Task Force 261

Multifunctional Medical Battalion (Fort Bragg, NC)

deployed to Joint Base Balad, Iraq. *Name changed for security reasons.
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