Military Personnel: Enhanced Collaboration and Process Improvements Needed for Determining Military Treatment Facility Medical Personnel Requirements
Published: 2010-07-29T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Military medical personnel, who are essential to maintaining one of the largest and most complex health systems in the nation, are in great demand due to the need to treat injured or ill servicemembers, and advances in technology that require specialized personnel. To determine how well the Department of Defense (DOD) and the services are developing their medical and dental personnel requirements, GAO evaluated (1) the extent to which the services have incorporated cross-service collaboration in their medical personnel requirement processes, and (2) the service-specific processes for determining their requirements for military and civilian medical personnel. To conduct this review, GAO evaluated manpower policies, analyzed the services' requirements data and determination processes, and interviewed officials from the Office of the Secretary of Defense (OSD) and each of the services.
section_title: What GAO Found
paragraphs: While DOD's 2007 Military Health System Human Capital Strategic Plan emphasizes developing human capital solutions across the services to enable departmentwide decision making and analyses, the services' collaborative planning efforts regarding requirements determination for medical personnel working in fixed military treatment facilities have been limited. In one effort to integrate operations, DOD is consolidating medical facilities in the Washington, D.C., area under a joint task force that calls for joint staffing of the military treatment facilities in the region. However, officials have faced challenges in developing the manpower requirements for the joint facilities due to the use of outdated planning assumptions. Separately, the Office of the Secretary of Defense (OSD) sponsored another joint medical effort to develop a cross-service medical manpower standard for mental health personnel. This standard is being used to determine the amount of personnel needed to meet common, day-to-day psychological health needs of eligible beneficiaries across the services. However, to date, this standard is the only one of its kind, and OSD officials said that no other similar efforts currently exist. The services' continued focus on separate medical personnel requirements processes may not be consistent with the DOD strategic plan's vision of a more integrated approach, and the services may have missed opportunities to collaborate and develop cross-service manpower standards for common medical capabilities that are shared across military treatment facilities. Sustained and committed leadership emphasis on developing more effective ways of doing business, such as the use of cross-service medical manpower standards, is key to successful, collaborative human capital strategic planning. To the extent that the services need to maintain separate processes, GAO also found that their requirements processes are not, in all cases, validated and verifiable, as DOD policy requires. Selected specialty modules in the Army's model contain some outdated assumptions, such as the level of care currently being provided, and only a portion of the modules have been completely validated. While the Navy has employed an approach that uses current manning as a baseline and adjusts its requirements based on emerging needs or major changes to missions, the approach is not validated or verified as required by DOD guidance. The Air Force said it may not know its true medical requirements as the model it has relied on also is not currently validated or verified. Each of the services has recognized the need to have processes that can be validated and verified, and has taken steps to address these issues in recent years. However, without processes that are validated and verifiable, the services cannot be certain they are determining their medical personnel requirements in the most effective and efficient manner. Also, the services do not centrally manage their processes for their civilian medical personnel requirements. While local commanders determine these requirements, the services may be missing the opportunity to make a strategic determination of how many civilian medical professionals are needed to carry out their expected workloads.
section_title: What GAO Recommends
paragraphs: GAO recommends that OSD and the services emphasize a long-term joint approach to medical personnel requirements determination by identifying the common medical capabilities shared across the services and developing cross-service medical manpower standards, where applicable; and that the services take actions to improve their respective medical requirements determination processes. In written comments to a draft of this report, DOD generally concurred with these recommendations.

section_title: Letter
paragraphs: The physicians, dentists, nurses, and other health care personnel who  work for the Department of Defense (DOD) are in great demand due to  projected nationwide medical personnel shortages over the next decade  and are essential to maintaining DOD’s substantial health care delivery  capability, which provides a full range of medical care to active duty  military personnel and all other eligible beneficiaries sometimes at no  cost. With more than 9.6 million eligible beneficiaries receiving care from  DOD’s 59 inpatient medical facilities, 364 health clinics, and, at times,  private-sector providers, the cost of DOD’s medical system has risen from  $17.4 billion in fiscal year 2000 to approximately $50 billion in fiscal year  2010, and it currently represents more than 9 percent of the DOD budget.  Moreover, health care costs are expected to continue to escalate in the  future. Because this amount does not include the cost of health care that is  needed overseas to support two concurrent wars, or the costs to recruit  and retain military personnel, the total amount DOD is spending on  military health care is even higher. U.S. forces are expected to continue  operations in Iraq and Afghanistan and, as a result, add to the workload of  military treatment facilities for servicemembers who become injured or ill.  Although tremendous advances in military medicine have led to reduced  mortality rates among U.S. servicemembers, these patients may require  lengthy hospital stays and extensive rehabilitation with highly trained staff  to meet their medical care needs. A higher demand for health care  personnel is also anticipated due to the increased numbers of overall  personnel in both the Army and the Marine Corps from an effort known as  Grow the Force. Key in its efforts to address the challenge of managing the  medical forces across the services and determining the right number and  mix of medical personnel to meet the various needs of the Military Health  System is DOD’s plan to promote collaboration and integration in human  capital management, while simultaneously respecting service-specific  doctrine. Further, DOD’s implementation of several strategic initiatives,  such as Base Realignment and Closure decisions and the development of  several joint ventures under its evolving framework for a Joint/Unified  Medical Command, have forced the department to undertake steps  designed to re-examine, among other things, its medical personnel  requirements.
Our previous work has highlighted a range of long-standing issues  surrounding DOD’s Military Health System. For example, we reported in  March 1995 that interservice rivalries and conflicting responsibilities  hindered Military Health System improvement efforts. We noted in that  report that the services have historically resisted efforts to change,  preferring to maintain their own health care systems, primarily on the  grounds that each service has unique medical activities and requirements.  In our February 2005 report on challenges facing the U.S. government   in the 21st century, we identified DOD’s health care system as an area in  which DOD could achieve economies of scale and improve delivery by  combining, realigning, or otherwise changing selected support functions.  That report noted that although DOD’s civilian and military leaders appear  committed to reform, DOD must overcome cultural resistance in the  individual services, as well as the inertia of various organizations, policies,  and practices (such as “stovepiping” or compartmentalizing of information  or functions) that became well rooted in the Cold War era. In October  2007, we reported that DOD had taken incremental steps toward  improving efficiencies within its Military Health System by establishing a  joint medical effort in the National Capital Region, as well as the Joint  Medical Education and Training Center in San Antonio, Texas. While we  recognized that incremental improvements are sometimes appropriate, we  recommended that DOD take steps to measure whether its efforts were  meeting the goal of eliminating unnecessary duplication. DOD concurred  with this recommendation and has identified the steps that the department  has taken to address it. Further, DOD’s April 2006 Quadrennial Defense  Review Roadmap for Medical Transformation recognized the  department’s need to transform its Military Health System, and the 2010  Quadrennial Defense Review acknowledged that DOD needs to reform  the way in which it does business and to eliminate challenges that hinder  its success.
The Senate Armed Services Committee, in its report accompanying the  National Defense Authorization Act for Fiscal Year 2009, directed GAO   to report to congressional defense committees on medical and dental  personnel requirements of the Departments of the Army, Navy, and Air  Force, including their reserve components, in order to, among other  things, meet their medical missions in support of contingency operations  and deliver high quality health care to eligible beneficiaries. In April 2009,  we responded to that mandate in a published briefing to the defense  committees on personnel authorizations and end strengths, by medical  specialty. Subsequently, we agreed with congressional defense  committees to undertake additional related work and initiated two reviews  on issues related to military medical and dental personnel requirements in  support of (1) fixed military treatment facilities and (2) contingency  operations in Iraq and Afghanistan. For this report, we focused on  medical and dental personnel requirements in support of DOD’s fixed  military treatment facilities. We evaluated (1) the extent to which the  services have incorporated cross-service collaboration in their planning  efforts for determining their medical personnel requirements, and (2) the  service-specific processes for determining their requirements for military  and civilian medical personnel.
For our first objective, we analyzed DOD and Army, Navy, and Air Force  policies, directives, and other relevant strategic planning documents. We  also obtained and analyzed memoranda and other documents related to  DOD and the services’ ongoing collaborative efforts. Further, we  interviewed various officials from the Office of the Assistant Secretary of  Defense for Health Affairs and each of the services to obtain a more  detailed understanding of the history, objectives, status, and challenges of  their ongoing cross-service medical efforts. For our second objective, we  analyzed instructions concerning personnel management procedures from  each of the services. We also obtained and examined personnel  requirements and authorized positions data for selected medical  specialties for fiscal year 2009 and evaluated the reliability of the data we  obtained and analyzed. We found it sufficiently reliable for the purposes of  this audit. Additionally, we obtained and analyzed existing service  requirements models in use and interviewed officials from each of the  services in order to understand the processes they implement to determine  their specific service’s medical personnel requirements. For more detailed  information on our scope and methodology, see appendix I.
We conducted this performance audit from August 2009 through July 2010  in accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: DOD’s medical mission is twofold in that it maintains a readiness mission  and a benefits mission. The readiness mission requires DOD to maintain  the needed availability of its uniformed medical personnel in order to  support the armed forces during military operations. The benefits mission  provides servicemembers, retirees, and their dependents with access to  health care at its military hospitals and clinics throughout the United  States and overseas. Military medical personnel are essential to  maintaining DOD’s large and complex health system and are in great  demand because of the need to treat injured or ill servicemembers and due  to advances in medical technologies that require specialized personnel.  They simultaneously support contingency operations, military operations  that are more routine in nature, medical research efforts, and the delivery  of beneficiary health care to patients across the globe.
The management organization of DOD’s Military Health System comprises  many levels. The Assistant Secretary of Defense for Health Affairs is the  principal advisor for all DOD health policies, programs, and force health  protection activities, and this official reports to the Under Secretary of  Defense for Personnel and Readiness, who in turn reports to the Secretary  of Defense. Health Affairs issues policies, procedures, and standards that  govern DOD medical programs and has the authority to issue DOD  instructions, publications, and directive-type memoranda that implement  policy approved by the Secretary of Defense. It integrates the services’  submissions and prepares, presents, and justifies a unified medical budget  that provides resources for the Military Health System. Health Affairs is  also authorized to communicate directly with the heads of DOD  components regarding these issues. Additionally, Health Affairs develops  policies and standards to ensure effective and efficient results through the  approved joint process for joint medical capabilities integration, clinical  standardization, and operational validation of all medical material.
The Secretaries of the Departments of the Army, Navy, and Air Force are  responsible (subject to the authority, direction, and control of the  Secretary of Defense) for the operation and efficiency of their  departments. In addition, the service secretaries issue implementation  instructions to their departments based on policies that Health Affairs  develops. By law, the service secretaries are also responsible (again,  subject to the authority, direction, and control of the Secretary of Defense)  for promoting cooperation and coordination among the military  departments and defense agencies to provide effective, efficient, and  economical administration, and to eliminate duplication.
The Army, Navy, and Air Force have their own Surgeons General who  have overall responsibility for medical operations within their respective  departments. Within the Army, the Army Surgeon General simultaneously  heads the Army Medical Department and the Army Medical Command. In  leading the Army Medical Department, the Surgeon General serves as the  primary advisor to the Secretary of the Army on all health and medical  issues. In addition, the Army Surgeon General has overall responsibility  for the Armywide health services system to include development, policy  direction, organization, and management of the system through such  activities as recruiting, organizing, equipping, supplying, and training, as  assigned by the Secretary of the Army. As the Commanding General of the  Army Medical Command, the Surgeon General leads five regional medical  commands and their fixed military treatment facilities, and other Army  Medical Department agencies. The Navy Surgeon General serves as the  Director of Naval Medicine and is the Chief of the Navy Bureau of  Medicine and Surgery. As the director of Naval Medicine, the Surgeon  General is the principal advisor to the Chief of Naval Operations on health  care service programs for the Department of the Navy, and develops and  issues health care policies and directions. As the chief of the Navy Bureau  of Medicine and Surgery, the Surgeon General oversees the delivery of  health care in the Navy and Marine Corps and commands the Navy shore  medical facilities. The Air Force Surgeon General is that service’s most  senior medical officer and head of the Air Force Medical Service. The   Air Force Surgeon General is responsible for guidance, direction, and  oversight for all matters pertaining to the formulation, review, and  execution of plans, policies, programs, and budgets related to carrying out  the mission of the Air Force Medical System to provide for the health care  of Air Force personnel and their families.
The service medical components contribute to the Military Health System  missions by operating military treatment facilities throughout the United  States and the world. These facilities consist of 59 hospitals capable of  providing diagnostic, therapeutic, and inpatient care, as well as hundreds  of clinics that primarily handle health screenings and ambulatory care.   The Army, Navy, and Air Force staff their military treatment facilities with  active duty, reserve, and civilian personnel. Contractors also play a role in  the execution of the Military Health System mission by providing medical,  clinical, and administrative staff and support services within both the  military treatment facilities and the network of private hospitals and  providers in the community. Reliance on contractors in the medical  community varies by location and need. DOD is not required by law to  include the number of medical contractors it employs in its annual Defense  Manpower Requirements Report; therefore, the number of medical  contractors onboard at any point in time is not readily available. DOD’s  medical force is comprised of approximately 228,000 personnel, including  about 116,000 active duty personnel, 67,000 reserve component personnel,  and 45,000 civilians. As seen in figure 1, the distribution of the medical  workforce is fairly proportional to the distribution of the total workforce  for each of the three services.
Although the personnel distribution varies by service, collectively the  active duty and reserve workforces make up approximately 80 percent of  the medical force, with the active duty comprising about 51 percent and  the reserves 29 percent. Civilians comprise 20 percent of the medical  workforce. In providing technical comments to a draft of this report,   DOD noted that among the military services, the Army has the highest  percentage of civilians. For example, within the Army Medical Command,  58 percent of its fiscal year 2011 medical workforce is projected to be  comprised of Army civilians.
According to the 2007 Military Health System Human Capital Strategic  Plan, the medical workforce is comprised of several specialty medical  corps, including Medical, Dental, Nurse, Medical Service, Medical  Specialist, Biomedical Sciences, Veterinary, Warrant Officers, Medical  Enlisted, and Dental Enlisted. This plan also states that the largest corps   is the active duty Medical Enlisted Corps, which consists of about 75,000  individuals and makes up about 65 percent of DOD’s active duty medical  force. Figure 2 represents the distribution of active duty medical personnel  by specialty.
A more detailed breakout of each of the services’ medical specialty  personnel levels is presented in appendix II. That appendix shows, for  fiscal year 2009, how each of the services allocated its positions within  each of its medical specialties based on identified needs, financial  resources, and personnel availability.
section_title: DOD’s Policy Emphasizes Jointness, although the Services’ Collaborative Efforts in Determining Medical Personnel Requirements Have Been Limited
paragraphs: While DOD has emphasized jointness and undertaken joint initiatives  across the department, the extent to which the services have incorporated  cross-service collaboration in their planning efforts for determining their  medical personnel requirements has been limited. The 2007 Military  Health System Human Capital Strategic Plan 2008-2013 emphasizes the  importance of planning, coordinating, collaborating, and developing  human capital solutions across the services to enable departmentwide  decision making. Additionally, a DOD directive requires developing plans  and procedures and pursuing common and cross-cutting modeling tools  and data. Furthermore, DOD is moving toward having joint medical  regions in which DOD-operated medical treatment facilities are staffed  using personnel from across the service such as the consolidation of the  military treatment facilities in the Washington, D.C., area. Also, DOD  established a cross-service, baseline medical manpower standard for  mental health providers, which was released in January 2010. While these  efforts represent progress by the services in working collaboratively, the  services have encountered challenges in their implementation.
subsections: section_title: DOD Emphasizes Jointness in Its Strategic Plan and Quadrennial Defense Review
paragraphs: Issued in November 2007, DOD’s medical personnel strategic plan—the  Military Health System Human Capital Strategic Plan 2008-2013— emphasizes coordination and collaboration across the services. This   plan sets forth a vision, guiding principles, goals, and objectives for   the management of the Military Health System’s medical personnel.   The strategic plan articulates a vision of an interoperable and agile total  medical force that meets the missions defined by National Security  Strategy requirements. Emphasized throughout this strategic plan is the  premise that the mission of the Military Health System can be better met  by increasing emphasis on planning, coordinating, collaborating, and  developing human capital solutions across the services. More specifically,  this strategic plan states that the Military Health System cannot continue  to recruit, develop, train, reward, and retain its workforce solely through  each service independently, as mission requirements demand that they  work together to achieve interoperability and agility.
The 2007 Military Health System Human Capital Strategic Plan also  aligns with critical areas on medical transformation initially presented in  the April 2006 Quadrennial Defense Review Roadmap for Medical  Transformation, which encouraged the Military Health System to create  standardized processes, tools, and resources to improve efficiency and  eliminate redundancies across the services. This goal is reiterated by a  specific DOD directive requiring the services to maximize commonality,  reuse, interoperability, efficiencies, and effectiveness of component- specific modeling data and tools. The Military Health System Strategic  Plan is also cited in the 2010 Quadrennial Defense Review, which  generally observes that DOD needs to reform the way in which it does  business to address challenges—such as parochial interests and  sometimes adversarial relationships within the Pentagon and with other  parts of government—that are hindering its success.
section_title: Joint Medical Effort in the Washington, D.C., Area Represents Cross-Service Collaboration but Has Encountered Challenges in Developing Its Military Medical Personnel Requirements
paragraphs: To eliminate redundancies in medical operations, integrate services, and  achieve better economies of scale, DOD is implementing a joint medical  effort in the National Capital Region of Washington, D.C., known as Joint  Task Force National Capital Region Medical. This effort stems from a 2005  Base Realignment and Closure (BRAC) Commission recommendation to  relocate patient care activities from the Walter Reed Army Medical Center  Washington, D.C., to the National Naval Medical Center, Bethesda,  Maryland, and to a new community hospital at Fort Belvoir, Virginia. The  BRAC Commission presented its list of final recommendations to the  President of the United States, which included a cost/savings estimate for  this joint medical effort. The President approved the recommendations in  their entirety and subsequently forwarded them to Congress, and they  became effective in November 2005. Our analysis of DOD fiscal year 2010  BRAC budget showed that the cost to implement this realignment is  estimated to be $2.4 billion, consisting primarily of $1.7 billion in  construction costs. That analysis also showed that DOD projects its net  annual recurring savings of this effort to be $172 million.
In September 2007, the Deputy Secretary of Defense issued a  memorandum that formally established Joint Task Force National Capital  Region Medical. One of its two facilities, the new Walter Reed National  Military Medical Center, will be located on the Bethesda campus, and  according to the Deputy Secretary of Defense, is expected to deliver  effective and efficient, world-class military health care, as well as  consolidate and realign military health care in the region. Its medical  services will include primary care, secondary care (that is, care provided  by a consulting physician at the request of a primary physician), and  tertiary care (that is, very specialized care performed by physicians with  facilities and skills for special investigation and medical treatment). DOD  plans to close the current Walter Reed Army Medical Center facility by  September 2011. The second facility at Fort Belvoir, Virginia, is being  expanded to provide comprehensive primary and secondary patient care  services. Joint Task Force National Capital Region Medical’s vision,  mission, and principles include as a key priority the establishment of  common standards and processes, and calls for interoperability.  According to a statement in the 2010 Comprehensive Master Plan for the  Nation Capital Region Medical, this medical realignment represents a  merger of nearly 10,000 healthcare and support staff. The document also  states that the department has currently determined an active duty  personnel distribution between the new Walter Reed National Military  Medical Center in Bethesda and the Fort Belvoir Community Hospital, and  that the services have identified the resources to meet the manning  requirements. Joint Task Force National Capital Region Medical, which  reached fully operational capability status on September 30, 2008,  represents an important initiative within the Military Health System  because, if successful, Joint Task Force officials believe it will be a model  for the future of military medicine. Officials also noted to us that this joint  medical effort in Washington, D.C., is a new process and, Joint Task Force  officials are working with the services to work through details to achieve  joint medical commands in the National Capital Region.
Officials, however, have faced challenges in consolidating and realigning  the medical manpower portion of this newly formed joint medical effort  within the National Capital Region. Additionally, according to officials we  spoke with, several assumptions used throughout the development of the  joint manning document—that (1) the population served would remain  static from 2004, (2) the clinical workload to be met would be based on  that of 2004, and (3) the 2004 medical missions would remain constant— have become outdated. According to officials, the military treatment  facilities in the National Capital Region have seen a significant increase in  their clinical workload over 2004 levels as a result of injuries sustained by  servicemembers following the acceleration in overseas operations in Iraq  that was announced in 2007. Further, they said these injuries entail  additional medical missions that the Joint Task Force officials have not  been able to fully incorporate into the clinical workload or the personnel  requirements determination. Such additional missions include an  increased need for advanced limb and wound care, and traumatic brain  injury care. Also, in order to develop the joint manning document for the  newly formed and jointly staffed facilities, officials had to fuse the results  of the services’ dissimilar medical personnel requirements determination  processes. In doing so, they found that the services’ official manning  documents contained inaccuracies. Several civilian and military Joint Task  Force officials, who analyzed manpower documents to determine the  levels of medical personnel currently on board for each service, told us  that the services had employed civilian and contract personnel at their  facilities but not recorded them on the manpower documents upon which  these officials based the development of the joint manning document.   For these various reasons, the joint task force officials have encountered  significant challenges in developing an accurate, complete, and realistic  joint manning document that lays out the medical requirements by  specialty for the newly formed joint facilities.
DOD officials attribute the problems to formative, early stage development  issues, and acknowledged that, if service manpower determination  processes had used similar language, nomenclatures, and approaches,   the creation of the joint manning document would have been a more  straightforward process. Officials also told us, however, that while the  collaboration encountered to date has been challenging, it has been  beneficial in building the relationship among the medical components and  operational components of the services. These officials stated that with  continued collaboration among the services and future operational  experience, the Joint Task Force’s leadership intends to identify data- driven refinements to projected manpower requirements that would better  capture efficiencies, enhance service quality, and build on selected  strategic interests.
section_title: DOD and the Services Collaborated to Develop a Recently Released Cross- Service Medical Manpower Standard for Mental Health Providers
paragraphs: A second joint medical personnel effort, quite different from that of the  realignment previously described, is DOD and the services’ ongoing  development and implementation of a cross-service medical manpower  standard known as the Psychological Health Risk-Adjusted Model for  Staffing (PHRAMS). PHRAMS represents the culmination of a  collaborative manpower requirements effort to develop a standardized,  more consistent approach across the services for determining mental  health personnel requirements. Health Affairs sponsored the development  of the cross-service PHRAMS manpower standard to address the growth   in demand for mental health services, as well as to give the services a  standard by which to develop mental health requirements needed to meet  the common, day-to-day psychological health needs of eligible  beneficiaries across the services. The model projects mental health  medical requirements over a 5-year planning horizon and provides a gap  analysis for the first year, in order to assist the services in addressing near- term personnel shortages. It also provides a consistent staffing standard  containing several fixed parameters, such as the size of the beneficiary  population and utilization rates, which Health Affairs will re-evaluate  annually when the model is updated. Finally, the model contains variables  that can change at the services’ discretion, such as the number of patients  seen annually by a provider and an adjustment rate to reflect increased  deployments for servicemembers in the hospital’s area of responsibility.  Health Affairs released the final model to the services in January 2010.  Currently, the Army, Navy, and Air Force are using PHRAMS to generate  mental health staffing requirements at their military treatment facilities  that are to be incorporated into the fiscal year 2012 budget submission  later this year and because the model was only recently released to the  services, the effect of its implementation on cost savings or requirement  numbers is still unknown. Additionally, Health Affairs officials said that  the services will continue to assess potential applications of PHRAMS.  While the services are not specifically required to use PHRAMS or to  develop more models, Health Affairs officials told us that the publishing of  the Military Health System Human Capital Strategic Plan has  encouraged dialogue among the services on collaboration, and such  dialogue may facilitate the identification of further opportunities for  development of manpower requirements models.
section_title: Service-Specific Medical Requirements Determination Processes Are Not Consistent with Collaborative Planning
paragraphs: To the extent that PHRAMS represents a positive collaborative initiative,  to date it is the only model of its kind. The services are responsible for  organizing, equipping, and training their respective forces, and service  officials assert that their respective needs are sufficiently different to  warrant maintaining service-unique processes for requirement  determination. While each of the services has unique operational medical  capabilities, such as Army veterinary medicine, Navy undersea medicine,  and Air Force aerospace medicine, the day-to-day operations at military  medical treatment facilities are very similar across the services, and they  could advantageously be more collaboratively managed. A DOD directive  requires the respective heads of the services to maximize the  commonality, reuse, interoperability, efficiencies, and effectiveness of  component-specific modeling data and tools, but Health Affairs officials  said that no other current collaboration efforts for determining medical  personnel requirements or developing medical manpower standards, other  than PHRAMS, are currently under way. Committed and effective  leadership is a critical aspect of enhancing collaboration. Committed  leadership by those involved in collaborative efforts from all levels of the  organization is needed to overcome the many barriers to working across  boundaries. Key organizational issues, like strategic workforce planning,  are most likely to succeed if, at their outset, top program and human  capital leaders set the direction, pace, and tone and provide a clear,  consistent rationale for the transformation. With leadership emphasis and  expectations that the services will continue to explore opportunities to  develop cross-service medical manpower standards, such as PHRAMS, and  consistent management focus on collaboration within DOD’s Military  Health System, the services will have more opportunities to develop  collaborative work force planning efforts for common medical capabilities  that they share throughout their military treatment facilities—an approach  that is consistent with the Military Health System Human Capital  Strategic Plan’s vision of a more integrated approach across service  lines.
section_title: The Services’ Respective Processes for Developing Requirements Are Not Validated and Verifiable in All Cases and Do Not Centrally Account for Civilian Personnel Requirements
paragraphs: While a need exists for the services to work more collaboratively to  determine their medical personnel requirements, the services’ also  maintain processes to address service-specific needs. In accordance with   a DOD directive, personnel requirements are to be established according  to workload at the minimum levels necessary to accomplish mission and  performance objectives. Additionally, a DOD instruction calls for the  models and associated data used to support DOD processes and decisions  to be validated and verified throughout their life cycles, and accredited for  the model’s intended purpose. While all of the services currently are taking  steps to update and refine their medical personnel requirement processes,  these processes, however, are not yet fully validated or verifiable. Further,  the services do not centrally manage their civilian medical personnel  requirements.
subsections: section_title: Army’s Model Contains Some Outdated Information and Is in the Process of Being Updated and Validated
paragraphs: The Army uses its Automated Staffing Assessment Model to determine  manpower requirements for Army fixed military treatment facility and  other Army Medical Command organizations. This model is based  primarily on approved population and workload data, but it also  incorporates industry performance data to determine manpower  requirements for the various medical specialties. The Automated Staffing  Assessment Model consists of over 240 modules for determining essential  medical requirements for many medical specialties such as physicians,  nurses, dentists, medical service corps, and veterinarians, to name a few,  at the work center level across Army fixed military treatment facilities.  The model uses the current population of the various military treatment  facilities as the major determinant of the number of medical personnel  needed at each facility. In addition, a number of key, workload-based  assumptions inform the model, including patient care hours, population  projections, provider-to-patient ratio, and provider-to-support technician  ratio. However, in certain cases, our analyses of selected modules revealed  areas that need improvement. For example, our analyses of the inpatient  nursing and dental modules revealed the use of some obsolete  assumptions. Specifically, we found that the Army’s nursing requirements  module had not been updated or used since 2005 to determine nursing  requirements. Further, according to dental command officials, the dental  module in use is an Army legacy model that is over 40 years old and does  not reflect the more advanced level of dental care currently being  provided, such as the increased need for complex dental repair work  rather than simple extractions. DOD noted in technical comments on a  draft of this report that the nursing and dental modules were recently  updated and submitted for validation.
According to Army officials, updates to Army medical manpower models  are subject to a review process by the U.S. Army Manpower Analysis  Agency, and to final approval by the Office of the Assistant Secretary of  the Army for Manpower and Reserve Affairs. A module can be approved  for 3 years if it is determined to be logical, analytical, verifiable, and based  on accurate data sources. However, if a module is based solely on data  provided by subject matter experts and functional estimates of the primary  tasks associated with the specialty, the model will be approved for 1  year—as is the case for the recently validated veterinary specialty module.  According to Army officials, prior to 2008, the Army required a random  sample of 2 percent of the requirements models to be validated for  reasonableness; however, currently, it uses a more stringent approach that  requires all models to be validated. Army documents show that the Army’s  manpower analysis agency completed validation of 4 of the 240 modules in  2009 and 2 more so far in 2010. In addition, 12 more modules have either  been submitted for review and approval or are nearing submission. In  technical comments to a draft of this report, DOD noted that the Army  believes the number of requirements covered by its staffing assessment  model is more important than the number of modules as we have  discussed. As such, the Army noted that nearly 20 percent of its medical  personnel requirements have been updated and about another 20 percent  of its requirements have been submitted for validation however are  pending approvals. Moreover, Army Medical Command officials have been  working with representatives from the Army Manpower Analysis Agency  to develop a specific time line and priorities for validation of the remaining  modules, but currently no definitive schedule has been set yet for  completing the validation.
Army officials recognized that the approach to model validation that they  had been using, including its previous reliance on sampling methods, was  not providing the Army with complete and sufficient information. With  committed and sustained leadership emphasis to complete and maintain  the validation of all the modules, the Army will be in a better position to be  certain it is determining its medical personnel requirements in an effective  and efficient manner.
section_title: Navy Does Not Have a Validated and Verifiable Process but Is Moving toward a Validated Model
paragraphs: The Navy has not used a model to determine the medical personnel  requirements for its fixed military treatment facilities. Instead, Navy  officials explained that, the Navy’s process is to use current manning as a  baseline and adjust the figure based on emerging needs or major changes  in its medical mission. Additionally, Navy officials explained that local  military treatment facility commanders prepare annual business plans for  their medical facilities and include proposed changes to the facilities’  personnel requirements based on such information as enrolled population,  utilization rates, and on expert functional knowledge at the military  treatment facility. These business case analyses are then submitted and  reviewed through the chain of command and approved by the Navy  Surgeon General as medical resources allow. While the Navy routinely  employs this approach to determine its medical personnel requirements, it  is not a validated or verified methodology as required by DOD guidance.
To better assess its medical personnel requirement needs at the medical  specialty level, the Navy is beginning to develop medical manpower  standards which officials indicate will be used as the basis for future  requirements determination. According to Navy officials, they plan to use  the Navy Medicine Benchmark Model for its 93 medical functional areas.  As this model will determine the benchmark for the number of personnel  needed in a medical specialty at a military treatment facility, the model  will be used to identify surpluses or shortages in personnel at each facility  and identifying the optimal military, civilian, and contractor mix. DOD  noted in technical comments responding to a draft of this report that the  Navy Bureau of Medicine and Surgery Headquarters is the approval  authority for determining whether a medical personnel requirements  model or process is valid and verifiable. Navy medical officials explained  that they are still in the process of determining the model’s validity for  each of its medical specialty areas, and they did not provide a time  schedule as to when this would be completed. Although the Navy is  implementing this model to help determine its medical personnel  requirements, Navy officials asserted to us that the Navy does not have  any unmet requirements, as it uses private-sector medical care when  military treatment facilities are unable to provide the care.
Navy officials recognized the business case analysis process did not  provide the validated and verifiable approach needed to determine their  medical manpower requirements. With committed and sustained  leadership emphasis to implement and maintain a fully validated  benchmark model, the Navy similarly will be in a better position to be  certain it is determining its medical personnel requirements in an effective  and efficient manner.
section_title: Air Force Currently Uses a Nonvalidated, Nonverifiable Model and Other Information to Determine Its Medical Requirements but Has Begun Developing a Newer Model
paragraphs: In 2002, the Air Force Surgeon General collaborated with the private  sector to design the Product Line Analysis and Transformation Tool that  produced medical manpower staffing models utilizing industry standards  and research and the experiences of Air Force medical personnel. While  the models were presented in 2003 for validation and approval, the   Air Force leadership did not approve this model for determining  manpower standards for its medical specialties because the models were  not based on objectively quantifiable data sources. Although the Air Force  considered any medical requirements developed using the model as  unverifiable, it allowed Air Force medical officials to continue to use the  models as a part of its requirements determination process. Currently,   Air Force medical officials use, in addition to the model, historical  workload, historical and like-size facility manning, industry models,  functional models, and statistical analysis of variance by facility to  generate their medical personnel requirements. The current requirements  development process can be performed using either a top-down or a  bottom-up approach. The top-down approach begins with Air Force  leadership, usually at the rank of general, determining that a military  treatment facility has a need for new requirements. The bottom-up  approach occurs when officials at a military treatment facility identify a  need for a new requirement and then work through the major commands  to change or alter its current requirements. The major commands then  work with the Air Force Medical Operations Agency to bring a request for  new or changed requirements to the Air Force Surgeon General. The new  or changed requirements undergo a vetting process that ranges from the  military treatment facility to the Chief of Staff before they are approved.  Any changes to requirements are based on identified need as experts in  functional areas obtain new data or refined standards.
To establish the feasibility of providing a verifiable means of medical  manpower standards development support to the Air Force medical  community, the Air Force Medical Service and the Air Force Manpower  Agency signed a Memorandum of Agreement whereby the Air Force  Manpower Agency will develop new manpower standards for all Air Force  medical specialties, based on data that have been collected for each.  According to officials, this effort began in January 2010, and they hope to  have completed developing all of the manpower standards by 2015.   In order to do so, the Air Force Manpower Agency is planning to hire   15 officials—10 civilians and 5 military—to research, develop, and validate  the new manpower standards. This effort will include such tasks as  developing the data collection approach, performing the analysis on all   of the data, developing the manpower models, and identifying process  improvement opportunities.
Air Force officials recognized that their recent efforts to develop medical  manpower standards stem from the Air Force’s need for a validated and  verifiable manpower requirements determination process. With committed  and sustained leadership emphasis on maintaining validated medical  manpower models, the Air Force is in a similar position as the other  services in that it would be in a better position to know its true medical  needs by medical specialty and to be certain it is determining its medical  personnel requirements in a more effective and efficient manner.
section_title: The Services Do Not Centrally Account for Civilian Personnel Requirements
paragraphs: DOD’s efforts to determine its medical personnel requirements at military  treatment facilities are further limited by the fact that the services have  not fully incorporated into their requirements processes the use of  civilians who deliver health care at the same stage in the process where  they determine their military medical personnel requirements. A DOD  directive requires that, for areas employing both military and civilian  personnel, manpower requirements shall be determined in total and  designated as either military or civilian, but not both, as an active, reserve,  or civilian determination must be made for each requirement. The  Military Health System Human Capital Strategic Plan also asserts that  more efforts should be made to have the optimal mix of medical  personnel. However, while civilian personnel constitute about 20 percent  of the services’ medical workforce, the services’ current requirements  processes are generic in nature and do not differentiate positions as  military or civilian. We found that all three services first determine their  collective requirements. Then, at the local level, after all of the positions   at a military treatment facility are staffed with the available military  personnel, the commander of the local military treatment facility  determines whether a position will be designated as civilian or contractor.  In making determinations to use civilian personnel, local commanders use  several factors, such as whether the position is military essential—to  support readiness or operational missions—or inherently governmental— which would require the position be filled with a government employee.  Additionally, commanders consider financial resources and the availability  of civilian or contractor personnel in the local area. In technical comments  provided in response to a draft of this report, DOD officials disagreed with  our statement that the services do not centrally account for civilian  personnel requirements. DOD noted that workload generated by civilians  is captured and depicted in a centralized information management system.  However, based on the explanation of this system given by DOD, we note  that this system captures the number of civilian personnel already on  board and the areas in which they are employed. It does not identify the  number of civilian personnel needed and required by each service to meet  the missions of fixed military treatment facilities, nor does it centrally  account for civilian personnel requirements. In addition, several military  treatment facility personnel told us that more direction or centralized  guidance would aid them, in many cases, in their management of their  civilian personnel. DOD’s 2009 update to its Civilian Human Capital  Strategic Plan lists global civilian end strength numbers for five mission  critical medical occupational series—medical officers, nurses,  pharmacists, clinical psychologists, and licensed clinical social workers.  This update also gives projected accession and recruiting goals needed to  reach those global end strength numbers. However, the update does not  project any civilian end strength numbers at the medical specialty levels  within these occupational series nor does it indicate the military treatment  facilities at which these civilians are needed. If the services do not identify  civilian personnel requirements for military treatment facilities in the  overall requirements planning process, the services may be missing the  opportunity to make a strategic determination of how many medical  professionals—military or civilian—are needed in total to carry out their  expected missions and workloads. The services assume added risk if their  medical requirements are not completely met, and if the requirements are  unknown, the extent of that risk cannot be estimated. If risk is unknown,  the services cannot develop appropriate risk-mitigation strategies for their  unmet medical personnel requirements.
section_title: Conclusions
paragraphs: To achieve a military health system that can respond to our country’s  changing national security needs by using both the right numbers and the  right mix of forces, DOD has emphasized the need for collaboration   of efforts in the medical arena, and committed and sustained leadership  emphasis is key to successful collaboration. The efforts taken to date   by OSD and the services to develop and implement specific cross-service  manpower related programs have been a step in the right direction for  building a collaborative approach to determining military medical  personnel requirements. As such, it is important that the services continue  to focus on developing programs, solutions, and measures for managing  medical personnel requirements across the services and focus on the long- term, broader picture. By doing so, OSD and the services will have more  opportunities to create departmentwide benefits and would more fully  support the Military Health System’s strategic planning goal of  collaboration. Also, as the services work toward a joint approach, it is  important for them to have sound medical personnel requirement  determination processes in place, to enable them to identify the personnel  numbers and mix they need to fully perform their medical missions. If the  services are to effectively and efficiently provide daily care to active duty  and retired servicemembers and their dependents in their fixed medical  facilities, it is important that each of their medical personnel requirement  processes reflects currency, validation, and verification. Areas of  improvement exist within the services’ medical requirements processes,  and until these processes are up-to-date, fully validated, and verifiable, it is  not clear whether the services can be certain they are determining their  medical personnel requirements in an effective and efficient manner.
section_title: Recommendations for Executive Action
paragraphs: Consistent with DOD emphasis on developing human capital solutions  across the services to enable departmentwide decision making and  analyses within its Military Health System, we recommend that the  Secretary of Defense direct the Assistant Secretary of Defense for Health  Affairs and the Service Secretaries to take the following two actions.
Identify the common medical capabilities that are shared across the  services in their military treatment facilities that would benefit from the  development of cross-service medical manpower standards; and    Where applicable, develop and implement cross-service medical  manpower standards for those common medical capabilities.
To improve the Army’s current medical personnel requirements  determination process, we recommend that the Secretary of the Army  direct the Army Surgeon General to take the following three actions.
Update assumptions and other key data elements contained within  specialty modules of the Automated Staffing Assessment Model;    Develop and implement a definitive revalidation schedule for the specialty  modules of the Automated Staffing Assessment Model; and  Include its reliance on civilian medical personnel in its assumptions as it  updates and validates their medical personnel requirements determination  modules.
To improve the Navy’s current medical personnel requirements  determination process, we recommend that the Secretary of the Navy  direct the Navy Surgeon General to take the following two actions.
Develop a validated and verifiable process to determine its medical  manpower requirements; and  Include its reliance on civilian medical personnel in its assumptions as it  develops, and then validates, its medical personnel requirements  determination model.
To improve the Air Force’s current medical personnel requirements  determination process, we recommend that the Secretary of the Air Force  direct the Air Force Surgeon General to take the following two actions.
Develop a validated and verifiable process to determine its medical  manpower requirements; and  Include its reliance on civilian medical personnel in its assumptions as it  develops, and then validates, its medical personnel requirements  determination model.
section_title: Agency Comments and our Evaluation
paragraphs: In written comments provided in response to a draft of this report,   DOD concurred or partially concurred with all of our recommendations.  DOD’s written comments are reprinted in appendix III of this report.  Additionally, DOD provided technical comments that we have  incorporated where appropriate.
In concurring with our recommendations regarding identifying,  developing, and implementing cross-service medical manpower standards  for medical capabilities that are shared across the services, DOD noted  that a cost-benefit analysis must precede a review of shared capabilities to  ensure that there is a significant, measurable benefit in cost, quality, or  access to medical care before department medical funds are expended.
We agree that this course of action would constitute a reasonable part of a  process to identify which specialties would benefit from such efforts.
In concurring with our recommendations to improve the Army’s current  medical personnel requirements determination process by updating  assumptions, developing and implementing a revalidation schedule, and  including its reliance on civilian medical personnel in its assumptions,  DOD stated that the Army will continue to update assumptions and other  key data elements within the Army Automated Staffing Assessment Model  as our recommendation suggested and will closely coordinate efforts  between Army Medical Command and the U.S. Army Manpower Analysis  Agency to implement a revalidation schedule for the medical personnel  requirements determination models. DOD further noted in its response   to a draft of this report that the Army will continue to capture civilian  contribution to the generation of medical workload in its Automated  Staffing Assessment Model, and that 58 percent of Army Medical  Command’s workforce is civilian. Although we believe Army’s efforts   to capture civilian contribution is important to understanding its  workforce, the intent of our recommendation is for the Army to better  delineate military versus civilian personnel requirements during the  requirements determination process as called for in DOD Directive 1100.4.
In its partial concurrence with our recommendations for the Navy to  develop a validated and verifiable process to determine its medical  manpower requirements and to include its reliance upon civilian medical  personnel in its assumptions, DOD noted that the Navy initiated a  comprehensive effort to redefine how medical manpower requirements  are determined, the results of which are expected by fall 2010. We note  this effort in our report, and it is in line with the intent of our  recommendation, but we continue to assert the need for this effort to be  completed. Further, DOD noted that the Navy Surgeon General has always  taken and will continue to emphasize a total force approach in future  planning and programming for medical personnel. We note, however, that  while we recognize the value of such an approach, our recommendation  concerns, as with the Army, the need for the Navy to delineate military  versus civilian personnel requirements during the requirements  determination process as called for in DOD Directive 1100.4.
In concurring with our recommendations that the Air Force Surgeon  General develop a validated and verifiable process to determine medical  manpower requirements and include its reliance on civilian medical  personnel in its assumptions, DOD noted that the Air Force is in the  process of developing new manpower standards for its medical specialties,  having finalized a Memorandum of Agreement between the Air Force  Medical Service and Air Force Manpower Agency in May 2010. We note   the potential of this effort as a strong step toward fulfilling this  recommendation. Further, DOD noted that the new Air Force manpower  standards will include the identification of civilian equivalents for those  positions not deemed military essential, and that civilian requirements are  also reviewed and determined through the Inherently Governmental /  Commercial Activity process. We agree that Air Force’s new medical  requirements determination standards, to include civilians, will have the  potential to address the intent of our recommendation. The Inherently  Governmental / Commercial Activity process, however, does not  completely address the need to delineate military versus civilian personnel  requirements during the requirements determination process as our  recommendation suggests and as called for in DOD Directive 1100.4.
Additionally, one of DOD’s technical comments concerns our  recommendations regarding the services’ need to include their reliance   on civilian medical personnel in their assumptions when developing and  validating their medical personnel requirements determination models. In  this technical comment, DOD suggested that we delete the section of our  report headed by the statement “The Services Do Not Centrally Account  for Civilian Personnel Requirements.” DOD noted that all three services  use a reporting system that captures and depicts workload generated by  civilians in a centralized information management system. However, we  note that the workload generated by civilians constitutes an after-the-fact  status of assignments rather than a consideration in generating the  requirements before these civilians are assigned to fill a requirement.  Thus, we continue to believe the validity of our aforementioned heading  reflecting our findings in this area has merit.
Finally, DOD provided in its technical comments to a draft of this report   a table that they believe illustrates recent collaborative efforts. Two of the  six examples—Psychological Health Risk-Adjusted Model for Staffing and  Joint Task Force National Capital Region Medical—are discussed  extensively in this report. DOD noted four more examples to illustrate  recent collaborative efforts, such as proposed legislation for financial  assistance to provide scholarships to civilian medical providers, that we  did not include in our report because we believe that these examples are  not directly related to the development of cross-service manpower  standards or medical personnel requirements, which is the focus of this  report. We have, however, reprinted DOD’s table in appendix III.
We are sending copies of this report to the Secretary of Defense and the  Secretaries of the Army, Navy, and Air Force. In addition, the report will  be available at no charge on the GAO Web site at http://www.gao.gov. If  you or your staff have any questions on the information discussed in this  report, please contact me at (202) 512-3604 or farrellb@gao.gov. Contact  points for our Offices of Congressional Relations and Public Affairs may  be found on the last page of this report. GAO staff who made key  contributions to this report are listed in appendix VI.
section_title: Appendix I: Scope and Methodology
paragraphs: This engagement examines the processes used by the military services to  determine their medical personnel requirements for staffing, to include the  number and specialty mix of military and civilian employees, at fixed  medical treatment facilities. We interviewed officials and, where  appropriate, obtained documentation at the following locations:   Office of the Assistant Secretary of Defense for Health Affairs,    Army Medical Command, San Antonio, Texas;    United States Army Manpower Analysis Agency, Fort Belvoir, Virginia;    Brooke Army Medical Center, San Antonio, Texas;    Navy Bureau of Medicine and Surgery, Washington, D.C.;    Navy Medical Support Group, Jacksonville, Florida;    Naval Medical Center Portsmouth, Portsmouth, Virginia;    Air Force Medical Service, Washington, D.C.;    Air Force Manpower Agency, San Antonio, Texas; and,    12th Medical Group—Randolph Air Force Base Clinic, San Antonio, Texas.
To evaluate the extent to which the services have collaborated in their  strategic planning efforts for the determination of their medical personnel  requirements, we reviewed manpower, personnel, and Military Health  System policies and plans for the Department of Defense and the services.  Especially pertinent were Department of Defense Directive 5000.59, on  Modeling and Simulation management, and the Military Health System  Human Capital Strategic Plan for Fiscal Years 2008 - 2013. We  compared the guidance, goals, and strategies in those documents with the  ongoing medical personnel requirements determination processes used by  the services, which we determined by analyzing documentation and  interviewing officials from each of the locations listed. We also analyzed  documentation and interviewed officials from Joint Task Force National  Capital Region Medical and the San Antonio Military Medical Center to  learn about joint medical operations that are being developed and  implemented. Further, we met with officials from the Center for Naval  Analyses who are currently working under a contract with the Office of  the Assistant Secretary of Defense for Health Affairs to develop a cross- service medical manpower standard for behavioral health specialties  known as the Psychological Health Risk-Adjusted Model for Staffing.
To evaluate the service-specific processes for determining their  requirements for military and civilian medical personnel, we reviewed  documentation provided to us by officials, whom we then interviewed,  from each of the offices previously cited. We obtained and reviewed the  Army’s Automated Staffing Assessment Model for four medical specialties:  physicians, dentists, nurses, and mental health care. We interviewed  agency officials who operate the models for each of these specialties to  understand how these models are used, how accurate the data are, and  whether the models had been validated by the Army’s Manpower Analysis  Agency. We additionally interviewed officials from the Navy Bureau of  Medicine and Surgery and the Air Force Medical Service regarding the  processes they use to determine their medical manpower requirements.  We also collected data on medical personnel requirements, authorized  positions, and end strengths for fiscal year 2009 from each of the services’  medical departments and from the Defense Manpower Data Center’s  Health Manpower Statistics Report. The Army is the only service that  provided service-specific data, while the Air Force and Navy deferred to  the Defense Manpower Data Center’s Health Manpower Statistics Report.  We coordinated our analysis and our results with a methodologist from  GAO’s Applied Research and Methods team. Additionally, with guidance  from the methodologist, we also evaluated the reliability of the data we  obtained and found it sufficiently reliable for the purposes of this audit.
We conducted this performance audit from August 2009 through July 2010  in accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
section_title: Appendix II: Summary of Fiscal Year 2009 Active Duty Medical Personnel Levels
paragraphs: The following data show the results of service-specific medical personnel  requirement processes (where available) in comparison with funded and  filled positions.
section_title: Appendix III: Comments from the Department of Defense
section_title: Appendix IV: GAO Contacts and Staff Acknowledgments
subsections: section_title: Acknowledgments
paragraphs: In addition to the individual named above, David Moser (Assistant  Director), Rebecca Beale, Chaneé Gaskin, Randy Neice, Cheryl Weissman,  Michael Willems, and Elizabeth Wood made key contributions to this  report.