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i 

55–173 2010

[H.A.S.C. No. 111–109] 

THE NEW WALTER REED: ARE WE ON 

THE RIGHT TRACK? 

JOINT HEARING 

BEFORE THE

READINESS SUBCOMMITTEE 

MEETING JOINTLY WITH

MILITARY PERSONNEL SUBCOMMITTEE 

OF THE

COMMITTEE ON ARMED SERVICES 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED ELEVENTH CONGRESS 

FIRST SESSION 

HEARING HELD 

DECEMBER 2, 2009 
(II) 

READINESS SUBCOMMITTEE 

SOLOMON P. ORTIZ, Texas, Chairman 

GENE TAYLOR, Mississippi 

NEIL ABERCROMBIE, Hawaii 

SILVESTRE REYES, Texas 

JIM MARSHALL, Georgia 

MADELEINE Z. BORDALLO, Guam 

HANK JOHNSON, Georgia 

CAROL SHEA-PORTER, New Hampshire 

JOE COURTNEY, Connecticut 

DAVID LOEBSACK, Iowa 

GABRIELLE GIFFORDS, Arizona 

GLENN NYE, Virginia 

LARRY KISSELL, North Carolina 

MARTIN HEINRICH, New Mexico 

FRANK M. KRATOVIL, JR., Maryland 

BOBBY BRIGHT, Alabama 

DAN BOREN, Oklahoma 

J. RANDY FORBES, Virginia 

ROB BISHOP, Utah 

MIKE ROGERS, Alabama 

TRENT FRANKS, Arizona 

BILL SHUSTER, Pennsylvania 

K. MICHAEL CONAWAY, Texas 

DOUG LAMBORN, Colorado 

ROB WITTMAN, Virginia 

MARY FALLIN, Oklahoma 

JOHN C. FLEMING, Louisiana 

FRANK A. LOBIONDO, New Jersey 

MICHAEL TURNER, Ohio 

DAVE SIENICKI, Professional Staff Member 

THOMAS HAWLEY, Professional Staff Member 

MEGAN PUTNAM, Staff Assistant 

MILITARY PERSONNEL SUBCOMMITTEE 

SUSAN A. DAVIS, California, Chairwoman 

VIC SNYDER, Arkansas 

LORETTA SANCHEZ, California 

MADELEINE Z. BORDALLO, Guam 

PATRICK J. MURPHY, Pennsylvania 

HANK JOHNSON, Georgia 

CAROL SHEA-PORTER, New Hampshire 

DAVID LOEBSACK, Iowa 

NIKI TSONGAS, Massachusetts 

JOE WILSON, South Carolina 

WALTER B. JONES, North Carolina 

JOHN KLINE, Minnesota 

THOMAS J. ROONEY, Florida 

MARY FALLIN, Oklahoma 

JOHN C. FLEMING, Louisiana 

DAVE KILDEE, Professional Staff Member 

JEANETTE JAMES, Professional Staff Member 
(III) 

C O N T E N T S 

CHRONOLOGICAL LIST OF HEARINGS 

2009 

Page 

HEARING: 

Wednesday, December 2, 2009, The New Walter Reed: Are We on the Right 

Track? .................................................................................................................... 1 

APPENDIX: 

Wednesday, December 2, 2009 ............................................................................... 29 

WEDNESDAY, DECEMBER 2, 2009 

THE NEW WALTER REED: ARE WE ON THE RIGHT TRACK? 

STATEMENTS PRESENTED BY MEMBERS OF CONGRESS 

Davis, Hon. Susan A., a Representative from California, Chairwoman, Military Personnel Subcommittee ............................................................................. 2 

Ortiz, Hon. Solomon P., a Representative from Texas, Chairman, Readiness 

Subcommittee ....................................................................................................... 1 

Wilson, Hon. Joe, a Representative from South Carolina, Ranking Member, 

Military Personnel Subcommittee ...................................................................... 3 

WITNESSES 

Kizer, Dr. Kenneth W., Chairman, Defense Health Board, National Capital 

Region Base Realignment and Closure Health Systems Advisory Subcommittee .............................................................................................................. 10 

Mateczun, Vice Adm. John M., USN, Commander, Joint Task Force, National 

Capital Region Medical ........................................................................................ 8 

Middleton, Allen W., Acting Principal Deputy Assistant Secretary of Defense, 

Health Affairs, U.S. Department of Defense ..................................................... 5 

Robyn, Dr. Dorothy, Deputy Under Secretary of Defense, Installations and 

Environment, U.S. Department of Defense ....................................................... 6 

APPENDIX 

PREPARED STATEMENTS: 

Davis, Hon. Susan A. ....................................................................................... 35 

Forbes, Hon. J. Randy, a Representative from Virginia, Ranking Member, 

Readiness Subcommittee .............................................................................. 37 

Kizer, Dr. Kenneth W. ..................................................................................... 63 

Mateczun, Vice Adm. John M. ......................................................................... 58 

Middleton, Allen W. .......................................................................................... 42 

Ortiz, Hon. Solomon P. ..................................................................................... 33 

Robyn, Dr. Dorothy ........................................................................................... 48 

Wilson, Hon. Joe ............................................................................................... 40 

DOCUMENTS SUBMITTED FOR THE RECORD: 

Letter from Representative Chris Van Hollen, dated December 2, 2009 .... 85 
Page

IV 

WITNESS RESPONSES TO QUESTIONS ASKED DURING THE HEARING: 

Mr. Taylor ......................................................................................................... 89 

QUESTIONS SUBMITTED BY MEMBERS POST HEARING: 

Ms. Bordallo ...................................................................................................... 99 

Mr. Loebsack ..................................................................................................... 101 

Mr. Ortiz ........................................................................................................... 93 
(1) 

THE NEW WALTER REED: ARE WE ON THE RIGHT 

TRACK? 

HOUSE OF REPRESENTATIVES, COMMITTEE ON ARMED

SERVICES, READINESS SUBCOMMITTEE, MEETING JOINT- LY WITH MILITARY PERSONNEL SUBCOMMITTEE, Washington, DC, Wednesday, December 2, 2009. 

The subcommittees met, pursuant to call, at 10:02 a.m., in room 

HVC–210, Capitol Visitor Center, Hon. Solomon Ortiz (chairman of 

the Readiness Subcommittee) presiding. 

OPENING STATEMENT OF HON. SOLOMON P. ORTIZ, A REPRESENTATIVE FROM TEXAS, CHAIRMAN, READINESS SUBCOMMITTEE 

Mr. ORTIZ. The subcommittee will come to order. Today the 

Readiness Subcommittee and the Military Personnel Subcommittee 

meet in a joint session to discuss the Base Realignment and Closure (BRAC) realignment of Walter Reed and whether the final 

plans are sufficient to meet a world-class standard. 

The realignment of the Walter Reed National Military Medical 

Center was one of the major decisions included in the 2005 Base 

Realignment and Closure process. Its overarching reach to close the 

Walter Reed Army Medical Center and relocate those activities to 

Fort Belvoir and Bethesda have not been without controversy or 

political carnage. 

Because of the substandard conditions found at Walter Reed, the 

former Army Surgeon General and former Secretary of the Army 

were relieved of duty. At the heart of this controversy is the fundamental discussion as to what level of care should our wounded warriors receive. In my estimation this simple question deserves a very 

simple answer: the best. 

What most intrigues me in this decision process is that I am not 

convinced that the Department of Defense (DOD) shares in this 

simple assessment. The Deputy Secretary of Defense indicated that 

‘‘development of a world-class medical facility is not a destination, 

but rather a journey of continuous improvement.’’ 

This seems to indicate that the Department cannot obtain a 

world-class medical facility as proposed in the BRAC process in the 

timeline provided. So where does this journey contemplated by the 

Department take us? It would provide us a medical facility capable 

of providing medical care to the military concurrent with the BRAC 

timeline, but it does not deliver the world-class expectation envisioned by the BRAC Commission or the Department. 

The Defense Health Board (DHB) recently stated that the current design would not attain world-class. I find this unacceptable. 

This inability to obtain a world-class medical center seems to hide 
2 

the fact that 4 years have passed since the BRAC Commission reported its findings, and yet we still have a disorganized medical 

command, a disjointed funding authority, and an inconsistent construction design in support of a $2.5 billion effort. 

I have visited the Bethesda campus several times since the 

BRAC Commission finalized its deliberations. While I am convinced 

that the new construction is on the right path, I think that the 

overall requirements to provide the best care to our wounded warriors needs to be reassessed, and the full scope of work, including 

related repair work, needs to be reviewed. 

I think the input provided by the Defense Health Board provides 

an excellent roadmap on issues to address. In the end I hope that 

this theory provides answers to the questions about what our 

wounded warriors deserve. I hope that at the conclusion of our deliberations, we will be united in saying that they do deserve the 

best. 

The chair now recognizes the distinguished chairwoman from 

California, Mrs. Davis, for any remarks you would like to make. 

[The prepared statement of Mr. Ortiz can be found in the Appendix on page 33.] 

Chairman Davis. 

STATEMENT OF HON. SUSAN A. DAVIS, A REPRESENTATIVE 

FROM CALIFORNIA, CHAIRWOMAN, MILITARY PERSONNEL 

SUBCOMMITTEE 

Mrs. DAVIS. Thank you, Chairman Ortiz. 

Well, here we are again. We are having a hearing about Walter 

Reed. And history, I think, to all of us is important. In 2004 the 

Military Personnel Subcommittee raised a number of concerns 

about how we were caring for our wounded warriors. The Department of Defense witnesses told us to trust them and that they 

would make sure that wounded warriors and their families were 

properly cared for. And our reward for that trust were the revelations of almost three years ago at Walter Reed. 

Ladies and gentlemen, any response of ‘‘trust us’’ simply doesn’t 

suffice. While the name ‘‘Walter Reed’’ is the same, I need to make 

an important distinction. What was revealed at Walter Reed almost 

three years ago was shameful. Wounded warriors and their families were allowed to fall through the cracks. They were often left 

to fend for themselves for administrative tasks such as pay and 

housing. 

However, there is one thing that was never questioned during 

the scandal that had to do with the quality of medical care provided at Walter Reed. It was and remains excellent. One of our key 

concerns is that the current plan and the organizational structure 

are simply inadequate and that patient care, wounded warrior 

care, will suffer as a result. Chairman Ortiz said it perfectly. There 

is only one acceptable standard of care for our wounded warriors, 

and that is the best. 

We have had concerns about the plans for the Walter Reed National Military Medical Center at Bethesda from the beginning. In 

hearings and meetings we have had Vice Admiral Mateczun tell us 

in effect not to worry, that everything is on track, but we have yet 
3 

to be convinced that that is true. And in fact, we have yet to be 

convinced that the Department takes our concerns seriously. 

In last year’s National Defense Authorization Act (NDAA), we required that an independent design review be done to validate the 

current plan, and that review was completed this last summer. And 

its results are simply unsettling. Among the troubling descriptions 

of the current plan are that it would not result in a world-class facility, that it would not meet joint commission accreditation standards and that it was ambiguous about the vision, the goals and expectations of the new century. 

As disconcerting as the independent design review’s findings 

were, however, they pale in comparison to the Department’s response to those findings. And for example—and this was mentioned 

already—‘‘development of a world-class medical facility is not a 

destination, but rather a journey of continuous improvement.’’ 

World-class is most decidedly a destination, one that Congress 

expects its new facility to arrive at before the center opens its 

doors. The definition of world-class will no doubt evolve over time, 

but as the independent design review has indicated, the current 

plan does not meet today’s definition, and that is unacceptable. 

As Chairman Ortiz mentioned, four years have passed since the 

BRAC recommendations were reported. Two years have passed 

since the Joint Task Force Capital Medicine was established. Still 

we do not know exactly who has overall responsibility for this 

project. Key decisions about funding, staffing and the chain of command have yet to be made, and we do not feel that the plan meets 

all of the requirements spelled out in law and the BRAC recommendations. 

And we have an independent design review that is highly critical 

of the current plan and organizational structure. Since this is our 

first hearing since the findings of the independent design review 

were released, I would like to hear how the Department plans to 

address the shortcomings identified. 

I also look forward to hearing directly from the chair of the independent design review, Dr. Ken Kizer, and hope that we will have 

a productive discussion about this incredibly important topic. When 

the hearing ends today, it is my desire that we will leave with a 

better understanding of what needs to be done to ensure that the 

new Walter Reed National Medical Center at Bethesda becomes everything that it is supposed to be. 

Thank you, Mr. Chairman. 

[The prepared statement of Mrs. Davis can be found in the Appendix on page 35.] 

Mr. ORTIZ. The chair now recognizes the distinguished gentleman from South Carolina, Mr. Wilson, for any remarks that he 

would like to make. 

STATEMENT OF HON. JOE WILSON, A REPRESENTATIVE FROM 

SOUTH CAROLINA, RANKING MEMBER, MILITARY PERSONNEL SUBCOMMITTEE 

Mr. WILSON. Thank you, Mr. Chairman. And thank you and 

Chairwoman Davis. 

As I begin, I would like to move unanimous consent to introduce 

a statement from Ranking Member Randy Forbes of the Sub-
4 

committee on Readiness. Congressman Forbes is currently at a 

markup of his Judiciary Committee. 

Mr. ORTIZ. Without objection, so ordered. 

[The prepared statement of Mr. Forbes can be found in the Appendix on page 37.] 

Mr. WILSON. And I appreciate joining our good friends on the 

Readiness Subcommittee today led by Chairman Solomon Ortiz and 

Ranking Member Randy Forbes for our hearing on the progress of 

the Walter Reed National Military Medical Center. 

I welcome the distinguished members of our witness panel. I believe that there is nothing more important than providing the outstanding members of our military, their families and our retirees 

world-class health care delivered in world-class medical facilities. 

There is no question in my mind they deserve nothing less. 

Our family has experienced a quality of service with two 

grandsons born at Bethesda Naval Medical Center and a granddaughter born at Portsmouth Naval Hospital. 

The Department of Defense has assured us on several occasions 

that merging Walter Reed Army Medical Center and the National 

Naval Medical Center at Bethesda, two icons of military medicine, 

would result in a single world-class medical center that would provide improved access to enhanced medical care for our troops and 

their families and veterans in the National Capital Region (NCR). 

Now, I understand that the National Capital Region Base Realignment and Closure Health Systems Advisory Subcommittee of 

the Defense Health Board has issued a report that calls into question whether the Department’s plan to merge these two facilities 

will result in a world-class facility. Further, I am aware that the 

Defense Health Board has expressed concerns regarding the Department of Defense’s Corrective Action Plan published in response 

to the findings and recommendations of the board. It appears that 

there is still doubt about the new facility being world-class. 

Before we hear testimony from our witnesses this morning, let 

me be very clear that the new Walter Reed National Military Medical Center opening as a world-class medical facility is not negotiable. We cannot accept anything less. 

With that, I would like to thank our witnesses for participating 

today. I look forward to your testimony. 

[The prepared statement of Mr. Wilson can be found in the Appendix on page 40.] 

Mr. ORTIZ. Thank you, Mr. Wilson. 

Today we have four distinguished witnesses. Representing the 

Department of Defense, we have Mr. Al Middleton, Acting Principal Deputy Assistant Secretary of Defense for Health Affairs; Dr. 

Dorothy Robyn, Deputy Under Secretary of Defense for Installations and Environment; Vice Admiral John Mateczun, Commander, 

Joint Task Force National Capital Region Medical; and Dr. Ken 

Kizer, Chairman, Defense Health Board, National Capital Region 

Base Realignment and Closure Health System Advisory Subcommittee. 

And without the objections, the prepared statement that you may 

have will be accepted for the record. And hearing no objection, so 

ordered. 
5 

Mr. Middleton, welcome. And you may proceed with your opening 

statement whenever you are ready. Good to have you here. 

And we are very honored to have an outstanding group of witnesses among us this morning. Thank you. 

Mr. Middleton. 

STATEMENT OF ALLEN W. MIDDLETON, ACTING PRINCIPAL 

DEPUTY ASSISTANT SECRETARY OF DEFENSE, HEALTH AFFAIRS, U.S. DEPARTMENT OF DEFENSE 

Mr. MIDDLETON. Thank you, sir. Mr. Chairman, Madam Chairwoman and distinguished members of the subcommittees, good 

morning. I am Al Middleton, the Acting Principal Deputy Assistant 

Secretary of Defense for Health Affairs. I am pleased to be here 

today to discuss progress in the implementation of the 2005 clinical 

BRAC recommendations for the National Capital Region. 

As you know, the BRAC Commission report to the President released in November of 2005 directed the Department to close Walter Reed Army Medical Center in Washington and to realign the 

facility with the National Naval Medical Center in Bethesda, creating the Walter Reed National Military Medical Center, and to 

build a new community hospital at Fort Belvoir, Virginia, by the 

BRAC deadline of September 15th, 2011. 

The Military Health System must fulfill a sacred responsibility 

to care for our Nation’s service men and women, their families and 

those who have served before us. I am grateful for the many dedicated men and women who have answered the call to duty, and we 

are working to ensure that we create a health care facility that is 

well positioned to meet our service men and women, veterans and 

wounded warriors in the National Capital Region and throughout 

the country. 

As principal advisor to the Secretary of Defense for the Department’s health care program, the Office of the Assistant Secretary 

of Defense for Health Affairs maintains oversight of the clinical 

BRAC actions, including the transformation of the National Capital 

Region currently under way. I am pleased to report that we are on 

track to implement the BRAC recommendations by the statutory 

deadline of 15 September 2011. 

However, we must acknowledge that completion of construction 

activities represents only part of the story. We sincerely appreciate 

the efforts of the Defense Health Board Subcommittee and acknowledge that their findings and recommendations can only help 

us in our quest to be world-class in the National Capital Region 

and throughout the Military Health System. 

Addressing the complexity and resolving the challenges of BRAC 

transformation in the National Capital Region clearly necessitates 

the knowledge and the insight that the members of the health system advisors of the subcommittee possess. 

Executing BRAC and creating an extraordinary health care delivery system in the National Capital Region in a relatively short 

period of time is certainly one of the most difficult undertakings in 

the history of the Military Health System. The Joint Task Force 

National Capital Region Medical (JTF CAPMED) was created to 

lead this clinical transformation in the National Capital Region. 
6 

Despite the challenges and complexities inherent in this task, we 

should not lose sight of the great progress that has been made to 

date. This single act of consolidating two medical centers into one, 

constructing a new robust community hospital in proximity to the 

majority of beneficiaries, is a major accomplishment. 

The creation of the JTF CAPMED as the overarching market 

manager has been important to this effort, and I am confident that 

we are headed in the right direction and appreciate the Defense 

Health Board Subcommittee’s detailed roadmap to achieve a worldclass delivery system built upon world-class facilities at Bethesda 

and Fort Belvoir. 

I look forward to working with the JTF CAPMED in the future 

and the military services and other stakeholders to implement the 

subcommittee’s vision. Although our primary focus has been completing the BRAC recommendations before the deadline, we understand that creating outstanding health care facilities as a longterm commitment to improve beyond BRAC, and additional investments are required to achieve that end state. 

We are prepared to support the JTF CAPMED and the military 

services in identifying additional non-BRAC requirements and to 

ensure that they are considered in the future budget requests. We 

continue to work to provide every man and woman in uniform with 

the best health care possible, and we appreciate this committee and 

the committee’s continued support as we strive to excel in everything that we do. 

Mr. Chairman, Madam Chairwoman and distinguished members 

of the subcommittee, I would like to thank you for the opportunity 

to address you today. I will be pleased to respond to any questions 

you may have in the ongoing dialogue that we will have to move 

us all closer to the jointly held goal of a world-class health system. 

Thank you. 

[The prepared statement of Mr. Middleton can be found in the 

Appendix on page 42.] 

Mr. ORTIZ. Dr. Robyn, you might proceed whenever you are 

ready. You can get close to the mic. 

STATEMENT OF DR. DOROTHY ROBYN, DEPUTY UNDER SECRETARY OF DEFENSE, INSTALLATIONS AND ENVIRONMENT, 

U.S. DEPARTMENT OF DEFENSE 

Dr. ROBYN. Oh, thank you. It helps to turn the mic on. 

Chairman Ortiz, Chairwoman Davis, Congressman Wilson, Delegate Bordallo, distinguished members of these two subcommittees, 

I am honored to appear before you to discuss the question of the 

new Walter Reed—are we on the right track? 

I am the Deputy Under Secretary of Defense for Installations 

and Environment (I&E). I have been in that position since July. 

My office is a major advocate within the Department of Defense for 

getting military facilities the budget they need in order to do their 

job effectively, mainly to support mission occupants. My office also 

oversees the BRAC process from start to finish. 

The BRAC has, among other things, been a significant engine for 

re-capitalization of our enduring military facilities. Hospitals and 

other medical facilities in particular have received a significant 
7 

amount of funding as part of the latest BRAC round, the 2005 

BRAC round. 

To answer the question posed by this hearing—are we on the 

right track with respect to the new Walter Reed—it is helpful to 

recall how we got to this point. Specifically, several concerns about 

the state of medical care in the National Capital Region drove the 

2005 BRAC decision. 

First of all, there was a growing mismatch between the location 

of the eligible beneficiaries with active duty families concentrated 

in the southern part of the region and the location of the major 

medical facilities to the north. Second, Bethesda and Walter Reed 

had significant excess inpatient capacity. 

And third, Walter Reed’s infrastructure was deteriorating due to 

the combination of heavy use and chronic under-investment. It 

would have, by our estimate, cost hundreds of millions of dollars— 

between $500 million to $700 million—to renovate or replace the 

existing Walter Reed facility and would have taken between 6 and 

15 years to accomplish that process. 

By closing Walter Reed, and expanding and improving facilities 

at Bethesda and Fort Belvoir, the BRAC decision allows the Department to more effectively channel its resources. And in the Department’s view, this reallocation of resources, combined with the 

shift to a joint service delivery approach in the National Capital 

Region, promises to transform medical care delivery in this area. 

With less than two years to go, we are on schedule, and we are 

on track to deliver the promised benefits by the BRAC deadline of 

September 2011. The Defense Health Board Subcommittee provided an excellent roadmap, to use your words, Chairman Ortiz, for 

that transition, but they have in recent weeks suggested that the 

Department should possibly delay the BRAC construction process, 

pending further planning of additional improvements—improvements that are outside the scope of BRAC that the subcommittee 

believes are necessary to make the new Walter Reed world-class. 

We fully agree with the need for additional improvements, but 

we think it is not necessary to halt the BRAC construction process. 

And we think to do so would jeopardize their benefits that this endeavor promises. And let me cite three reasons why I believe that. 

Most important, without the discipline of the BRAC process, we 

could not have overcome the inertia and the impediments to change 

that created the problems that are described in the first place. But 

we need to keep the discipline of the BRAC process in place in 

order to solve that problem. 

Second, we need to continue to operate the existing Bethesda 

Naval Hospitals even as we renovate and expand this facility. It is 

a little bit like building a new Woodrow Wilson Bridge while continuing to operate the existing bridge. We have to do both things 

at once. So there is a real limit to the amount of construction and 

activity that we can undertake there at one time. 

And third, by and large the kinds of additional improvements 

being discussed to make the new facility world-class can be addressed separately and subsequently. Thus, continuation of the 

BRAC construction process will not result in wasted effort. By contrast, if we suspend the BRAC construction process, we will sub-
8 

stantially delay and possibly jeopardize the benefits that this promises. 

So in conclusion, it is a large, complex undertaking, as you have 

heard, but it represents a reasonable and balanced approach to 

combining the functions of the old Walter Reed with the new. And 

it will result in a delivery system that is superior to what we have 

now, and one on which we can continue to build in the future. My 

message is simple. This undertaking would not have been possible 

without BRAC, without discipline of BRAC. If we relax that discipline, we jeopardize those benefits with little, if any, offsetting 

benefit. 

So in conclusion, my simple message is keep the pressure on. Let 

us stay the course. Thank you very much. 

[The prepared statement of Dr. Robyn can be found in the Appendix on page 48.] 

Mr. ORTIZ. Thank you. 

Vice Admiral Mateczun, whenever you are ready with your statement, you can proceed, sir. 

STATEMENT OF VICE ADM. JOHN M. MATECZUN, USN, COMMANDER, JOINT TASK FORCE, NATIONAL CAPITAL REGION 

MEDICAL 

Admiral MATECZUN. Thank you, Chairman Ortiz, Chairwoman 

Davis, Ranking Member Forbes, committee members. Thank you 

for the opportunity to share with you the progress of the Department in realigning the medical assets of the National Capital Region to create the Military Health System’s first fully integrated, 

jointly operated and staffed health care delivery system. 

This transformation will allow the DOD and the military services 

to capitalize on their collective strengths, maintain high levels of 

readiness, provide world-class health care to our Armed Forces and 

their families, both active and retired. 

I want to take the opportunity to thank the Military Personnel 

and Readiness Subcommittees for their continuous support and 

oversight. Your visit to Bethesda back in March was greatly appreciated, and the meetings that we have had since then have certainly provided the guidance and direction that we needed. I would 

like to commend Dr. Kizer and the Defense Health Board Subcommittee on the NCR for their work in defining world-class, and 

then their recommended steps to achieve that world-class. 

The attributes that they talk about in the world-class institutions 

do not all exist in any one place that I know of in the world. They 

are goals that we must strive to achieve, and there are many of 

those attributes of world-class that exist today at Walter Reed—not 

just world-class, but best-in-class, best-in-the-world. 

If you want amputee and prosthetics care, Walter Reed is the 

place that you want to be today. If you have an open traumatic 

brain injury, then Bethesda is the place that you want to be. Those 

are examples of some of the quality of care that is going to go on 

when we combine these two centers. There will be no diminishment 

of any of those attributes of world-class care that already exist 

today at Walter Reed or Bethesda. 

Our goal now is to strive towards the rest of the attributes that 

Dr. Kizer’s committee has so well put together. Now, Dr. Kizer’s 
9 

getting ready to publish and make these guidelines available. They 

have been enacted into statute in the Fiscal Year (FY) 2010 NDAA 

and provide a new guideline for us. So as part of that evolution, 

as they have gone from BRAC to the post-February 2007 commitment to our wounded warriors, we now have a new standard just 

established within the last two months. 

We have had the Defense Health Board report to be able to work 

on. We are not disagreeing with any of the recommendations that 

the Defense Health Board has made. We are committed to achieving world-class standards at the new Walter Reed National Military Medical Center and the Fort Belvoir Community Hospital. 

The Capital Region Medical BRAC projects and the journey to 

world-class are inextricably linked. The DHB required a master 

plan to be developed. And in fact, in the Fiscal Year 2010 NDAA, 

there is a requirement that the Department do that. This comprehensive master plan will synchronize the current efforts that 

are going on, both with the BRAC and then those other efforts that 

will be needed to achieve as many as possible of the attributes of 

world-class that the panel so well laid out. 

That master plan will satisfy the requirements of 2714 of the 

Fiscal Year 2010 NDAA, which is required by the 31st of March. 

I would say that the Department is on schedule to meet the BRAC 

deadline. In our former briefs to you, I told you about our progress 

towards the initial outfitting and transition contract. That contract 

was awarded last week, and we have a highly competent group of 

general and subcontractors that will be performing that activity. 

That was one of the last contractual pieces that we will have to 

meet in terms of the construction and outfitting to be able to 

achieve the BRAC deadline. And there are no data points, and I 

will reiterate again there are no data points that I know, that say 

we would be unable to meet the BRAC deadline. 

Casualty care is my number one priority. We are committed not 

just to world-class care, but to the best care that can be provided 

anytime, anyplace, to the wounded that are coming to us from the 

theaters in Iraq and Afghanistan. And we will suffer no diminishment of care or patient safety during this transition to be able to 

achieve the goals that the Department has. 

Chairman Ortiz, Chairwoman Davis, Ranking Member Wilson, 

committee members, thank you again for your interest and support 

in the transformation. We are committed to providing this health 

care not just to our wounded, but to all of our beneficiaries. Your 

support and oversight have made immeasurable contributions to 

this process. The Department will continue to work with the military services to make this integrated regional health care system 

the first in the country within the Military Health System. 

We look forward to a fruitful and collaborative partnership with 

this committee. Thank you for the opportunity to be with you 

today. 

[The prepared statement of Admiral Mateczun can be found in 

the Appendix on page 58.] 

Mr. ORTIZ. Thank you, Admiral. 

Dr. Kizer, whenever you are ready, sir. 
10 

STATEMENT OF DR. KENNETH W. KIZER, CHAIRMAN, DEFENSE 

HEALTH BOARD, NATIONAL CAPITAL REGION BASE REALIGNMENT AND CLOSURE HEALTH SYSTEMS ADVISORY 

SUBCOMMITTEE 

Dr. KIZER. Good morning, Chairman Ortiz, Chairwoman Davis, 

Ranking Members Forbes and Wilson, distinguished members. 

Thank you for inviting me to make some comments this morning. 

Everyone here knows the history of how we got here this morning, 

so I will not take any time to make comments in that regard. And 

I thank you for including my written testimony in the record. 

I would like to use my allocated time for comments to make two 

main points that will augment my written testimony. 

First, in your consideration about the evolution of Walter Reed 

to become a world-class medical facility, it is important to keep in 

mind that the committee’s work to date has reviewed only the design plans for the visible architecture of the new Walter Reed National Military Medical Center. That is, we have reviewed only the 

design plans for the physical structure of the facility. It is not yet 

possible to review the invisible architecture of the facility. 

By ‘‘invisible architecture’’ I mean the values and the culture of 

the organization, the attitude or morale of the staff, and other less 

tangible design features of the new facility that will in the long run 

be the most important determinant of whether the new Walter 

Reed performs at a level of excellence that would make it worldclass. 

No matter how new or modern or sophisticated is the visible architecture of the facility, the physical structure alone can never 

make a world-class medical facility. More importantly, however, it 

can prevent the facility from becoming world-class. 

The second point I would like to highlight is that, as has been 

commented on by others, that there does not appear to be any significant disagreement about the deficiencies that have been identified in the plan, nor about ultimately what needs to be done to correct them. The Department seems to agree with the subcommittee’s 

findings—the subcommittee that I represent—and acknowledges 

that the current design plans will not produce a world-class medical facility. 

We applaud their candor in this regard, and we recognize that 

the road getting us to this point has had some hills and curves, to 

use that metaphor. We also applaud the good work and the diligent 

efforts of many individuals to make Walter Reed the world-class facility. 

And while the Department has stated that it is committed to 

achieving world-class status, and we commend this expressed commitment, its response to the committee’s report does not provide 

sufficient detail or specificity to determine whether the planned 

corrective actions are on the right track or will be achieved in a 

reasonable time or at a reasonable cost, in my committee’s judgment. 

I believe that the committee would feel more confident that 

things were on the right track if the statements about commitment 

were accompanied by detailed plans for fixing the problems, if 

those plans had clear milestones and deadlines, and if it were clear 

that someone had the necessary authority and control to execute 
11 

those plans. Until these latter things are in hand, I do not see how 

we as an independent panel would feel confident that we are in 

fact on the right track. 

I should perhaps clarify a bit a point made by one of the other 

witnesses, and that is that the Defense Health Board has not recommended that construction be delayed or suspended. We do believe that there is a limited time opportunity and a diminishing 

window of opportunity to fix some of the identified problems at a 

lower cost and with less disruption and inconvenience to patients 

and the staff, if these problems are fixed sooner rather than later. 

In closing, let me say that I believe there are few issues more 

important to readiness in military personnel than our troops knowing that the best possible health care will be there for them when 

they are harmed in the defense of our Nation. I am reminded of 

this by frequent health care related questions from my daughter, 

who is currently on active duty as a recruiter with the Marine 

Corps. And her recruits often ask her about the health care that 

they will receive if they enlist or should they be injured on duty. 

And she not infrequently picks up the phone and says, ‘‘Dad, what 

about this?’’ 

Frankly, when we send our children into harm’s way, we have 

a responsibility to ensure that they have the peace of mind of 

knowing that they will have world-class medical care, should they 

need it. And anything less than that is simply not good enough. 

Representing the committee that has produced the report that 

you are familiar with, we would urge that whatever action is necessary be taken to ensure that the new Walter Reed National Military Medical Center, and indeed our entire military health care 

system everywhere, is world-class. Thank you. I would be pleased 

to answer any questions that you may have. 

[The prepared statement of Dr. Kizer can be found in the Appendix on page 63.] 

Mr. ORTIZ. Thank you, Doctor. 

Mr. Middleton, I have a question for you. I have read the Joint 

Task Force’s issued statement that they are committed to establishing a world-class medical center at the hub of the Nation’s premier regional health care system. Is the Department committed to 

obtaining this vision? I mean I think they are, but I would like to 

hear from you. When do you expect to obtain this capability, and 

at what additional cost? Maybe you can enlighten the committee on 

my question. 

Mr. MIDDLETON. Thank you. Thank you for that question, sir. 

I think directly the answer to your question is yes. There has 

been in my view no evidence that we are not committed to that vision, that every effort that was made into BRAC—and I think all 

of you are familiar with the additional resources that were added 

to enhance and to accelerate the BRAC construction in the National Capital area, both at Fort Belvoir and at Bethesda, where 

a big investment by the Department to bring that capability on 

board as soon as we possibly could. 

The addition of warrior treatment centers, you know, the enhancements that we are making with centers of excellence at Bethesda, as you are well aware of, the involvement of the Fisher 

Foundation in putting in another Intrepid Center of Excellence 
12 

there as a donation to the government, I think all speak to that 

commitment that we have all made to make this world-class. 

I think that what we have to do is realize that within the BRAC 

confinement of what we do in BRAC, we want to get that capability 

onboard as soon as we can. We know at Bethesda that is going to 

be 66 single rooms, for example, okay, modern, first-class rooms up 

there. We know that there’s a lot of rooms out there that we are 

going to have to get back to and renovate. And as Dr. Robyn said, 

you can’t tear the whole thing apart at one time. 

We know down at Fort Belvoir we are building perhaps the finest 

community hospital that has been built in this country in terms of 

its capabilities, in terms of what is going to happen at that facility, 

and the facility itself. I think that the commitment is there. 

But I am reminded of Dr. Kizer’s comments about the six domains of world-class, only one of which is core infrastructure. 

There are other parts of being world-class, and there are plenty of 

examples in this country of operations that are not necessarily in 

first-class facilities, but are world-class operations. And so our commitment is to both. 

We want to do the facilities at a time phase. We will have to go 

beyond the BRAC deadline in order to do some of these renovations 

up at Bethesda. That is part of our plan. And as Admiral Mateczun 

and the JTF folks put in their master plan for the National Capital 

area, we will see that time phasing, the BRAC phase, the concurrent phase, the phase that occurs during BRAC and goes after 

BRAC. 

And then there are things we will have to do after BRAC—not 

go back and redo what we have done. We will have to use that 

space as a leverage point, then, to launch. If we had built a new 

Belvoir 10 years ago, we would have that at a leveraged spot that 

we could do, but we are going to get that all at the same time. 

So once we get that platform done, then we can swing around 

and do the rest of the facility so that the plan is at the same time 

we have to work on those other five domains that are articulated 

in the subcommittee’s report. So to answer you correctly, sir, directly we are committed to it—absolutely. 

Mr. ORTIZ. There was another part to the question. Maybe you 

can touch on it—at what additional cost? 

Mr. MIDDLETON. That has not been determined, sir. I mean it 

would be presumptive of me to give you a dollar figure, because I 

think as the master plan is built, as we build that master plan, you 

know, over the next few months, we will have a better articulation 

of, well, okay, what is it going to take, then, to go back and renovate this space? 

You know, we need some demand analysis, too. We need to know 

precisely the number of beds and the kinds of beds—for example, 

new operating rooms (ORs). How many ORs do we need? We know 

that we have 17—16, 17—ORs that need to be renovated. Do they 

all need to be at 600 square feet? Or can some of them be procedure rooms? Do we need to have—those are all the things that 

have to come out in the master plan. And that will then inform the 

budget decision, sir. 

Mr. ORTIZ. And I can understand Dr. Kizer saying that maybe 

we should try to do it all at the same time now. I am pretty sure 
13 

we are going to hear some complaints from some of our constituents, the families of the wounded warriors, when they are assigned 

to the new facility, the new operating rooms versus the old ones. 

And I would not—I guess you ladies and gentlemen will be at the 

forefront to answer those questions to the constituents. Why in the 

world did I go to this 12, 15, old surgery rooms instead of going 

to the 2 or 3 new surgery rooms? I mean how are we going to address that? Do you think that might be a problem to any of you? 

Admiral MATECZUN. Chairman Ortiz, let me talk specifically to 

the question of the operating rooms at Bethesda. When we came 

to brief the Deputy’s response to the DHB report, we had a number 

of questions about the coordination of the renovation plan that the 

Navy is doing on the OR projects with the overall vision, taking 

that back, called everybody to the table. We were just out at the 

University of California-Los Angeles (UCLA) to take a look at the 

ORs of the future out there. 

And our goal right now is to evolve those operating rooms as we 

go. So the three new operating rooms are certainly extraordinarily 

large. They were being built in a new construction. And we will arrive at a vision that will help us to move towards the world-class 

in terms of the operating rooms that currently exist and the renovations that are there. 

That will potentially leave us with a shortfall of operating rooms. 

We can either make that up through changing the ORs’ schedules. 

That is, start times can extend well into the day to do the same 

number of cases, or we can potentially look at new OR construction 

in the future. 

But we are committed to moving ahead and moving towards that 

world-class standard at this point. I haven’t made the final decision 

yet. I have to see what the cost is going to be. But we have taken 

that at your advice and tried to incorporate that into the movement 

towards world-class. 

Mr. ORTIZ. When is that coming now? 

Admiral MATECZUN. We should be finished this month with the 

review, the costing to the contractors, and arrival at a decision. 

Mr. ORTIZ. This next month did you say? Did I hear correct? 

Admiral MATECZUN. December—yes, sir. 

Mr. ORTIZ. Yes. Okay. 

I just have one more question, and then I am going to yield to 

my good friend, Chairman Davis. 

But, Dr. Robyn, I understand that several fiscal accounts are 

being used to implement the BRAC recommendation of a premier 

medical center, including BRAC funds, Defense Health funds, and 

Operation and Maintenance funds. However, I am not convinced 

that all of these funding sources are being used to obtain the same 

vision. I can be mistaken now, but can you explain how the Department intends to synchronize these facility accounts and obtain a 

world-class medical center? Maybe you can bring everything together. How are we going to do that? 

Mic. 

Dr. ROBYN. As I said, we are focused on trying to take advantage 

of the discipline of the BRAC process to achieve the goals that were 

set out as part of the BRAC recommendation. And that will be de-
14 

liver an integrated health care delivery system in the National 

Capital Region that is superior to what we have now. 

It will not be everything that it can be and should be, and so it 

will be necessary to go beyond the BRAC process in order to 

achieve world-class and to use funding outside of the BRAC process. 

How will that be synchronized? I mean I think that is where the 

master plan will guide us in terms of how much additional funding 

that would take. But we are using as much in the way of BRAC 

resources as it takes to achieve and go beyond the BRAC vision. 

As you well know, we have gone well over the initial estimate of 

what the BRAC reconstruction renovation would take, the difference between. We have gone to $2.4 billion. The national estimate was about $800 million. That is not mostly inflation and construction costs. That mostly represents actual additional expansion, 

additional improvements, the kinds of things that Mr. Middleton 

talked about that were not originally part of the BRAC vision. 

So I think the master plan will be the mechanism for synchronizing it. How much will it cost? We are still trying to figure that 

out. 

Mr. ORTIZ. Chairwoman Davis. 

Mrs. DAVIS. Thank you. Thank you very much. 

I want to talk a little bit about the structure. And, Dr. Kizer, you 

mentioned in your comments that you would be confident if there 

were more detailed plans and whether or not you were certain that 

you could get there with the necessary authority and control. 

And I wanted to turn to Mr. Middleton and ask about that, because part of the concerns have been around those issues. The Military Health System operates with the Assistant Secretary of Defense at the top. And that is the way it is structured today—not 

necessarily making a judgment about that, but that is the way it 

is structured. 

How does the current arrangement with JTF CAPMED fit into 

that structure? Vice Admiral Mateczun reports directly to the Deputy Secretary of Defense, but there has really been a question 

about who is the arbiter when there is disagreement between 

Health Affairs and JTF CAPMED, between the services and JTF 

CAPMED. Who is the arbiter there? Does everything need to be 

handled by Deputy Secretary Lynn? 

And then we go over to the staffing as well. Would the services 

still be responsible for programming and budgeting personnel for 

the facilities under the control of JTF CAPMED? Will JTF 

CAPMED assume this responsibility? I know that that has been a 

concern. Could you help us better understand that? And what have 

been the discussions to see whether in fact that is on the right 

track? 

Mr. MIDDLETON. Thank you. It is a complex issue, as you articulated, Madam Chairman. 

Well, a couple of points. We have established within the Department an integrated product team, a team that actually the Assistant Secretary or currently, Ms. Ellen Embrey, who is performing 

the duties of the Assistant Secretary, formerly Dr. Ward Casscells, 

and Dr. Robyn’s predecessor, Wayne Arny and now Dr. Robyn—an 
15 

Overarching Integrated Product Team (OIPT), we call it, in order 

to articulate the issues that come up, that arise. 

What are the concerns? What are the issues? We haven’t had 

that meeting for some time, because we haven’t had a series of 

issues that require that. And that gets back to the authorities 

question. We have worked through last year—and I know Dr. 

Mateczun can articulate this better than I—a series of meetings in 

order to articulate the authorities over the personnel. And we 

worked on manning documents for the military personnel, and we 

have still an issue about the civilian personnel and which Title authorities that Dr. Mateczun would have over those folks. 

There remains, I think, still the issue of the ultimate end state 

as to, okay, who is actually going to be responsible for the resources within that? On our side on the Health Affairs and 

TRICARE management activities side, we recognize the fact that 

in order to actually run the operation for the National Capital 

Area, they will have to have the authority over the resources. 

What we can offer to Dr. Mateczun, and have offered to Dr. 

Mateczun and the JTF, is the ability to have transparency and visibility into all of the budgeting issues that occur within those facilities. You know, there are 37 facilities within the National Capital 

Area. That is a lot of facilities, and they cross three different accounting and finance systems. So this gets more complicated the 

deeper you get into it on how you actually do this. So what we have 

tried to do is provide him and his staff with all the transparency 

and where the resources occur. 

In terms of the differences, I will tell you that there haven’t been 

many differences between Health Affairs and the JTF CAPMED on 

moving forward with world-class vision, with getting all the authorities, with teeing up these issues so that Secretary Lynn can 

make the decision. I think that represents in some respects Secretary Lynn’s deep interest in all this and wants to be informed, 

as did his predecessor. 

So it is a very complicated matter, Chairwoman, that I don’t 

think is yet resolved. I think that is what we are about to do in 

the next several months is to work through these thorny issues of 

the authorities. 

We have a lingering issue as to what actually physically constitutes the Walter Reed National Medical Center, which buildings 

on the Bethesda campus belong to the National Medical Center 

versus which are infrastructural issues that belong to the Navy 

Medicine or what are the issues that belong to the Navy Installations Command. So we have to work through all of these issues. 

Mrs. DAVIS. I think the concern is that we are so far down the 

line, and yet these issues still exist. 

And, Dr. Kizer, you know, you have been looking at this as well. 

Does it make you feel any better to hear what Mr. Middleton just 

said? 

Dr. KIZER. Well, on the one hand, it is a complicated issue. I acknowledge that. But on the other hand, it is also a very simple 

issue. Someone has to be in charge. And to make an integrated delivery system work, one entity has to be vested with both the operational and budgetary control. On an editorial note, I suppose the 

committee is a little perplexed that this foundational issue of au-
16 

thority is problematic to resolve in a hierarchical organization like 

the Armed Forces. 

Mrs. DAVIS. Is that part of the problem—that there are obviously 

multiple services here as well? 

Mr. MIDDLETON. I think Dr. Kizer, you know, would say that. I 

think what Dr. Kizer is alluding to is the fact that it should be 

easy to make those decisions, because it is a hierarchical organization. Someone just needs to make the decision and do it. 

Mrs. DAVIS. But there are several hierarchies. 

Mr. MIDDLETON. There are several hierarchies and there’s a lot 

of equities in this issue, you know, between the Surgeons General. 

They have authorities here, and they have responsibilities for these 

folks. And Dr. Mateczun will, and his office will, ultimately have 

some responsibilities and authorities as well. And we are just going 

to have to work through each one of those. 

And we have worked through a couple of them. And we have 

worked through the military piece, the military personnel piece, 

last year. We are working now through the civilian personnel piece 

and the Title 5 authorities and those kinds of issues. We are working through those now. 

Mrs. DAVIS. Could you give any kind of a timeframe, because 

there is a number of concerns about construction, and obviously 

personnel as well. But when do you think we appropriately should 

be able to say, okay, you know—— 

Mr. MIDDLETON. We are there. 

Mrs. DAVIS. Yes, exactly. 

Mr. MIDDLETON. Yes, yes. Anything I would say would be speculative on my part, because I am not sure I even fully understand 

all of the thorny contracting issues that go—the contentiousness 

that could occur. But I would hope that as we re-energize the OIPT 

here very soon, that we will be able to work through these in a fairly expeditious way. 

And my commitment then would be that to both committees that 

we will report back on that, you know. We can report back on 

where we stand on these issues and articulate those to you in the 

weeks and months ahead, if that is reasonable for you. 

Mrs. DAVIS. Is the master plan itself—I mean we have asked you 

to create the master plan. Are some of these decisions beyond the 

ability of the Department to make? Should somebody else help 

make them? 

Mr. MIDDLETON. I don’t believe that is true. I don’t believe that 

is true. I think we have all the authorities we need to make these 

decisions. If there is a special—if there is something that I am unaware of, and I would refer that to Dr. Mateczun as well; he may 

know something—but I don’t know of any authority that we don’t 

have to make the decisions. 

There are some matters around Title 5 authorities that get a little thornier—for instance, second and third order issues about auditing and things like that, but I think we have the authority to 

do it. But I defer that to Dr. Mateczun. 

Admiral MATECZUN. Chairwoman Davis, as part of the master 

plan that is due back, the authorities issue is one of the threads 

that we are interweaving. We have a group that is working specifi-
17 

cally on all authorities issues, and as far as I know, there are none 

that are outside the authorities of the Department. 

Mrs. DAVIS. Congress, you know, had asked for this master plan. 

Do you think that kind of work would have gone on irrespective of 

that request? 

Admiral MATECZUN. Yes, ma’am, absolutely. In fact, two of those 

are—actually, three of them are pending decisions left for the Deputy Secretary that we have had identified. We had the manpower 

and civilian personnel issues. The other three that are still pending 

are the force mix between the two hospitals, the resources—how do 

the resources flow, which is highly technical, and we will come to 

an answer on that. 

And then ultimately, what is the governance of the JTF? So 

these are identified issues that that Defense Health Board, you 

know, sees this issue as foundational. We agree. It is a difficult 

thing to struggle with, to think about aligning authorities in a different way than they exist today in the Department. 

Mrs. DAVIS. Thank you. I appreciate that. 

Thank you very much, Mr. Chairman. I have some additional 

questions, but I want to be sure everybody has a chance to ask. 

Thank you. 

Mr. ORTIZ. Mr. Wilson. 

Mr. WILSON. Thank you, Mr. Chairman. 

And thank you, Madam Chairwoman, too. 

For the panel, thank you for being here today. 

And in particular, Secretary Middleton, I appreciate your work 

with TRICARE. This is crucial for our military, for their families, 

for our veterans, and for survivors. So your stewardship is greatly 

appreciated by me. 

As we proceed today, Dr. Kizer, the advisory committee reported 

several findings and recommendations that would bring the new 

Walter Reed closer to the goal of being a world-class medical facility. Which of the recommendations that you feel DOD did not adequately address in their assessment is the most critical to delivering safe, quality patient care, and why? 

Dr. KIZER. I think there are several levels that one could address 

that. I think the issues that the committee views as paramount at 

the moment is the authority issue, which we have talked about 

some already, the alignment of funding streams, which continues 

to seemingly be at the root of many of the issues related to the 

master plan, which I would put as the third critical issue. 

And when I speak of the master plan, there are, again, several 

types of master plans that are needed. Ostensibly, they would all 

roll into one master plan, but there is the master plan for the Walter Reed facility itself. There is a need for a master plan of the Bethesda campus, where the Walter Reed facility is co-located or approximate to multiple other facilities that it will work with on an 

intimate basis. And then there is the need for a master plan for 

the entire National Capital Region and the more than 30 different 

medical commands that reside within that multi-state area. 

Now, beyond that there are a number of other issues relating to 

operating rooms and surgical pathology and a number of other 

things, which we had detailed, and I would defer to my written testimony and other comments that were made already about those. 
18 

But I think fundamentally until the authority issue is resolved, 

we really can’t deal with the—or at least it is hard to understand 

how you are going to deal with the funding issue. And until the 

funding issue is dealt with, it is hard to understand how you are 

going to deal with the master plan issue. And then you get into all 

of the specifics about operating rooms and then single rooms and 

information technology (IT) systems, et cetera, et cetera. 

Mr. WILSON. And you brought up about authority. 

And, Admiral Mateczun, you are facing such extraordinary challenges, so best wishes trying to—in your position. And what authority do you currently have to direct the funds to resolve the design and construction issues that have been raised by the Defense 

Health Board? 

And, of course, there has been a reference several times, and 

again just a second ago, about the situation of two patients to a 

room instead of one, particularly in light of the concern that everyone has about the rise of infections in hospitals in the United 

States. 

Admiral MATECZUN. The monies that have been needed to correct 

these deficiencies are all working within the Department, and the 

funds are identified, not programs yet, not allocated completely, 

but each of the issues that Dr. Kizer identified in terms of the current construction and the deficiencies we have been able to work 

with. 

There is a question of whether or not there will need to be new 

construction that we have to do in the master plan. There are going 

to be 52 double patient rooms left at Bethesda. Part of the Department’s change in 2007 in enhance and accelerate was to start renovation of those rooms and conversion into single patient rooms. 

Still, 54 will remain at the—or 52 will remain at the end of BRAC. 

And the question is what to do with those rooms, not disagreeing 

with, you know, the need and the movement in the country as the 

country is moving towards a single patient room standard. That 

will require renovation of those remaining rooms. And since there 

is no space in the construction left, that would likely require new 

construction. 

We are also taking a look at the fundamental demographics of 

the population and their demands as we work towards an integrated delivery system to validate the—the number of beds that we 

would need and integrate that into the master plan as well. 

Mr. WILSON. And I hope again that—and I know you are looking 

into that. And as I visit hospitals, I frequently find that they have 

quickly been rearranged for a single patient. 

And, Dr. Kizer, a final question for me. The Army has indicated 

they will be managing 400 warriors in the transition at the new 

Walter Reed and needs 300 barracks rooms for the soldiers. Please 

explain the plan for accommodating not only the Army Warrior 

Transition Unit (WTU) population, but the Navy and Marine recovering wounded warriors as well. In addition, please explain the 

plans for accommodating the families of the wounded warriors at 

the Bethesda campus. 

Dr. KIZER. Well, sir, I don’t think I am the right person to answer that question, since those are questions that frankly we 

raised in our report, were issues like that, as to how they would 
19 

in fact—a number of these other services that need to be provided, 

how they would be, because it was not apparent from the plans 

that we saw. And this is, of course, part of what is needed in the 

master plan. 

I would just add to—on the prior question—to the response that 

Admiral Mateczun gave that one of the findings of the committee 

was the need for current and prospective forward-looking demand 

analysis for the services. The current capacity and design of the facility was based on a 2004 retrospective, backward-looking demand 

analysis. Things have changed. The population has changed. Technology has changed. Care practices have changed. And we really 

need a more forward-looking demand analysis to guide the master 

plan and as a design piece. 

Mr. WILSON. And to conclude, Admiral Mateczun, I think it was 

passed to you. If you could comment, that would be very nice. 

Admiral MATECZUN. Yes, Mr. Wilson. Thank you. This is additionally one of those—partially, one of those instances of changing 

requirements. The Army is taking a hard look at how it manages 

the warrior transition and in particular the non-medical attendants, as well as family members. 

And so each of the services has a different requirement generations mechanism that they use to take a look at that. We are at 

this moment combining all of those requirements. The Center for 

Army Analysis has done a study on that requirement. We will be 

incorporating those. Admiral Mullen has a specific interest in this, 

and I believe we will come to resolution on that issue very quickly. 

Mr. WILSON. Well, we appreciate your efforts. 

Thank you, Mr. Chairman. 

Mr. ORTIZ. Before I yield to Mr. Taylor, I would like for the 

record to include a statement from our good friend, Chris Van Hollen, for the record. Hearing no objection, so ordered. 

[The information referred to can be found in the Appendix on 

page 85.] 

Mr. ORTIZ. Mr. Taylor. 

Mr. TAYLOR. Thank you, Mr. Chairman. And thank you for having this hearing. 

Admiral Mateczun, I am going to shift gears just a little bit, but 

I don’t get to see you that often. Over the past couple of years, the 

different service secretaries have been very cooperative. Let me 

backtrack. It seems that every young amputee that I have met with 

expresses a very strong desire to—to continue to serve. They have 

paid a terrible price for their participation on the team. They want 

to stay on the team. 

And one of the ways that I would think that we could help them 

to stay on the team and do something meaningful would be to have 

them assigned to the different service academies either as assistant 

coaches or squad level officers, plumbers, carpenters, whatever, depending on what their Military Occupational Specialty (MOS) was 

and what they did in the private sector before they joined the service. 

And to the best of my knowledge, every one of the service secretaries have signed onto this. But also to the best of my knowledge, 

very few have actually been assigned to the service academies. It 

has also been the intention of Chairman Skelton to expand this to 
20 

the different Reserve Officer Training Corps (ROTC) programs, 

with the thought being that the service academies are limited to 

Colorado and New England states, whereas the ROTC programs 

are in every state. So again, they would be doing meaningful work, 

in the case of the ROTC programs, closer to home. 

There is a Capitol Hill guide. I regret that I don’t know his 

name, but every week he brings wounded warriors to the Capitol. 

Every week we stop and say hi to them, and every week I ask 

these kids if they have been told about this program. And not one 

of them is aware of it. 

Again, I know you have got a million things on your plate, and 

I can only imagine how difficult your job is. But how can we do a 

better job of making these opportunities available to folks so they 

can stay on the team, do meaningful work for their nation, continue to wear the uniform, and do something worthwhile for their 

nation, which is what their desire is, and give them a seamless 

transition, should their decision be to go back to the private sector, 

a seamless transition back to the private sector and buy them some 

time. What could we do to get that word out? 

Admiral MATECZUN. Thank you, Mr. Taylor. It is, you know, a 

wonderful thing that is going on now. We moved into a rehabilitation, capabilities-based rehabilitation model in the services that 

really didn’t exist before these current operations in Iraq and Afghanistan. And so based on the capabilities that the individuals 

have, the limbs that they have lost and where they might be able 

to go, I know that almost everybody would like to have them work 

in their areas and work with them. 

One of the opportunities that we will have at the Walter Reed 

National Military Medical Center is an area where we will jointly 

be able to provide information to all those folks. Since all of the 

amputees as they go through rehabilitation will be at Walter Reed, 

we will be able to disseminate that through each of the service 

mechanisms in a more comprehensive and joint way. We are committed as well to making sure that they understand all of the opportunities that they have. 

Mr. TAYLOR. Well, Admiral, this has been policy for well over a 

year. And again, not one of these young people that are taking 

tours of the Capitol has been made aware of it. And so again, I do 

understand that you have a heck of a lot of responsibilities, but I 

would make this request of you face-to-face, that your organization 

do a better job making this available. 

And if there are some impotence either administratively or in the 

code that are keeping this from happening, let us know so we can 

address it in next year’s session. And I will just give you one for 

instance. Merchant Marine Academy Captain Ebbs is our chief 

staffer for the Seapower Subcommittee—just came back. 

They have barracks that don’t have hot water. For $30,000 worth 

of plumbing equipment and the properly skilled people in that 

building to fix that, we could fix that tomorrow. And I have got to 

believe that you have got some injured Seabees who could be doing 

that job or Army people from the Army construction battalions. 

Again, I do see some opportunities to provide these young people 

with meaningful work while they stay in the service. We are miss-
21 

ing them somehow. And I would hope that you would get back to 

me on how we are going to correct that. 

Admiral MATECZUN. Yes, Mr. Taylor. I will take that back. 

[The information referred to can be found in the Appendix on 

page 89.] 

Mr. TAYLOR. Okay. Thank you very much, Admiral. 

Thank you, Mr. Chairman. 

Mr. ORTIZ. Dr. Fleming. 

Dr. FLEMING. Yes, thank you, Mr. Chairman. 

I would like to ask the panel to elaborate on the concept of 

world-class medical facilities as it applies to what would emerge 

from this merger, if you will. 

Admiral MATECZUN. Dr. Fleming, thank you. You know, we are 

headed towards an integrated delivery system for the first time 

within the Military Health System. The National Capital Region is 

the largest concentration of military medical forces and beneficiaries that we have in the country—500,000 beneficiaries, 

300,000 enrolled in the TRICARE Prime program that we have. 

As we move towards this integrated delivery system, we are 

working, trying to come to our master plan on how to integrate 

both specialty and primary care into that integrated delivery system. What you will see at Bethesda will be one of the premier quaternary medical centers that we have in the country in the end 

state. And what we need to do—it will be both the referral medical 

center and a specialty medical center for the area. 

The community hospital at Fort Belvoir will provide general specialty services to what is now the majority of the area’s population, 

which is shifting south over the last couple of years. And so those 

things will come together as part of the integrated delivery system. 

In terms of the vision itself for what will not be happening at 

Walter Reed, we are taking a look at integrating not just the current terrific capabilities for amputee care, traumatic brain injury. 

There is also the National Intrepid Center of Excellence, which is 

going to be there for Traumatic Brain Injuries (TBI) and Post Traumatic Stress Disorder (PTSD), working with Dr. John Niederhuber 

from the National Cancer Institute (NCI) in a collaboration where 

we will start moving towards a comprehensive cancer center with 

NCI designation for all of our beneficiaries. That will be the first 

within the Military Health System. 

And in each of the areas that we are moving towards, we are 

looking towards achieving world-class. We are in a particularly 

good location. We are right across the street from the National Institute of Health, and we have a medical school right on our campus. As part of the strategic plan, we are looking at how to bring 

together the medical center and medical school in a new model for 

academic medicine for the country. So those are some of the things 

that we are doing. I don’t know if that answers your question, sir. 

Dr. FLEMING. Let me follow up, and then I will open it back up 

to the panel. When you say ‘‘integration,’’ do you mean assigning 

Air Force physicians or providers to Navy facilities and vice versa? 

Are we looking at integrating all providers into one service? 

What—can you elaborate on that? 

Admiral MATECZUN. The facilities themselves will be—the personnel will be jointly assigned—that is, that personnel from all of 
22 

the services will be at both of the facilities. In terms of the integration, from the patient perspective what we are looking at is having 

them see an integrated delivery system. They will see joint providers, providers from all the services. But what we are really 

working towards is what they will see as the integrated delivery 

of care across all the services that we have. 

Dr. FLEMING. And will this tend to happen in facilities around 

the world? Will you begin to see this jointness? Or are we talking 

about just in this area here? 

Admiral MATECZUN. No, there are only a few areas in the country where there is more than one service hospital. The National 

Capital Region and San Antonio are the two biggest, so it is unlikely that you will see much of this anywhere else. 

Dr. FLEMING. I see. 

Others? 

Mr. MIDDLETON. Jointness is not unprecedented. We have had 

Air Force staff working in the hospital in Landstuhl for a number 

of years. We will do the same endowment as we close the Wilford 

Hall Medical Center down in San Antonio. Much of that staff is 

going to go to the Brooke Army Medical Center, and that will be 

a jointly staffed hospital. 

I think the integration also speaks to the way in which patients 

flow through the system seamlessly so they can move from the primary care setting that we have around the area to our secondary 

and tertiary care facilities as well. So I think the integration piece 

and how information flows seamlessly, I think that is all part of 

the world-class vision. 

So talking about around the globe, we want to make sure that 

information flows along with the patient. So whether it is a serviceman injured in Iraq or Afghanistan that is coming back to 

Landstuhl, or whether it is someone who gets in a motorcycle accident outside St. Louis, they are moved through the process as 

seamlessly as we can. 

Dr. KIZER. If I might make two comments, one just to amplify a 

little bit on what Vice Admiral Mateczun said, that at least when 

I was a naval officer 30 years ago or so, the nature of my work was 

such that I not infrequently was assigned to both Army and Air 

Force units and had the opportunity to delve into all these. And I 

would say that there are very different cultures in the services, and 

integrating into a single joint Armed Forces medical culture is not 

an easy task, and we recognize the challenges here. 

The second point I would make is the Congress is very clear, and 

the Department certainly agrees, that the facility should be worldclass, but the Congress did not provide much operational definition 

for what world-class should be taken to mean. So much of the work 

of the subcommittee that I chaired and the report that we issued 

actually had to do with defining in operational and functional 

terms what world-class would mean. And there are many pages detailing that in 6 different domains and 18 conditions. 

But perhaps, if I might just state in perhaps a different way than 

what was said earlier, I think the subcommittee views a worldclass medical facility as one that goes above and beyond compliance 

with the professional accreditation and certification standards, 

where there is a palpable commitment to excellence. 
23 

A world-class facility is one in which highly skilled professionals 

work together with precision and passion as practice teams within 

an environment of inquiry and discovery and in one that creates 

an ambience or an atmosphere that inspires trust and communicates confidence. 

I think a world-class facility constantly envisions what could be 

and goes beyond the best-known medical practices to advance the 

frontiers of knowledge and to pioneer. Improved processes appear 

so that the extraordinary becomes ordinary, and the exceptional becomes routine. So perhaps that is a different way of 

operationalizing or thinking about this concept of world-class. 

Dr. FLEMING. Sure. I know I am out of time, but I don’t know 

how much—I would like to follow, if I could, one other question, 

Mr. Chairman? 

Mr. ORTIZ. Go ahead. 

Dr. FLEMING. The issue of electronic medical records (EMR), 

which is a wonderful thing—it is a wonderful—I am a strong believer as a physician myself. My medical clinic had an EMR since 

1997. I am also very familiar with the challenges, and certainly a 

worldwide system that then has to integrate with the Veterans Affairs (VA) system is an unbelievable challenge. But I do hear complaints about the functionality of the system. 

Obviously, as you integrate and you have more jointness and all 

these things, that is going to become even more critical. Do you 

have plans to improve that? Or I understand that the platform is 

really an old platform which may limit how much you can improve 

it. Can you elaborate any on those points? 

Admiral MATECZUN. Yes, Dr. Fleming, thank you. It is a great 

challenge. You know, we have probably one of the world’s largest 

databases for the Military Health System in the central data repository, where we have tremendous amounts of information, so we do 

have some expertise. Our platform is sometimes not user-friendly. 

We are working at changing that. 

We are committed to arriving at the Administration’s mandate 

for interoperability between the VA and the DOD. Particularly, we 

are working right now on an inpatient system to cross over the two 

systems and then interoperability between the two platforms, 

which are Armed Forces Health Longitudinal Technology Application (AHLTA) and Veterans Health Information Systems and Technology Administration (VistA) that are out there today. 

Mr. MIDDLETON. If I could help there, too, as you know, sir, we 

have our system. The VA has their system. We have a mandate 

from the Administration to put together the virtual lifetime electronic record for our veterans, a huge challenge. 

The VA system, and I know Dr. Kizer knows it as well as anyone 

in this room, also has its challenges in its old architecture and 

things like that. We recognize that in our own. We and the Department are working on the way ahead for a new architecture. We are 

in the process of that now, actually picking folks to be part of that 

team to move forward with that. 

We have a commitment from the Department to help us in that 

endeavor in terms of not only the expertise, but in some resources 

as well. So we think we are on our way to a different place with 

electronic health record. That is not to say that the health record 
24 

we have today hasn’t served us very well for a number of years, 

but it is time for a change. 

And as I am sure you are familiar, we now also have the national 

standards, the National Health Information Network (NHIN) 

standards that are evolving. We are going to do some programs, 

some pilot programs, perhaps with some civilian activities, to see 

if we can share information between the Departments as well as 

civilian activity. So there’s a lot of exciting things coming in electronic health record, but it is a huge challenge—absolutely, sir. 

Dr. FLEMING. Thank you. 

I yield back, Mr. Chairman. 

Mr. ORTIZ. Thank you. 

Mr. Middleton, you know, I find it troubling that we have programmed $2.5 billion for the realignment of Walter Reed, but we 

still have so many fundamental issues outstanding. We have programs that will cost almost another $5 billion in other medical centers. 

And do you think that our inability to manage the Capital Region will also have an impact at other locations in the United 

States? And how do we ensure that lessons learned are incorporated to other sites? And I think somebody questioned on Brooke 

Medical Center in San Antonio. So how are we going to implement 

some of those lessons learned today and through this process of realigning Walter Reed and Bethesda? 

Mr. MIDDLETON. Thank you, sir. I think the first is to articulate 

some of the lessons that we have learned. I think that is an important issue. And, of course, those lessons are always ongoing. 

One key area is acquisition strategy. There’s multiple ways in 

which you get buildings acquired. One of those is design-build. One 

is integrated design-bid-build. We are actually testing that out. 

Frankly, the way we are doing it in Bethesda has allowed us to actually meet these timelines. Had we gone through some traditional 

methodologies, we would have been struggling. So we have been 

fortunate in that. 

I think we have to learn the lesson of how we deal with our 

agents, the Corps of Engineers and the Naval Facilities Engineering Command (NAVFAC) in an effective way. We have, I think, 

built a strategy. What we learned in Bethesda is how we can sit 

down with the I&E, Dr. Robyn’s staff, our staff, JTF CAPMED 

staff, to make sure that we are identifying the requirements as 

early as we can. 

We have over the last couple of years built a series of criteria for 

evidence-based design, which is sort of the buzzword for the kinds 

of facilities that we want to build. And so back in 2007, we put together a package that articulated what those design features ought 

to be. 

And we held a conference in 2008 with civilian activities to articulate those kinds of world-class facilities issues around evidencebased design—things like natural light and enhanced privacy for 

infection control, as Mr. Wilson talked about in single rooms, patient safety features that are built-in, the way in which we observe 

the patients in the rooms, and the way in which hand cleaning has 

occurred, and the kinds of technology that we can advance. 
25 

All of those are part of where we go in the future, so everything 

that we do at Fort Belvoir particularly, because it was a greenfield 

site, are things that we tend to want to extrapolate, so when we 

go to build the new Fort Hoods of the world and the Fort Blisses 

of the world or the new Air Force base hospitals, where we are 

building those new design features into that, and we are learning 

that based on what we are learning in Bethesda. 

We have seen also there are some negative lessons. We know 

how difficult it is to build and operate the facility at the same time. 

You know, this is much akin to the old analogy of flying the airplane while you are fixing it, only we are doing it at hypersonic 

speed. And that is a big lesson. 

So where we don’t have to do that in the future, that may be a 

lesson that we want to learn as well—how difficult this can be to 

operate a really first-class medical facility at the same time you are 

trying to renovate it and enhance it at the same time. 

So all those will be built into our building strategy, our acquisition strategy, our world-class strategy. And I think where the Defense Health Board Subcommittee has helped to articulate those 

other six domains, not just the core infrastructure, we do need to 

talk about the leadership processes of care, and we need to talk 

about performance, how we are doing knowledge management. 

And to that end we are having our conference. Our main Health 

and Human Services (HHS) conference in January is going to—basically, the theme is going to be knowledge management, how we 

share information, because we don’t want Bethesda to become—we 

want it to be a center of excellence, but we don’t want it to become 

an island of excellence. That is not the only place where excellence 

needs to occur. Many years ago I commanded a small hospital in 

South Dakota, and I want that place to be as excellent as well for 

the care that they can provide at that facility. So those are all the 

lessons that we are trying to learn to build the future, sir. 

Mr. ORTIZ. Chairwoman Davis. 

Mrs. DAVIS. Thank you, Mr. Chairman. 

I wanted to ask about one of the issues that I think Dr. Kizer 

raised about the kind of invisible structure and the concern, I 

think, that there may not have been or—and part of my question 

is is there an ongoing process for clinician input into the communities of interest, essentially, that occur within hospitals? 

And one of the concerns is with—the amputee community today 

I know is together, and that provides, you know, some great benefits that I think that a number of the clinicians think is a good 

idea. We also know for breast cancer patients, for example, that 

they are also together. 

It is my understanding that some of the organization, and there 

are different philosophies about that, you know, whether it is more 

related to acuity or it is more related to the particular kind of 

issues that patients are working with and perhaps have an ability 

to share. 

So what are we seeing within that structure? And have we resolved all those issues? Is there still opportunity for clinicians to 

be able to present their points of view around that? Where are we? 

Admiral MATECZUN. Chairwoman Davis, on that, a couple of examples just on end-user input into design, we are still accepting 
26 

some of that. As recently as two weeks ago, we were at meeting 

on some of the rooms at Fort Belvoir. And we can’t do big design 

changes, but we are working still with end-user input to make sure 

that we are able to on the design phase do as much as we can. 

In terms of the delivery of care, there are differences of opinion 

on organization. When we made a move towards a comprehensive 

cancer center, there were a number of desirable attributes of that 

form of care—for instance, the consolidation of cosmetic services, 

the consolidation of psychological counseling for cancer members 

that sometimes seemingly conflicted with the independent provision, for instance, of breast care centers. 

And so we have been working with the clinicians about that. 

They are still providing input. And we are continuing to do that. 

We have got a meeting coming up with all of the cancer chiefs, 

where we will be continuing to work with those questions about organization to make sure that they feel they are able to provide the 

best care, but that our patients are getting integrated care across 

the system. 

One of the problems that we have is that as we focus in an individual lane like breast care, then we sometimes lose focus on the 

integrated delivery of care for the other problems they may or may 

not have. So we are struggling with that, and I think we will come 

up with a good model. 

Mrs. DAVIS. All right. I would appreciate that, because I think 

that certainly the people that have created what we know is to be 

an exceptional care for our wounded warriors particularly, we need 

to continue to have that kind of input, I think. 

Admiral MATECZUN. The amputee care will be organized exactly 

as it is today so that that whole part of the organization is getting 

imported. And one of the questions I frequently get is, well, is that 

an Army structure? Actually, it is a tri-service structure today. So 

it will come over intact. The way that they deliver care will be preserved. 

Mrs. DAVIS. Thank you. I wanted—two quicker questions to just 

pick up on a few issues that were raised. One of those have to do 

with Section 1635 of the FY 2008 NDAA. It required the interoperability between the DOD and the VA. And Health Affairs had 

briefed our staff—I guess this is to Mr. Middleton—that you have 

fulfilled the requirements of 1635, and yet we just heard today that 

it sounds like it is, you know, a work in progress. 

Mr. MIDDLETON. I think there’s two things. I think there is meeting the requirements, which is the interoperability, our ability to 

transfer information. I am sure we have been over and talked before about bi-directional information and one-directional information with the Veterans Administration. I think we have articulated 

and can prove that we can do that. 

I think the bigger question that I alluded to before is what is the 

backbone like? What does the architecture look like going forward, 

as both departments have to modernize their facility? And we have 

come a long way from the architecture that we built this with 

many, many years ago. 

Modern technology, the Internet, there’s all kinds of things now 

that afford us an opportunity to make it better and make it even 

more interoperable. And I think that is what I wanted to make 
27 

sure that you understood is that we think we meet the requirements of your—but we need to do better. 

I mean we could, for example, we can push a lot more information right now than the Veterans Administration can absorb at one 

time because of some architectural issues within their system. So 

we need to solve that collectively. We don’t necessarily have to 

have the same system. We have to be able to make sure that a 

larger system is more interoperable, and I think that is where we 

want to go, as well as modernize our own system. 

Mrs. DAVIS. Thank you. 

Admiral Mateczun, you mentioned earlier that funds had been 

identified to address and fix the concerns of the independent review, and I just wanted to turn to Mr. Middleton and Dr. Robyn. 

And is that true? I mean as far as you know, have those funds been 

identified that can address the concerns of the review? 

Admiral MATECZUN. Let me clarify, Madam Chairwoman. The 

funds that are identified were with the ongoing construction. For 

anything that required new construction in the master plan, those 

funds have not been identified. So all of the deficiencies within the 

current construction are certainly there. Things like single patient 

rooms and achieving those or new ORs, should they be needed, 

funds have not been identified. 

Mrs. DAVIS. Funds have not been identified for those. All right. 

You would agree with that. All right. Thank you. 

Mr. ORTIZ. I think we have had some wonderful testimony today, 

and me personally, I think I have learned a lot from your testimony. And we need to stay ahead of the curve. If we do send—the 

President recommended that we send 30,000 soldiers to Afghanistan, which means that—and I pray to God that we don’t have any 

more casualties or, you know, young men and women coming back 

with injuries. 

And we are just going to have to be ready for whatever comes 

between now and then. And I know that, you know, you and I and 

this committee, we have huge obligations and responsibilities to 

our warriors. They have done a great job. Some of them just came 

back from Landstuhl this last week, and we visited some of the soldiers deploying from Italy and Germany back at their—who are 

there now, because they left two or three days ago. 

But I know that all of us mean well. I mean we are a team sitting in different locations, but we want the best for our warriors. 

I just want to thank each and every one of you for your testimony 

today. And hearing no more questions, this joint hearing we had 

today stands adjourned. Thank you so much. 

[Whereupon, at 11:30 a.m., the subcommittees were adjourned.] 

A P P E N D I X 

DECEMBER 2, 2009 

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DOCUMENTS SUBMITTED FOR THE RECORD 

DECEMBER 2, 2009 

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WITNESS RESPONSES TO QUESTIONS ASKED DURING 

THE HEARING 

DECEMBER 2, 2009 

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RESPONSE TO QUESTION SUBMITTED BY MR. TAYLOR 

Admiral MATECZUN. Each of the Military Services has programs to provide 

wounded, ill, or injured Service members who remain in the military opportunities 

for meaningful work. At the Office of the Secretary of Defense level, the Operation 

Warfighter program helps connect recovering wounded warriors with meaningful 

employment activities outside of the hospital environment. Operation Warfighter allows wounded warriors to explore employment interests, develop job skills, build a 

resume, and gain valuable work experience as interns with Federal agencies in the 

National Capital Region. It provides valuable assistance to wounded warriors 

transitioning back to the military or into the civilian community and workplace. 

[See page 21.] 

QUESTIONS SUBMITTED BY MEMBERS POST HEARING 

DECEMBER 2, 2009 

(93) 

QUESTIONS SUBMITTED BY MR. ORTIZ 

Mr. ORTIZ. Walter Reed Army Medical Center (WRAMC) was essentially closed 

by Base Realignment and Closure (BRAC) 2005 and the functions principally realigned to Bethesda, MD, and Fort Belvoir, VA. BRAC-related costs have increased 

significantly and the Department will be challenged to meet the September 2011 

BRAC deadline. What steps is the Department pursuing to limit cost and schedule 

growth? Will the Department be able to meet the BRAC statutory deadline of September 2011? What are the biggest challenges that will need to be addressed in 

order to meet the BRAC statutory deadline? 

Mr. MIDDLETON. The Department utilizes a well established vetting and approval 

process to limit cost and schedule growth. The Deputy Secretary of Defense is the 

final approval authority. As a result, the Department is on schedule to meet the 

BRAC statutory deadline. The biggest challenges facing the Joint Task Force, National Capital Region Medical (JTF CAPMED) and the Department are not related 

to construction but include governance, financial management, potential workforce 

attrition, and transition to the new facilities. 

The scope of the transformation in National Capital Region (NCR) Medical has 

evolved since the original BRAC recommendations. Per the Naval Facilities Engineering Command and the Army Corps of Engineers, the Department is currently 

on schedule to complete the NCR Medical BRAC transfer of functions by the September 15, 2011 deadline. As such, there is minimal schedule risk left in the construction at Bethesda and Fort Belvoir. JTF CAPMED, via its Project Management 

Office, is overseeing the Walter Reed transition and has awarded the Initial Outfitting & Transition contract for both hospitals as well. This contract brings together 

the industry leaders to ensure that outfitting the buildings and transition of patients and staff will occur safely by September 15, 2011. To maintain schedule, the 

Department is working with the contractors to find efficiencies so it can mitigate 

potential delays should they occur. 

The Department is putting to bear all its available resources to mitigate inherent 

operating risks both WRAMC and the National Naval Medical Center (NNMC) pose 

during BRAC. At WRAMC, it will be important to maintain the civilian workforce 

to preserve current capability and to staff both of the new hospitals. The Department has identified a military force mix for Walter Reed National Military Medical 

Center (WRNMMC) and Fort Belvoir Community Hospital (FBCH). It is also working to finalize the manning document to make notifications to employees of their 

locations in the end state by spring 2010. At NNMC, the Navy must continue to 

provide healthcare while renovations require the relocation of many functions. During the actual movement of patients from WRAMC to WRNMMC and FBCH, direct 

care system patients will be appropriately transferred to the private sector or other 

military hospitals temporarily to allow for the transition. 

Bethesda—The Department continues to apply a wide range of acquisition and 

construction strategies, tactics, and techniques to limit cost and schedule growth 

while performing complex construction and renovation work on the active Bethesda 

campus. Significant customer input was collected both during concept development 

and early in the Design-Build process to create the schedule which supports the 

BRAC statutory deadline. The dialogue with end-users is still being maintained 

throughout each design stage and the ongoing construction phases. Once the requirements were determined, agreements were developed with all stakeholders to 

maintain the aggressive schedule, and to control cost for fixed scopes of work. The 

Defense Contract Audit Agency was used to perform contractor audits, which established reasonable market rates for design and construction needed to meet customer 

requirements. While maximizing patient safety, construction phasing for the renovation areas was organized to temporarily relocate functions, coordinate patient versus 

construction boundaries, and reduce the number of phases. All these Department efforts have maximized efficiency by reducing cost and shortening the schedule. 

Fort Belvoir Community Hospital—The FBCH was contracted under the fast 

track, Integrated Design Bid Build process. This method operates in a cost-reimbursable mode during design development and is then converted to a firm, fixed 

price once the design is substantially completed. The design is complete and the De-
94 

partment is currently in negotiations with the contractor to make the contract definite. 

During the design phase of the project, risk of cost and schedule growth was significantly higher than it currently is. During the design period, the project team 

spent an extensive amount of energy and time coordinating with the Army’s Health 

Facilities Planning Agency, JTF CAPMED, and Assistant Secretary of Defense for 

Health Affairs to ensure optimal design incorporating evidence-based design components and met the needs of the medical mission by providing a ‘‘world-class’’ medical 

facility. Since the design is now complete, the risk of additional cost and schedule 

growth beyond what has already been identified is significantly reduced. However, 

the entire project team must remain vigilant to minimize changes to the final design 

so the risk of additional costs and delays are minimized. In the event a change to 

the final design is identified, it will be scrutinized by management of all major 

stakeholder organizations to assure that it is absolutely essential and steps will be 

taken to mitigate cost and schedule impacts to the greatest extent practicable. To 

ensure that the Department is paying a fair-market price for this facility, it has engaged Defense Contract Audit Agency early in the project and is currently auditing 

the Contractor’s proposal to assure all costs identified by the contractor are allowable and allocatable. 

Evolution to World Class—The Department is committed to achieving world-class 

standards, as defined and directed under the law, at Bethesda and Fort Belvoir 

Community Hospital. However, completion of NCR Medical BRAC projects and the 

evolution to world class standards at Bethesda are two separate and necessarily sequential efforts. The Department is developing an NCR Medical Comprehensive 

Master Plan, as required by Section 2714 of the National Defense Authorization Act 

for Fiscal Year 2010, which will synchronize both of these efforts to maximize the 

effective use of resources while maintaining patient safety. 

Mr. ORTIZ. Much progress has been made to improve the diagnosis and treatment 

of the so-called ‘‘silent wounds of war’’—traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD). However, medical practitioners at the National Naval 

Medical Center (NNMC) currently use somewhat different tools and approaches for 

the detection and treatment of TBI and PTSD compared to their counterparts at the 

Walter Reed Army Medical Center (WRAMC). What measures will be needed to reconcile diagnostic and treatment differences for these conditions? To what extent will 

findings from the Defense Centers of Excellence for TBI and PTSD be relied upon 

to standardize the diagnosis and treatment for TBI and PTSD at the NNMC? To 

a large extent, the NNMC and WRAMC have become specialized in different medical disciplines—the NNMC in brain injury and neurosurgical procedures and 

WRAMC in amputation and physical rehabilitation. In the future at a merged 

NMMC, will the Navy and Army largely continue to maintain these specializations? 

If so, how will this affect the organization, staffing, and management of medical 

treatment at the NMMC? 

Mr. MIDDLETON. In the future, world-class medical care in each of these specialties will be available at the new facility. Clinical expertise in the Navy’s brain injury 

and neurosurgical procedures and the Army’s amputee care and rehabilitation programs will be merged and integrated at the new Walter Reed National Military 

Medical Center (WRNMMC). The complexity of TBI and psychological health requires specialized care that crosses a multitude of specialties. Unified leadership 

across these specialized services will ensure comprehensive holistic care throughout 

the continuum of care within the military and veterans’ health care system. The 

TBI services will soon become one integrated service combining the concept of operation and assets from both the NNMC and the WRAMC. Access to TBI services will 

be at a single site in the clinical building at WRNMMC. There, the clinical screening 

teams, case managers, and multidisciplinary treatment teams will meet the patients 

and family members in one defined location. With a fully integrated staff, all members of the WRNMMC staff required in the management of patients with TBI will 

be appropriately trained and utilized regardless of their Service affiliation. 

Amputee care and physical rehabilitation will be available as part of the Orthopedic and Rehabilitation Department. Space allocations and personnel resources 

have been dedicated to support all of these programs. Medical, nursing, and support 

staff will be fully integrated, appropriately trained, and utilized in the management 

of amputee care and rehabilitation regardless of their service affiliation. 

Mr. ORTIZ. Congress has appropriated more than $5 billion to support ongoing 

construction and renovation over the past three years. What are the current lessons 

learned from the ongoing realignment of Walter Reed? How will the lessons learned 

be incorporated into future military construction contracts at other ongoing construction locations? Will elements of a world-class and premier military treatment 
95 

facility be incorporated into future designs? What is the goal of Department of Defense (DoD) Health Affairs in military construction? 

Mr. MIDDLETON. At this point, it is premature to fully evaluate the success of the 

different acquisition strategies utilized at Bethesda and Fort Belvoir. A full assessment of both will be conducted in conjunction with the U.S. Army Corps of Engineers and the Naval Facilities Engineering Command upon completion of both 

projects. The assessment will not be limited to simply cost and schedule metrics, but 

will also evaluate the degree to which key stakeholders, including patients, families, 

and staff, feel these new facilities provide patient-centric healing environments. The 

aggressive design/build and integrated design/bid/build strategies utilized by the design/construction agents were necessary and allow the Department to achieve the 

Base Realignment and Closure deadline set by law. The standard design/bid/build 

process would not have done so. Lessons learned will be incorporated into future 

military construction contracts at other locations where appropriate. This will be 

done through updates to current DoD Directives and adjustments to acquisitions 

strategies by our design/construction agents. 

The key tenets of ‘‘world-class’’ infrastructure identified by the Defense Health 

Board are already included in current DoD guidance for hospital design and construction and are being incorporated into future designs. 

The goal of OASD (Health Affairs) in military construction is to design and build 

health facilities that meet the tenets of ‘‘world-class’’ and promote a patient-centric 

healing environment while employing evidence-based design principles. 

Mr. ORTIZ. Wide discretion is provided to the Department to implement design 

standards. However, this leads to a significant disparity in the quality of facilities 

and in the case of the Bethesda Naval Medical Center, a significant difference between the new construction and the rest of the medical center. 

• In determining the construction/renovation criteria of a construction contract, 

does the Department seek to obtain the latest construction standard or does the 

amount of funding determine the scope of construction? 

• What is being done to ensure adequate housing and support services for the 

families of patients receiving extended inpatient and outpatient care at the National Military Medical Center? In addition, are there plans to improve the accommodations of Mercy Hall at NNMC to the level now found at the Malogne 

House on the WRAMC campus? 

Dr. ROBYN. [The information was not available at the time of printing.] 

Mr. ORTIZ. DUSD (I&E) has indicated their intent to limit further BRAC investments and defer further renovation investments until after BRAC so that Service 

O&M funds can be obtained. 

• Will the strategy of limiting Service O&M investments until after BRAC 

achieve the vision of a world-class medical center? 

• Does the current construction plan require BRAC appropriations to renovate 

the remaining Bethesda campus? Will the responsible services then be required 

to renovate these areas again using Operation and Maintenance appropriations? 

Dr. ROBYN. [The information was not available at the time of printing.] 

Mr. ORTIZ. According to the Defense Health Board report: ‘‘The BRAC funding 

process entails a number of constraints and limitations that do not support the creation of a comprehensive plan and construction strategy, particularly for renovation 

of existing facilities. These limitations have been, and continue to be, a major impediment to designing the new WRNMMC to be a world-class medical facility. The 

BRAC 2005 appropriation limits use of these funds.’’ Later on the report states that 

there is no need to halt construction of the new facilities if a plan can be developed 

to accomplish backfill renovations in a timely manner. 

However, there has been some discussion between DOD and the Defense Health 

Board about whether or not to halt construction while a master plan is developed 

and whether or not the BRAC law and funding process would permit development 

of a Master Plan using BRAC funds. 

• Is the Defense Health Board recommending a halt to construction while a master plan is developed? If so, how likely is DOD to meet the statutory deadline 

of September 15, 2011 for completion of this BRAC recommendation? 

• What is the timeline for DOD to create a comprehensive facility master plan? 

• How will development of a master plan affect DOD’s ability to complete construction by the September 15, 2011 deadline? 

Dr. ROBYN. [The information was not available at the time of printing.] 
96 

Mr. ORTIZ. The Army and the Navy’s approach to support to wounded warriors 

and their service members vary significantly. With this merger of these two cultures 

at the militaries premier medical center, there has been a clash of military cultures. 

• What is being done to ensure adequate housing and support services for the 

families of patients receiving extended inpatient and outpatient care at the National Military Medical Center? In addition, are there plans to improve the accommodations of Mercy Hall at NNMC to the level now found at the Malogne 

House on the WRAMC campus? 

Dr. ROBYN. [The information was not available at the time of printing.] 

Mr. ORTIZ. Bethesda National Military Medical Center Transition. The Joint Task 

Force has advocated for the transition of the Walter Reed Army Medical Center to 

occur after all construction is complete and during an abbreviated timeline of a few 

days in August 2011. This timeline raises the risk to maintaining patient care and 

has the potential for inducing a significant disruption. Will patient care suffer during the accelerated transition period? 

Admiral MATECZUN. While the NCR Medical BRAC construction and initial outfitting & transition (IO&T) timeline for Bethesda and Fort Belvoir is aggressive, the 

Department, through integrated program and project management, has developed 

comprehensive milestone schedules and a transition of operational plans as part of 

its Master Transition Plan (MTP) for the Walter Reed transition. JTF CAPMED’s 

BRAC Transition Program Management Office (PMO) is coordinating transition 

planning across all three facilities (Walter Reed Army Medical Center, National 

Naval Medical Center and Dewitt Army Community Hospital) and developing risk 

management plans to ensure patient safety and patient care is maintained during 

all phases of the transition. In addition, firms in the private sector retain hospital 

transition activities as a core competency and the IO&T contract that JTF CAPMED 

just awarded will leverage that competency. 

Patient care will not suffer during an accelerated transition period. This notion 

is supported by industry standards from world-class institutes such as UCLA, which 

transitioned all hospital services over 14 day time period, including 342 patients 

which were moved in a five hour period. 

The key to maintaining patient care and ensuring patient safety during all phases 

of the BRAC transition is proactive and comprehensive transition planning. The Department provided its initial MTP to Congress on September 30, 2009, as part of 

its response to section 1674(a) of the National Defense Authorization Act (NDAA) 

for Fiscal Year 2008. The MTP, an iterative document, explained in February 2009, 

the Joint Task Force, National Capital Region Medical (JTF CAPMED) held a Transition War Game to commence the initial transition planning among the NCR Medical stakeholders. At this War Game, group consensus was services should not transition from Walter Reed Army Medical Center (WRAMC) to Walter Reed National 

Military Medical Center (WRNMMC) and Fort Belvoir Community Hospital (FBCH) 

until all critical activities are completed at the Bethesda campus or appropriate 

mitigation strategies have been instituted. One key trigger activity is ensuring all 

essential clinical and supporting services are in place and fully functional. Several 

facilities, including clinics, staff parking garages and the Warrior Transition Center 

Complex, are not expected to be ready for occupancy until late summer 2011. The 

consensus of the group was that it is an unnecessary risk to attempt to transition 

patients and staff when the necessary facilities may not be fully operational. Following completion of these critical activities, the Department is prepared to execute 

a well orchestrated, consolidated transition of staff and patients from WRAMC will 

occur. 

To ensure industry standards and best practices are incorporated into our transition plans, JTF CAPMED conducted an in-depth study on seven major medical centers that have relocated to new facilities in the past three years. The findings of 

this study support the Transition War Game recommendation for transitioning inpatients over a consolidated period of time, as was done at major tertiary care facilities such as Catholic Health Initiatives: St. Joseph’s Medical Center in Reading, PA. 

This 200 bed teaching hospital relocated eight miles with all in-patients transferred 

in six hours. The key to a successful move with patient safety maintained is assembling a transition team to develop a move plan, ensure training and orientation of 

staff prior to the relocation, and executing a phased move of all non-patient essential functions early when space permits. 

The Department maintains that conducting a well-planned, abbreviated transition 

is the least risky option for it patients. 

Mr. ORTIZ. The Army incorporated a single-patient room standard at Fort Belvoir. 

The Navy has elected to retain the vast majority of patient rooms at two per room. 

The Independent Design Review panel has indicated that a single-patient room 
97 

standard is general practice for most medical facilities. Why did the Department include different patient room standards at Bethesda and Fort Belvoir? What is the 

industry standard? Did costs limit the ability of the Department to implement a consolidated standard? Why does the Department provide such latitude in construction 

standards? 

Admiral MATECZUN. The American Institute of Architects guidelines mandate single-patient rooms only for new hospital construction. There is no mandate to retrofit 

existing facilities, although application of this standard will be considered when undertaking major renovations of existing facilities. The Department’s standard mirrors that of the industry and is being applied to all new hospital construction in 

the Department. As a result, Fort Belvoir includes all single-patient rooms and Bethesda does not. The Department did provide additional funds to incorporate singlepatient rooms for our Wounded Warriors at Bethesda, so cost was not a factor in 

that decision. The Department will consider the need for additional single-patient 

rooms post Base Realignment and Closure as part of the ongoing master planning 

effort at the Bethesda campus. 

Mr. ORTIZ. It has been reported that the Joint Task Force is not accepting any 

additional clinician input into the design process. Will the Department continue to 

accept clinician input into the design and construction process? Will these suggestions result in changes into the overall layout? 

Admiral MATECZUN. Clinician as well as patient input has been integral to ensuring the design of the new Walter Reed National Military Medical Center, and the 

Fort Belvoir Community Hospital will meet all future mission requirements and 

provide an unparalleled standard of care for this Nation’s most deserving patients. 

However, as the construction process moves forward and in some portions of the 

project nears completion, there is less flexibility in adjusting designs without significantly delaying delivery of the buildings, incurring an unacceptable increase in cost, 

or violating contractual agreements. 

Regardless of these obstacles the Department continues to evaluate clinician and 

patient input. Also, where it is prudent to preserve the safety and quality of patient 

care, it has sought additional funding to incorporate these changes. Some of these 

changes have significantly changed the interior designs of the wards and clinics but 

have not impacted the exterior design of the buildings. The revised design of the 

Cancer Center and the improved design of the Optometry Clinic are indicative of 

the changes the Department has made during the construction process. 

The Department continues to compile inputs from clinicians to appropriately implement in the non-BRAC projects that the Department identifies are required to 

achieve ‘‘world-class’’ standards, as defined under section 2714 of the National Defense Authorization Act for fiscal year 2010. 

Mr. ORTIZ. Medical Care and Facilities Merging. The impending merger has produced a high degree of anxiety among many medical and non-medical staff. Some 

staff report that they have been informed that their positions will be terminated; 

some have been told that staffing plans have been changed and that they will be 

retained after all; some are in limbo. What is being done to ensure adequate housing 

and support services for the families of patients receiving extended inpatient and 

outpatient care at the National Military Medical Center? In addition, are there 

plans to improve the accommodations of Mercy Hall at NNMC to the level now 

found at the Malogne House on the WRAMC campus? 

Admiral MATECZUN. Medical Centers within the Department of Defense are always constructed to meet current and future mission requirements by using the 

most up-to-date standards. All medical projects at Walter Reed National Military 

Medical Center (WRNMMC) and at Fort Belvoir are designed based upon standards 

as described in the Unified Facilities Criteria (UFC) 4–510–01, ‘‘Design: Medical 

Military Facilities’’ issued by the Department of Defense. The UFC is developed and 

maintained by DoD medical engineering and design experts based upon the ‘‘best 

practices’’ in industry. As such, DoD medical projects have always been required to 

meet, if not exceed, industry standards. Currently, the Department is developing a 

Comprehensive Master Plan for the NCR Medical that will identify the requirements to achieve ‘‘world-class’’ standards, as defined and directed under section 

2714 of the National Defense Authorization Act for fiscal year 2010, at Bethesda. 

The Department is utilizing existing assets and construction donated by private 

entities to provide housing for families of patients receiving extended inpatient and 

outpatient care at the WRNMMC. Currently, existing Navy Lodge, Fisher Houses, 

and Visiting Officer Quarters are available to provide temporary housing for families of patients. Those facilities will be augmented by three (3) new Fisher Houses 

which are currently under construction and will provide an additional 60 family 

suites. At present, there are no plans for additional renovation of Mercy Hall. Mercy 

Hall was built in 1968 and renovated to current Americans with Disabilities Act 
98 

(ADA) standards in 2008, providing 98 fully ADA compliant single occupancy rooms. 

The Hall is sited near inpatient and certain administrative services for wounded 

warriors and has proven to be an excellent facility in which to house wounded warriors that require close proximity to these services and require additional supervision to function as an outpatient. There is no intention to use Mercy Hall as temporary family accommodations. However, the Department is working diligently to 

define additional temporary housing requirements for the families of patients that 

will receive care at the new WRNMMC. 

Regarding support services, there are already plans in place to expand support 

services on the Bethesda Campus. The Navy Exchange (NEX) will start construction 

of its new facility in Calendar Year 2010. The new NEX will be more than triple 

the size of the current NEX and will allow the NEX to carry a broader array of 

goods tailored to meet the needs of wounded warriors and their families. The Department will also provide a great number of services for Warriors in Transition 

(WIT) to include a physical fitness center that will be sized to properly accommodate 

the space and access requirements of the WRNMMC WIT population and allow 

them to exercise alongside other Warriors and caregivers. This will support integration and re-integration of WITs into their community, and the reestablishment of 

the warrior/athlete ethos. Additionally, Commander Navy Installations Command 

(CNIC) is proactively seeking to significantly expand child care services. These services are not currently available on the Campus. 

Mr. ORTIZ. Medical Care and Facilities Merging. The impending merger has produced a high degree of anxiety among many medical and non-medical staff. Some 

staff report that they have been informed that their positions will be terminated; 

some have been told that staffing plans have been changed and that they will be 

retained after all; some are in limbo. What is being done to facilitate a successful 

merger of the NNMC and WRAMC personnel? What is being done to maintain morale before, during, and following the merger? In addition, what are the current and 

planned post merger staffing by department or function at NNMC and WRAMC? If 

changes are planned post merger, why are these changes needed and what will be 

the impact on the provision of needed medical care? 

Admiral MATECZUN. At Walter Reed Army Medical Center (WRAMC), it will be 

important to maintain the civilian workforce to preserve current capability and to 

staff both of the new hospitals. Extensive planning has been accomplished to implement the Department mandated Guaranteed Placement Program (GPP) for WRAMC 

hospital personnel and to effectively merge Army and Navy employees into a single 

workforce of civilians at the new Walter Reed National Military Medical Center 

(WRNMMC). Leadership representatives from the four National Capital Region hospitals are members of the Civilian Human Resources Council, a group chartered to 

ensure placement of employees who remain at WRAMC through closure. In order 

to meet the dual goals of the GPP commitment and the creation of a ‘‘world-class’’ 

workforce, the Council will identify Service best practices to develop the new National Capital Region Medical culture of the future. The Council members are working collaboratively to modify current position management and hiring processes at 

WRAMC and the National Naval Medical Center (NMMC) in order to maximize the 

placement of WRAMC employees in their location of choice in 2011. The Department 

plans to begin notifying individuals of their work locations in the end-state in 

Spring/Summer 2010, after the final validation of the new hospital staffing plans 

is complete. 

The Department’s civilian workforce is a center of gravity. It strives to maintain 

morale by communicating updates on the BRAC Integration and Transition progress 

to employees using venues such as monthly Town Hall meetings, electronic, and 

print media. This type of communication will continue after the BRAC integration 

to facilitate ongoing dialogue needs of employees. A detailed plan has been developed to guide the transition and integration of employees from WRAMC to 

WRNNMC and Fort Belvoir Community Hospital (FBCH). Beginning with the approval of a Joint Table of Distribution (JTD), it seeks to align the current workforce 

using workforce planning techniques that optimize the assignment of employees, coordinate efforts by civilian Human Resources Specialists (HR), and establish standardized policies/processes that will ensure quality HR support in the future. 

Mr. ORTIZ. What recommendations can be offered to ensure that the construction 

designs obtain a world-class standard? 

Dr. KIZER. The National Capital Region Base Realignment and Closure Health 

Systems Advisory Subcommittee (NCR BRAC HSAS) of the Defense Health Board 

has made many specific recommendations for what needs to be done for the design 

of the new Walter Reed National Military Medical Center (WRNMMC) to more likely achieve world class status. These recommendations were detailed in our report 
99 

last June, copies of which, I understand, were provided to the House Armed Services 

Committee by the Department of Defense last July. 

In viewing our recommendations it should be remembered that this is not a static 

process and that as design changes and renovations are made additional concerns 

or issues may arise. Also, as noted in our report and in my testimony, the facility 

design and construction will not in and of itself make the new WRNMMC a world 

class medical facility, although it may prevent it from achieving such a level of excellence. Most of what will make the new WRNMMC a world class medical facility 

will be its ‘‘invisible architecture’’—i.e., its values, culture, leadership, staff morale 

and processes of care. 

As noted in our report and in my testimony, the three most urgent needs in this 

regard are to: (1) resolve the authority issue; (2) align funding sources; and (3) rapidly develop a master plan. 

Mr. ORTIZ. If changes are implemented in the renovation effort, could they be implemented and still obtain the September 2011 BRAC deadline? 

Dr. KIZER. It will be very difficult. If this deadline is to be met, then substantive 

work on the master plan and changes in the renovation effort must begin immediately. The likelihood of meeting the deadline diminishes every day that progress 

is not made in addressing the identified needs. 

Mr. ORTIZ. In your estimate, what is the risk associated with moving the Walter 

Reed functions to Bethesda/Fort Belvoir by September 2011? What are the consequences (in terms of patient care)? 

Dr. KIZER. If the NCR BRAC HSAS recommendations are addressed and implemented then there should be little risk. If they are not adequately addressed, then 

the consequences will depend on what problem(s) is/are not addressed, among other 

factors. 

Depending on what specific problem(s) is/are not addressed, then care could be 

compromised in multiple ways, including patient safety, infection control, patient 

and family comfort, staff morale, confusion in way finding, physician and nurse productivity, and provision of critical services, to name some. 

QUESTIONS SUBMITTED BY MS. BORDALLO 

Ms. BORDALLO. Section 722 the National Defense Authorization Act for Fiscal 

Year 2008 called for the establishment of a Joint Pathology Center as a successor 

to the current Armed Forces Institute of Pathology. The legislation established a 

mandate to perform at least for core minimum functions: 

1. Diagnostic pathology consultation services in medicine, dentistry, and veterinary sciences; 

2. Pathology education, to include graduate medical education, including residency and fellowship programs, and continuing medical education; 

3. Diagnostic pathology research; and 

4. Maintenance and continued modernization of the Tissue Repository and, as appropriate, utilization of the Repository in conducting the activities described in 

paragraphs (1) through (3). 

Notwithstanding this mandate, the Defense Health Board has on two separate occasions criticized the concept of operations for the Joint Pathology Center as insufficient to carry out the its mandate. Furthermore, in light of the National Defense 

Authorization Act for Fiscal Year 2010’s mandate to create a master plan that will 

‘‘ensure the delivery of world class military medical facilities across the National 

Capital Region’’, what concrete actions is the Department of Defense taking to ensure that the Joint Pathology Center will meet that world class standard? 

Mr. MIDDLETON. Section 722 of the National Defense Authorization Act (NDAA) 

for Fiscal Year (FY) 2008 mandated a Joint Pathology Center (JPC) be established 

in to function as the reference center in pathology for the Federal Government. Is 

stated that the JPC should provide at a minimum: 

• Diagnostic pathology consultation in medicine, dentistry, and veterinary services; 

• Pathology education, to include graduate medical education, including residency 

and fellowship programs; 

• Diagnostic pathology research 

• Maintenance and continued modernization of the Tissue Repository 

Additionally, the JPC must be established consistent with BRAC law. 
100 

The Department of Defense (DoD) chartered a JPC work group in April 2008, that 

included senior leadership from the Armed Forces Institute of Pathology (AFIP), 

Uniformed Services University of the Health Sciences (USUHS), Military Services, 

Department of Veterans Affairs, and Department of Health and Human Services to 

develop options for a JPC within the Department. The JPC Working Group was instrumental in developing the initial Concept of Operations (CONOPS) to meet the 

mandate under Section 722 of the NDAA for FY 2008. Based on the initial 

CONOPS, the Department chose to establish the JPC under the Joint Task Force, 

National Capital Region Medical (JTF CAPMED). 

Upon delegation of the JPC mission to JTF CAPMED in December 2009, an interim director was appointed. Prior to this, JTF CAPMED took the lead in establishing an inter-organizational Implementation Team consisting of members from 

the three Services, VA, USUHS, AFIP, OASD (Health Affairs), and Office of the 

Army Surgeon General to carefully review the concept of operations, identify gaps 

in proposed services, and develop an expanded concept of operations and implementation plan. As a result of this analysis, several critical services were identified and 

additional personnel requirements to appropriately staff the JPC were also identified. A detailed concept of operations and implementation that includes these critical services and personnel requirements is being finalized. Additionally, the JPC is 

working closely with AFIP to finalize a phased implementation plan for the JPC to 

enable the proper transfer of function to the JPC without loss of continuity of clinical care while appropriately balancing and addressing civilian personnel considerations. 

The Defense Health Board (DHB), in its advisory role to the Department, reviewed the initial JPC CONOPS, which was not a detailed implementation plan. 

The implementation plan under development by the JPC Implementation Team addresses the concerns of the DHB and will meet the recommendations of the DHB 

review with the exception of JPC oversight being provided by a Board of Governors. 

Based on the JPC’s mission set, the Department recommends a Federal Board of 

Advisors comprised of primary stakeholders. 

The depth and scope of clinical services provided by the JPC include, but are not 

limited to the list below. In some areas, the services will be more robust than those 

provided by AFIP. 

• The JPC will provide full-spectrum, comprehensive, expert secondary pathology 

consultation to the federal government utilizing state-of-the-art immunohistochemical and molecular diagnostic studies. 

• The JPC will be one of the few centers in the country offering full-service muscle biopsy analysis and comprehensive Depleted Uranium testing and imbedded 

fragment analysis in support of our wounded warrior population and operations 

in-theater and will provide full-spectrum pathology support for the critical 

Armed Forces Medical Examiner mission. 

• The JPC will continue and expand the AFIP mission of providing telemedicine 

expert consultation (telepathology) to remote hospitals and in support of pathology services in theater and overseas. 

• The JPC will continue the AFIP mission of providing a one-of-a-kind comprehensive Veterinary Pathology service to the Department and several other 

federal government agencies that includes Veterinary Pathology Consultation, 

research, education to veterinarians worldwide, and a Veterinary Pathology 

Residency Training Program for the Department. 

• The JPC will leverage state-of-the-art and evolving technology in providing its 

education mission through robust online educational opportunities to government physicians worldwide and will provide graduate medical education in support of government residency and fellowship programs nationwide. 

• The JPC will support critical clinical research missions such as the Combat 

Wound Initiative and Traumatic Brain Injury initiatives. 

• JTF CAPMED recognizes that the Tissue Repository is an invaluable asset that, 

if appropriately utilized, could be the leading Tissue Biorepository and greatly 

advance medical knowledge and technology. The JPC will partner with leaders 

in medical research and biorepository management to carefully develop a comprehensive plan to fully utilize the vast Tissue Repository in support of medical 

research throughout the federal government and in partnership with civilian 

academic institutions. 

Ms. BORDALLO. Some members of the community surrounding the current Bethesda Naval Hospital have raised concerns about the level of interagency cooperation specifically between Navy, Army and NIH. In particular, there is significant 
101 

concern about the impact to traffic in the area. The stretch of Wisconsin Avenue 

that is impacted greatest by the realignment is already extremely congested during 

peak travel hours. A recent GAO report on the Guam military build-up reiterated 

the need for the convening of a meeting of the Economic Adjustment Committee to 

better coordinate all federal government resources. Would a meeting of the Economic Adjustment Committee better help facilitate an improved federal government 

interagency process to address the ‘‘outside the fence’’ impacts at Bethesda Naval 

Hospital? 

Dr. ROBYN. [The information was not available at the time of printing.] 

QUESTIONS SUBMITTED BY MR. LOEBSACK 

Mr. LOEBSACK. How will you assure that patients receive the absolute best care 

in specialties such as pain care, mental health, TBI care, and prosthetic care at the 

new Walter Reed facility in Bethesda? Particularly on the pain care issue—Walter 

Reed is a leader in this specialty amongst the military medical facilities. How will 

this care be maintained and enhanced in the new facility? Are there specific issues 

that must be taken into account for specialties such as pain care and physical therapy that are being incorporated into the design plans for the new campus? 

Mr. MIDDLETON. The Department will continue to provide absolute best care to 

patients at the new Walter Reed National Military Medical Center (WRNMMC). 

The Army’s capabilities at WRAMC with amputee care are leading transformations 

in prosthetics and rehabilitation and the Navy’s expertise in open Traumatic Brain 

Injury (TBI) at NNMC is renowned world-wide. The integrated clinical chiefs of all 

the current departments within the National Naval Medical Center (NNMC) and 

the Walter Reed Army Medical Center (WRAMC) are dedicated to preserving the 

tradition of excellence that distinguishes both healthcare providers today. 

Pain Management—WRAMC has become a center of clinical expertise for the art 

and science of advanced regional anesthesia techniques and acute pain management. This has become invaluable in the management of pain in both the austere 

environment of war and in the civilian clinical setting. Since this clinical advancement plays such a significant role in current and future operations, dedicated clinical space and personnel have been committed for both regional anesthesia and 

chronic pain management clinics planned for the Walter Reed National Military 

Medical Center. In Building 9, 8,500 sq. ft. of space is dedicated to the Pain Care 

Center of Excellence which will maintain the ‘‘world-class’’ expertise and training 

capabilities currently available at WRAMC. 

Mental Health—Psychological health issues have become one of the most prominent injuries of the current conflicts. The Department has increased capacity to address these issues commensurate with the mission requirements. The new organizational structure will include both psychiatry and psychology as separate departments with personnel assigned that match these needs. In the new outpatient clinic, 

45,000 sq. ft. of space primarily on the sixth level of Building A is dedicated to outpatient behavioral health. A robust partial hospitalization program to decrease the 

demand for inpatient beds has been designed in line with the current program at 

WRAMC and the Defense Veterans Brain Injury Center (DVBIC) clinical component. There will be two new inpatient psychiatry wards (27,000 sq. ft. in Building 

10) with a total bed capacity of 28. An additional 12 inpatient beds and partial hospitalization capabilities are designed for the new Fort Belvoir Community Hospital 

(FBCH). 

Traumatic Brain Injury (TBI)—Treatment for Traumatic Brain Injury will include 

a six bed specialty inpatient ward and a highly functional multi-disciplinary clinical 

group that includes clinical neurologists, psychiatrists, psychologists, orthopedists, 

physical and occupational therapists, neuropsychometrists, and other traumatic 

brain injury specialists. These programs will transition and integrate available expertise from both NNMC and WRAMC programs. All clinical expertise will be in 

close proximity to the new National Intrepid Center of Excellence at Bethesda that 

is dedicated to research, diagnosis and treatment of military personnel and veterans 

suffering from traumatic brain injury and psychological health issues. 

Prosthetic Care—Military beneficiaries (active duty, retirees and dependants) 

with upper and lower extremity amputations currently receive the best medical care 

in the world. Nearly one whole floor in the new outpatient clinic addition (Building 

A) will be dedicated to physical medicine modalities with additional services and diagnostic support provided on two other floors. Over 115,000 sq. ft. is dedicated to 

Physical Therapy, Physical Medicine and Rehabilitation, Occupational Therapy, Amputee Center, Orthotics, Prosthetics, Chiropractic Services, Orthopedics, Podiatry, 

and a satellite Laboratory, Radiology, and Pharmacy on the first three floors of the 
102 

new outpatient clinic. This represents the largest physical medicine footprint in all 

of the Department of Defense and will continue to provide WRAMC’s current capabilities in the care of amputees and the manufacture and adjustment of state-of-theart upper and lower extremity prosthetics. 

Physical Therapy—Physical therapy plays a major role in the rehabilitation of 

amputees, traumatic brain injured, and psychologically injured patients. Clinical 

space in the new clinical building outlined above and in the inpatient areas have 

been designed to offer the best medical care to these injured patients. Appropriate 

personnel have been designated on the current manpower document to complete the 

mission in these areas. 

Mr. LOEBSACK. How will you assure that patients receive the absolute best care 

in specialties such as pain care, mental health, TBI care, and prosthetic care at the 

new Walter Reed facility in Bethesda? Particularly on the pain care issue—Walter 

Reed is a leader in this specialty amongst the military medical facilities. How will 

this care be maintained and enhanced in the new facility? Are there specific issues 

that must be taken into account for specialties such as pain care and physical therapy that are being incorporated into the design plans for the new campus? 

Dr. ROBYN. [The information was not available at the time of printing.] 

Mr. LOEBSACK. How will you assure that patients receive the absolute best care 

in specialties such as pain care, mental health, TBI care, and prosthetic care at the 

new Walter Reed facility in Bethesda? Particularly on the pain care issue—Walter 

Reed is a leader in this specialty amongst the military medical facilities. How will 

this care be maintained and enhanced in the new facility? Are there specific issues 

that must be taken into account for specialties such as pain care and physical therapy that are being incorporated into the design plans for the new campus? 

Admiral MATECZUN. The Department will continue to provide absolute best care 

to patients at the new Walter Reed National Military Medical Center (WRNMMC). 

The Army’s capabilities at WRAMC with amputee care are leading transformations 

in prosthetics and rehabilitation and the Navy’s expertise in open Traumatic Brain 

Injury (TBI) at NNMC is renowned world-wide. The integrated clinical chiefs of all 

the current departments within the National Naval Medical Center (NNMC) and 

the Walter Reed Army Medical Center (WRAMC) are dedicated to preserving the 

tradition of excellence that distinguishes both healthcare providers today. 

Pain Management—WRAMC has become a center of clinical expertise for the art 

and science of advanced regional anesthesia techniques and acute pain management. This has become invaluable in the management of pain in both the austere 

environment of war and in the civilian clinical setting. Since this clinical advancement plays such a significant role in current and future operations, dedicated clinical space and personnel have been committed for both regional anesthesia and 

chronic pain management clinics planned for the Walter Reed National Military 

Medical Center. In Building 9, 8,500 sq. ft. of space is dedicated to the Pain Care 

Center of Excellence which will maintain the ‘‘world-class’’ expertise and training 

capabilities currently available at WRAMC. 

Mental Health—Psychological health issues have become one of the most prominent injuries of the current conflicts. The Department has increased capacity to address these issues commensurate with the mission requirements. The new organizational structure will include both psychiatry and psychology as separate departments with personnel assigned that match these needs. In the new outpatient clinic, 

45,000 sq. ft. of space primarily on the sixth level of Building A is dedicated to outpatient behavioral health. A robust partial hospitalization program to decrease the 

demand for inpatient beds has been designed in line with the current program at 

WRAMC and the Defense Veterans Brain Injury Center (DVBIC) clinical component. There will be two new inpatient psychiatry wards (27,000 sq. ft. in Building 

10) with a total bed capacity of 28. An additional 12 inpatient beds and partial hospitalization capabilities are designed for the new Fort Belvoir Community Hospital 

(FBCH). 

Traumatic Brain Injury (TBI)—Treatment for Traumatic Brain Injury will include 

a six bed specialty inpatient ward and a highly functional multi-disciplinary clinical 

group that includes clinical neurologists, psychiatrists, psychologists, orthopedists, 

physical and occupational therapists, neuropsychometrists, and other traumatic 

brain injury specialists. These programs will transition and integrate available expertise from both NNMC and WRAMC programs. All clinical expertise will be in 

close proximity to the new National Intrepid Center of Excellence at Bethesda that 

is dedicated to research, diagnosis and treatment of military personnel and veterans 

suffering from traumatic brain injury and psychological health issues. 

Prosthetic Care—Military beneficiaries (active duty, retirees and dependants) 

with upper and lower extremity amputations currently receive the best medical care 

in the world. Nearly one whole floor in the new outpatient clinic addition (Building 
103 

A) will be dedicated to physical medicine modalities with additional services and diagnostic support provided on two other floors. Over 115,000 sq. ft. is dedicated to 

Physical Therapy, Physical Medicine and Rehabilitation, Occupational Therapy, Amputee Center, Orthotics, Prosthetics, Chiropractic Services, Orthopedics, Podiatry, 

and a satellite Laboratory, Radiology, and Pharmacy on the first three floors of the 

new outpatient clinic. This represents the largest physical medicine footprint in all 

of the Department of Defense and will continue to provide WRAMC’s current capabilities in the care of amputees and the manufacture and adjustment of state-of-theart upper and lower extremity prosthetics. 

Physical Therapy—Physical therapy plays a major role in the rehabilitation of 

amputees, traumatic brain injured, and psychologically injured patients. Clinical 

space in the new clinical building outlined above and in the inpatient areas have 

been designed to offer the best medical care to these injured patients. Appropriate 

personnel have been designated on the current manpower document to complete the 

mission in these areas. 

Æ