Military Personnel: DOD Addressing Challenges in Iraq and Afghanistan but Opportunities Exist to Enhance the Planning Process for Army Medical Personnel Requirements
Published: 2011-02-10T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: For ongoing operations in Afghanistan and Iraq, military medical personnel are among the first to arrive and the last to leave. Sustained U.S. involvement in these operations has placed stresses on the Department of Defense's (DOD) medical personnel. As the U.S. military role in Iraq and Afghanistan changes, the Army must adapt the number and mix of medical personnel it deploys. In response to Congress' continued interest in the services' medical personnel requirements in Iraq and Afghanistan, GAO evaluated the extent to which (1) DOD has assessed its need for medical personnel in theater to support ongoing operations, (2) the Army has adapted the composition and use of medical units to provide advanced medical care, and (3) the Army fills medical personnel gaps that arise in theater. To do so, GAO analyzed DOD policies and procedures on identifying personnel requirements, deploying medical personnel, and filling medical personnel gaps in Iraq and Afghanistan, and interviewed officials.
section_title: What GAO Found
paragraphs: Medical officials in theater continually assess the number and the types of military medical personnel they need to support contingency operations in Iraq and Afghanistan and analyze the risks if gaps occur. Given congressional interest about deployed civilians, DOD reported to Congress in April 2010 that with each new mission, the need for new civilian skills has resulted in an increase in deployed civilians and that these civilians are not immune to the dangers associated with contingency operations. Although GAO did not learn of any DOD deployed civilians turned away for care in theater during this review, it is unclear the extent they can expect routine medical care in theater given that a DOD directive and theater guidance differ with regard to their eligibility for routine care. By clarifying these documents, DOD could reduce uncertainty about the level of routine care deployed DOD civilians can expect in theater and provide more informed insights into the military medical personnel requirements planning process. Army theater commanders have been reconfiguring or splitting medical units to cover more geographical areas in theater to better provide advanced emergency life-saving care quicker, but Army doctrine and the organizational design of these units, including needed staff, have not been fully updated to reflect these changes. Studies show that for those severely injured or wounded, 90 percent do not survive if advanced medical care is not provided within 60 minutes of injury. Officials in theater told GAO they are using specialized personnel documents to staff these medical units with more up-to- date personnel requirements to address gaps caused by splitting medical units, and that current doctrine and organizational design were not sufficient to address the capability needed for splitting medical units. According to an Army regulation, it maintains its lessons learned program to systematically update Army doctrine and enhance the Army's preparedness to conduct current and future operations. By updating Army doctrine and organizational documents for the design of medical units that could be used in other theaters, the Army could benefit from incorporating its lessons learned, where appropriate, and be better assured the current practice of splitting medical units to quickly provide advanced life-saving emergency medical care to those severely injured or wounded does not lead to unnecessary staffing challenges. Army commanders have used two approaches--cross-leveling and backfilling--to fill medical personnel gaps that arise in theater due to reasons such as illnesses, emergency leave, and resignations of medical personnel. When these gaps in needed medical personnel occur, the Army's 90-day rotation policy--while intended to ease the financial burden of deploying reserve medical personnel and help retain them--has presented some challenges in quickly filling these gaps in theater with reserve medical personnel when a medical provider is not able to deploy. However, Army data show the magnitude of these unfilled gaps or late arrivals for the reserve component medical providers ranged from about 3 percent to 7 percent from January 2008 to July 2010.
section_title: What GAO Recommends
paragraphs: GAO recommends that (1) DOD clarify the level of routine medical care that deployed DOD civilian employees can expect in theater and (2) the Army update its doctrine and the organizational design of split medical units. In response to a draft of this report, DOD generally concurred with the recommendations.

section_title: Letter
paragraphs: When contingencies such as Operation Enduring Freedom in Afghanistan  and Operation Iraqi Freedom arise, military medical personnel are among  the first to arrive and the last to leave. Sustained U.S. involvement in Iraq,  Afghanistan, and elsewhere has placed stresses on the Department of  Defense’s (DOD) medical personnel, particularly for certain high-demand  specialists such as psychiatrists and physician assistants. DOD medical  personnel have dual responsibilities to provide medical care at health care  facilities in the United States and abroad to servicemembers, former  servicemembers, and other beneficiaries, and, when called upon, to  provide urgent, lifesaving medical care on the battlefield and medical  support to U.S. armed forces.
Providing military medical care for ongoing operations in Iraq and  Afghanistan presents other challenges. For instance, as the number and  mix of medical personnel specialists decreases in Iraq, in line with the  theaterwide reduction of forces, the military must continue to provide  medical support while adapting to reduced numbers of medical personnel.  At the same time, medical units deployed to Afghanistan face logistical  challenges created by geography and the lack of physical infrastructure  such as roads and utilities that complicate their ability to provide  advanced medical care to warfighters.
In our past reports, we have highlighted several issues concerning military  medical personnel requirements. For example, in September 2006, we  reported that some combat support and combat service support skills,  including medical, were in particularly high demand to meet requirements  for operations in Iraq and Afghanistan. That report also found that  medical and other support skills, which reside primarily in the Army’s  reserve components, were in increasingly short supply due to restrictions  on the length and frequency of reserve deployments. In April 2009, we  noted that DOD faced challenges in accessing and retaining medical  officers, such as the limited supply and high demand for qualified medical  professionals; the lower pay generally offered to them by the military  compared to the private sector; the stress, length, and frequency of  deployments; and the length of required service commitments. In July  2010, we reported that the services’ collaborative planning efforts  regarding requirements determination for medical personnel working in  fixed military treatment facilities have been limited. We also noted that  the services’ requirements processes are not always validated and  verifiable, as DOD guidance requires.
In response to the congressional committees’ continued interest in the  medical and dental personnel requirements of the military services,  including their reserve components, needed to, among other things, meet  their medical missions in support of contingency operations and deliver  high-quality health care to eligible beneficiaries, we agreed to undertake  additional work on issues related to DOD’s medical personnel. For this  report, we focused on military medical support for contingency operations  in Iraq and Afghanistan, and as such, we evaluated the extent to which   (1) DOD has assessed its need for military medical personnel to support  ongoing operations, (2) the Army has adapted the composition and use of  its medical units to provide advanced medical care, and (3) the Army fills  medical personnel gaps that arise in theater.
For our first objective, we analyzed DOD’s policies and processes that  govern the medical personnel requirements determination process and  compared DOD guidance and theater-level guidance regarding medical  care for deployed DOD civilians and noted how they differed. For our  second objective, we evaluated Army doctrine and the organization of  medical units and assessed the extent to which they capture current  practices in Iraq and Afghanistan regarding the use and composition of  these units. For our third objective, we reviewed the approaches used by  Army theater medical commanders to meet medical personnel  requirements when gaps in needed personnel coverage occurred in Iraq  and Afghanistan. We also analyzed Army guidance for deploying medical  personnel in its reserve components and assessed Army data to determine  the extent to which medical units of the Army reserve components had  their authorized numbers of medical personnel from January 2008 to   July 2010, given this is the time period in which the Army had data. We  assessed the reliability of the data by interviewing the agency official  responsible for collecting and summarizing the data and determined that  the data were sufficiently reliable for the purposes of this report. For all  three objectives, we augmented our document analysis by interviewing  DOD and service officials, including officials from United States Forces- Iraq and United States Forces-Afghanistan; U.S. Central Command; Joint  Forces Command; Joint Staff; Office of Secretary of Defense for Health  Affairs; Offices of the Surgeons General for the Army, the Navy, and the  Air Force; and U.S. Marine Corps Headquarters. Throughout the  engagement we relied upon our staff in Baghdad, Iraq to conduct  extensive field work and interviews with officials in Iraq. For details on  our scope and methodology, see appendix I. We conducted this  performance audit from August 2009 through January 2011 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: At the end of July 2010, over 10,000 military medical personnel were  deployed to Iraq and Afghanistan, 70 percent of whom were Army  servicemembers. Of that number, about 4,000 medical personnel were in  Iraq and about 6,000 were in Afghanistan. The United States’ military  presence in Iraq is scheduled to end no later than December 31, 2011, and,  according to administration estimates, as of September 2010, about  104,000 U.S. military personnel were deployed in Afghanistan.
Figure 1 shows the breakdown of all military medical personnel in Iraq  and Afghanistan by service at the end of July 2010.
subsections: section_title: Levels of Medical Care in Iraq and Afghanistan
paragraphs: DOD has established five levels of medical care to treat injured or sick  military personnel, extending from the forward edge of the battle area to  the continental United States, with each level providing progressively  more intensive treatment. Over the course of operations in Iraq and  Afghanistan, the military has integrated more advanced medical care into  the first three levels of care, which are typically provided in theater, in  order to provide the most comprehensive care possible closest to the point  of injury. Figure 2 illustrates the different levels of medical care that may  be provided to U.S. servicemembers who become ill or injured while in  theater.
Level 1 – First responder care. This level provides immediate medical care  and stabilization in preparation for evacuation to the next level, and  treatment of common acute minor illnesses. Care can be provided by the  wounded soldiers, medics or corpsmen, or battalion aid stations.
Level 2 – Forward resuscitative care. This level provides advanced  emergency medical treatment as close to the point of injury as possible to  attain stabilization of the patient. In addition, it can provide postsurgical  inpatient services, such as critical care nursing and temporary holding.  Examples of level 2 units include forward surgical teams, shock trauma  platoons, area support medical companies, and combat stress control  units.
Level 3 – Theater hospital care. This level provides the most advanced  medical care available in Iraq and Afghanistan. Level 3 facilities provide  significant preventative and curative health care. Examples include Army  combat support hospitals, Air Force theater hospitals, and Navy  expeditionary medical facilities.
Level 4 – Overseas definitive care. This level provides the full range of  preventative, curative, acute, convalescent, restorative and rehabilitative  care, most typically outside of the operational area. An example of a level  4 facility is Landstuhl Regional Medical Center in Germany.
Level 5 – U.S. definitive care. This level provides the same level of care as  a level 4 facility, but most typically is located in the continental United  States. Examples include Walter Reed Army Medical Center in  Washington, D.C.; National Naval Medical Center in Bethesda, Maryland;  and Brooke Army Medical Center at Fort Sam Houston, Texas.
Not all patients progress through all five levels of care, and patients being  evacuated may skip one or more levels of care as appropriate. In addition,  joint and service definitions for each level of care vary marginally due to  service-specific support requirements, but they essentially align with one  another. For purposes of this report, we focused primarily on level 2 and  level 3 facilities and their personnel, which provide the most  comprehensive and advanced medical care in Iraq and Afghanistan.
section_title: Organizational and Command Structure of Medical Forces in Iraq and Afghanistan
paragraphs: The U.S. command structure in Iraq and Afghanistan has evolved over  time. In 2009, the designation of U.S. troops in Afghanistan became United  States Forces-Afghanistan. In 2010, the designation of U.S. troops in Iraq  became United States Forces-Iraq. The commanding generals of United  States Forces-Iraq and United States Forces-Afghanistan both are advised  by a lead surgeon on medical policy and procedures, according to theater  medical officials. Each theater also has a medical task force—the Task  Force 1st Medical Brigade and its successor, the Task Force 807th Medical  Brigade in Iraq and the Task Force 30th Medical Command and its  successor, Task Force 62nd Medical Command in Afghanistan—that,  according to theater medical officials, consist of professional staff  members who coordinate care in theater and directly command medical- only units in theater, such as forward surgical teams and combat support  hospitals. The theater surgeon and medical task forces command mostly  Army medical facilities. According to a DOD official, the other services  maintain and operate additional medical facilities in theater that may be  outside the direct command of the medical task force but under the  direction of United States Forces-Iraq and United States Forces- Afghanistan. For example, the Air Force operates a theater hospital in  Balad, Iraq but coordinates closely with the task force medical brigade in  Iraq. The United States Forces-Iraq Surgeon and staff collaborate closely  with the task force medical brigade commander and staff in Iraq to  coordinate medical policy and care. The positions of United States   Forces-Afghanistan Surgeon and the commander of the task force medical  command in Afghanistan are filled by the same individual.
section_title: DOD Uses Its Global Force Management Process to Meet Medical Personnel Requirements
paragraphs: According to DOD officials, DOD meets theater medical personnel  requirements through its Global Force Management process. DOD  designed the Global Force Management process to provide insight into the  availability of U.S. military forces to deploy, including medical personnel.  Figure 3 depicts the process and the key participants in Global Force  Management.
Once the Secretary of Defense designates a service to meet a medical  requirement, that service identifies and selects units and personnel to fill  the requirement. While the procedures and systems used by each service  to select medical personnel vary, the services’ processes for filling  requirements all result in units and personnel deploying to an operational  theater to carry out a mission.
Identifying and selecting medical personnel and units to fill requirements  can often be challenging due to shortages of medical personnel, but DOD  officials told us they have been able to fill almost all medical personnel  requirements since the Global Force Management process was established  in 2005. More information on the Global Force Management process and  the services’ personnel filling processes can be found in appendix II.
section_title: Theater Commanders Continually Assess Medical Personnel Requirements, but DOD’s Directive on Routine Medical Care for DOD Deployed Civilians Is Not Consistent with In-theater Guidance
paragraphs: Medical officials in theater continually assess the number and the types of  military medical personnel they need to support ongoing contingency  operations in Iraq and Afghanistan. Theater officials also analyze gaps in  medical care and the associated risks given different potential scenarios.  However, it is unclear what level of care deployed DOD civilian employees  can expect in theater because a DOD directive governing medical care for  DOD deployed civilians is inconsistent with in-theater guidance with  regard to eligibility for routine medical care for deployed DOD civilian  employees. In response to congressional interest about deployed civilians,  the Secretary of Defense reported to Congress in April 2010 that with each  new mission, the need for new civilian skills have resulted in an increase  in the number of deployed civilians and that these civilians are not  immune to the dangers associated with contingency operations. Although  we did not learn of any DOD deployed civilians turned away for care in  theater during the period of our review, officials in theater did say this  could be a concern if the number of civilians increased, and at that time  they would assess the impact of a civilian increase on the need for more  medical personnel. At the conclusion of our audit, an Army official   agreed that if there is an inconsistency between departmental guidance  and theater guidance, it should be clarified. Thus, by examining  inconsistencies in departmental guidance compared to theater guidance  on the level of routine medical care, DOD could reduce the uncertainty  about the level of routine care these deployed civilians can expect in  theater. In response to a draft of this report, DOD mentioned to us that its  operating units have sufficient organic medical support and the medical  needs of deployed civilians are being met. DOD also agreed that the  Commander of U.S. Central Command should revise its guidance to clarify  the level of care that deployed civilians should receive.
subsections: section_title: Theater Officials Analyze Mission Plans and Medical Data to Assess Their Need for Medical Personnel
paragraphs: Theater operational and medical officials determine how many and the  types of medical personnel needed to support operations in Iraq and  Afghanistan through an ongoing assessment, which includes an evaluation  of the operational mission and other planning factors, such as historical  injury statistics and medical workload data. In their assessment, theater  officials also analyze gaps in medical care given different potential  scenarios and the associated risks. This ongoing assessment takes place in  theater and allows theater officials to identify new medical personnel  requirements and regularly reevaluate existing medical personnel  requirements. Further, theater operational and medical officials also  consider operational limitations when developing their medical personnel  requirements, including the limit on the total number of forces in theater  and shortages of and high demand for certain medical personnel.
In determining the number of military medical personnel and the medical  specialties needed, theater operational and medical officials told us that  they begin by evaluating various mission planning factors, such as the  number and dispersion of U.S. forces, the expected intensity of combat,  capabilities of the adversary to inflict harm, geography, and climate.  Officials said that this information allows them to determine the level and  structure of medical care they expect to need to support missions  throughout the theater of operations. For example, in planning for the  increase of U.S. forces in Afghanistan beginning in early 2010, officials  with the U.S. Central Command requested additional medical personnel to  provide medical care to the increased number of U.S. military personnel in  theater, including a theater hospital and a preventative medicine unit. In  addition, during the offensive in Bastion, Afghanistan, officials with the  Task Force 30th Medical Command told us that they relocated some mental  health providers in Afghanistan to Bastion for the duration of the  heightened operational tempo so this type of care could be better provided  in the area experiencing hostilities.
To further assess the need for specific types of medical specialists in a  given unit and across the theater, medical officials analyze data from the  Joint Theater Trauma Registry, the Joint Medical Work Station, and  service and joint data on disease and non-battle injuries to determine  trends in medical workload. Officials use this information to increase or  decrease the number of medical personnel in line with demand for medical  services. For example, DOD medical officials conducted an analysis to  determine the need for cardiovascular specialists in Iraq and Afghanistan  based on, among other variables, the volume of cardiovascular-related  medical evacuations in theater. Officials also analyze gaps and risks in the  medical care structure under different possible scenarios. For example,  the Task Force 1st Medical Brigade in Iraq conducted an analysis that  identified possible requirements for additional medical personnel with  certain specialties, such as general surgeons, at locations in northern Iraq  given the possibility of adverse weather conditions that would prohibit  medical evacuation of patients to more advanced medical care facilities.  Further, when confronted with a need for additional medical personnel,  the theater commanding general can submit a request for forces through  DOD’s Global Force Management process. For example, we learned of two  Army sustainment brigades—the 82nd and the 43rd Regional Support  Commands—that deployed to Afghanistan with their authorized medical  personnel but did not have enough medical personnel to provide full  support to their convoys and forward locations. In response, Task Force  62nd Medical Command in Afghanistan requested additional forces for  these two brigades. Officials told us that DOD met this requirement by  deploying 22 Air Force medics to Afghanistan.
Additionally, medical officials in Iraq and Afghanistan told us that they  must consider two operational limitations which affect how many medical  personnel they formally request. First, the cap on the total number of U.S.  forces allowed in Iraq and Afghanistan requires theater commanders to  balance the number of medical personnel they request with many other  types of forces needed to conduct and support ongoing operations. For  instance, officials in Afghanistan told us that when they initiate requests  for additional personnel, the requesting unit is asked to offset the increase  in forces on a one-to-one basis within the unit. If they are unable to do so,  operational and medical officials determine if the request for additional  medical forces takes precedence over the need for other types of  personnel already in theater, and if so they decide which personnel will  redeploy out of theater to stay within the authorized force cap. Second,  shortages of and high demand for medical personnel in certain specialties  also plays a role in decisions about whether to request medical forces.   For example, officials in Iraq determined that 16 additional veterinary food  inspectors were needed for food safety inspections, but they did not  formally initiate that request due to the current shortage of these  specialists.
section_title: The Level of Care That Deployed DOD Civilian Employees Can Expect in Theater is Unclear
paragraphs: Although DOD primarily provides both emergency life-saving medical care  as well as routine medical care to U.S. military personnel in Iraq and  Afghanistan, it is unclear what level of routine medical care deployed DOD  civilian employees can expect in theater. DOD relies on its own deployed  civilians to carry out or support a range of essential missions, including  logistics support, maintenance, intelligence collection, criminal  investigations, and weapon systems acquisition. About 2,600 DOD civilian  employees were deployed to Iraq, and about 2,000 DOD civilian employees  were deployed to Afghanistan according to DOD’s April 2010 report to  Congress on medical care for injured or wounded deployed U.S. federal  civilians. In response to congressional interest, DOD reviewed the  department’s existing policies for medical care for DOD deployed civilians  and federal civilian employees that might be injured or wounded in  support of contingency operations and reported to Congress on the results  in April 2010. DOD noted in its report that with each new mission, the  need for new civilian skills has resulted in an increase in the number of  deployed civilians and that these civilians are not immune to the dangers  associated with contingency operations, since they too incur injuries or  wounds in their efforts to support the missions in Iraq and Afghanistan.
Although DOD guidance clearly provides that deployed DOD civilians will  receive life-saving emergency care, it is unclear to what extent DOD  civilians can expect routine medical care in theater because a DOD  directive and theater guidance differ with regard to their eligibility for  routine medical care. Specifically, DOD Directive 1404.10 states that the  department’s civilian employees who become ill, are injured, or are  wounded while deployed in support of U.S. military forces engaged in  hostilities are eligible to receive health care treatment and services at the  same level and scope provided to military personnel. However, theater  guidance for Iraq and Afghanistan, which provides detailed information  on medical care to deployed civilians, among others, states that DOD  civilians are eligible for emergency care but most routine care for them is  subject to availability. This differs from the DOD directive that states care  should be at the same level and scope provided to military personnel.
In addition, we found that the theater guidance document for care in  Afghanistan provided additional guidance that is inconsistent with both  the DOD directive and with guidance provided elsewhere in the document  as to the level of care to be provided to DOD deployed civilians.  Specifically, one section of the guidance stated routine care for all  civilians was to be provided subject to availability while another section   of the same guidance stated routine care was to be provided for deployed  DOD civilians in accordance with a previous issuance of DOD Directive  1404.10. The previous version of DOD Directive 1404.10 indicated that  civilians designated as emergency essential employees would be eligible  for care at the same scope provided to military personnel, while the  current January 2009 DOD directive extends the provision of routine  medical care to a much wider group of DOD deployed civilians.
Medical officials in Afghanistan told us that they provide routine medical  care to U.S. federal civilians on a space-available basis, and that they  would not turn away any person with injuries that presented a danger to  life, limb, or eyesight, regardless of the employment status of an  individual. This issue has received continuing congressional interest.   For example, in April 2008 the House Armed Services Committee  Subcommittee on Oversight and Investigations issued a report on  deploying federal civilians and addressed the medical care provided to  them when they are wounded, ill, or injured while in a war zone.  Furthermore, DOD’s report to Congress on deployed DOD civilians stated  that the department believes it is imperative that each federal civilian  understands where, when, and how they can receive medical treatment in  theater. Although we did not learn of any deployed DOD civilians being  turned away from receiving routine care in theater during the time of our  review, officials in theater said it could be a concern if the number of DOD  civilians that deploy increases, and that theater medical officials would  assess the impact of any increase on the planning process for determining  medical personnel requirements. However, if theater officials concluded  that they needed more medical personnel due to increases in numbers of  DOD deployed civilians, we recognize that an increase in medical  resources would have to be balanced against other high-priority needed  resources due to the force cap limiting the overall numbers of military  personnel that can be in theater. For example, the former commander who  oversaw military medical units in Afghanistan noted to us that while there  is no medical-specific force cap, including a limit on the number of  medical personnel within the larger force cap, any additional military  personnel needed in theater must be balanced by the loss of other military  personnel in other areas, such as a transportation unit, and that the force  cap has played a role in their decisions in determining medical personnel  requirements. Additionally, the current commander who oversees military  medical units in Afghanistan stated that local base commanders can  request additional medical personnel if they believe that the number of  U.S. soldiers or civilians merits an increase. The official stated that an  increase of about 800 to 1500 civilians would have to occur before they  would consider revising military medical personnel requirements. At the  conclusion of our audit, an Army official agreed that if there is an  inconsistency between departmental guidance and theater guidance,   it should be examined. As long as theater guidance differs from the  requirements of departmental directives, uncertainty about deployed  civilians’ eligibility for routine care in theater will remain and the military  medical personnel requirements planning process may not be fully  informed by department-level expectations.
section_title: Medical Units Are Being Reconfigured to Provide Advanced Emergency Care More Quickly and Over Broader Geographical Areas, but Army Doctrine Does Not Fully Reflect These Reconfigurations
paragraphs: Theater commanders in Iraq and Afghanistan are providing quicker access  to advanced emergency medical care by placing more medical units in  more geographical areas to save lives. However, Army doctrine, which is  the starting point for defining and planning a unit’s capabilities, has not  been updated fully to reflect these changes in theater. Also, the  organizational design of these medical units used in theater, which  indicates the number and mix of skilled medical personnel these units  should have, has not been updated to reflect current practice in theater.  Specifically, commanders in Iraq and Afghanistan have been splitting or  reconfiguring medical units typically designed to operate in one location  into multiple smaller units to cover a wider geographical area. For  example, as of December 2009 the Task Force 28th Combat Support  Hospital in Iraq—a field hospital typically designed to be in one   location—was split to be at three separate sites in Iraq—Baghdad, Tallil,  and Al Kut—to better cover this large operational area. Theater medical  commanders split these units because they found that the field hospital’s  standard design configuration was no longer suitable for the model of care  that has evolved in Iraq, which requires access to more advanced medical  care—particularly surgical care—over large geographical distances to  better save lives.
Splitting medical units, such as level 3 combat support hospitals and level  2 forward surgical teams, in order to locate them in more areas increases  the opportunities to provide advanced emergency care quicker and could  save more lives. According to documents from the 28th Combat Support  Hospital, the number of surgical sites has increased due to the emphasis  on providing troops access to surgical care within 60 minutes of being  injured. DOD has stated that by providing advanced life-saving emergency  medical care quicker, generally within 60 minutes of injury, survival rates  increase significantly. In fact, studies show that for those severely injured  or wounded, 90 percent do not survive if advanced medical care is not  provided within 60 minutes of injury, thus creating urgency for rapid  access to the wounded.
Medical officials in Iraq acknowledged that Army doctrine and the  organizational design of medical units were top issues that needed to be  updated to better reflect the current practice of splitting medical units  such as combat support hospitals. For example, in a December 2009   Mid-Tour Report, the Task Force 1st Medical Brigade—the medical unit  that provided oversight over medical units in Iraq before being replaced by  Task Force 807th Medical Brigade—noted that the organization for combat  support hospitals, including the list of needed medical specialties, should  be redesigned to reflect the actual use of combat support hospitals across  multiple locations and that certain lessons learned could be considered in  the redesign. Specifically, Task Force 1st Medical Brigade reported that  splitting full-sized combat support hospitals into smaller parts can create  medical personnel gaps in certain specialties, including those related to  the operation of pharmacies, laboratories, and patient administration.   The medical brigade’s report also went on to note that personnel with  these smaller combat support hospitals are spread so thinly that when  personnel take leave or are evacuated out of theater due to injury, the  medical brigade has to make difficult decisions on where to find needed  personnel to mitigate coverage gaps. Given these lessons learned, officials  with the Task Force 1st Medical Brigade told us that they were concerned  about outdated policies, guidance, doctrine, and field manuals related to  the determination of medical personnel requirements in theater and stated  specifically that the current design of combat support hospitals is not  flexible enough to accomplish what they are now being asked to do.   As such, they now have to continuously use what is referred to as  specialized personnel documents to manage staffing rather than staff as  indicated in established doctrine and the organization design of these  units. Specifically, officials with the Task Force 1st Medical Brigade noted  to us that staffing of medical units is now done in a “very non-doctrinal  fashion” and that they had similar concerns about splitting area support  medical companies and using them in theater in a non-doctrinal fashion,  given these area support medical companies now function as two separate  level 2 troop medical clinics when they are staffed to function as one.  Finally, the Task Force 1st Medial Brigade report went on to recommend  that the organizational composition of combat support hospitals be  redesigned to include redundant capability to accommodate expected  attrition in staff.
Additionally, officials with the U.S. Forces-Iraq Surgeon Office told us in   a separate interview that medical doctrine, specifically the organizational  design for both personnel and equipment, should be assessed and updated  given the current experience in Iraq. These officials said that the splitting  of combat support hospitals and forward surgical teams has gained  acceptance over time but should be examined given how  counterinsurgency doctrine is implemented in Iraq. These officials with  the Surgeon Office in Iraq also said that flexibility in the doctrine is  critical, but that doctrine needs to reflect the realities of operations on the  ground and the degree to which current practice of splitting medical units  has filtered into medical doctrine has been limited.
Recognizing these lessons learned in an environment that is continuing to  evolve to provide advanced medical care to save more lives, officials with  the Army Medical Department Center and School who are responsible for  updating medical doctrine and the organizational design of medical units  recently updated the forward surgical team field manual, noting that  changes in the number and mix of specialists that make up a forward  surgical team might be necessary if such teams are to operate as smaller  stand-alone units. However, the updated manual did not specifically  suggest what those changes in the number and mix of medical specialists  that make up a forward surgical team should be if the team is providing  advanced emergency care as a stand-alone unit. We were told that Army  planners have adjusted medical personnel requirements for forward  surgical teams to account for changes in these smaller nonstandard  medical unit reconfigurations by increasing the number of personnel  assigned to those units, but the updated field manual still does not specify  what the number and mix of medical specialists should be. Furthermore,  by splitting or dividing the standard traditional design for combat support  hospitals, DOD has also had to adjust the number and mix of medical  personnel in those units as well. Instead of relying on the standard  traditional doctrine design for medical units in theater, Army medical  officials have been developing specialized personnel documents to staff  these medical units to identify the medical skill sets now needed to  operate split medical units across multiple locations for  counterinsurgency operations. Specifically, officials with the Task Force  1st Medical Brigade told us these specialized personnel documents allow  for more up-to-date establishment of personnel requirements to address  gaps caused by splitting medical units. However, the process is difficult  and it came about because current doctrine and organizational design  were not sufficient to address the capabilities needed for splitting medical  units such as combat support hospitals and area support medical  companies.
Although the Army medical officials we spoke with said that they believe  splitting and reconfiguring units in theater is necessary and helps to  increase survival rates by providing advanced life-saving emergency  medical care generally within 60 minutes of injury, the Army has not fully  incorporated these current practices into Army doctrine and  organizational documents, which ordinarily determine the size,  composition, and use of these units. In response to a draft of this report,  DOD explained to us that Army leadership has recognized that split hybrid  operations and the dispersed environment in the theater of operations  have generated a requirement for additional medical structure. According  to an Army regulation, the Army maintains a lessons learned program to,  among other things, systematically update Army doctrine to enhance the  Army’s preparedness to conduct current and future operations. By  updating Army doctrine and organizational documents for the design of  medical units that could be used in other theaters, the Army could benefit  from incorporating its lessons learned, where appropriate, and be better  assured the current practice of splitting medical units to quickly provide  advanced life-saving emergency medical care to those severely injured or  wounded does not lead to unnecessary staffing challenges.
section_title: Theater Commanders Have Used Two Approaches for Filling Medical Personnel Gaps
paragraphs: When medical personnel gaps unexpectedly arise in Iraq or Afghanistan,  Army commanders have used two approaches to fill those gaps, according  to medical officials in theater. Gaps in medical capabilities can occur  when medical providers do not deploy as expected for reasons such as  resignation, or a medical provider is determined to be medically  nondeployable. Medical personnel gaps can also occur when individual  medical personnel need to leave the unit for reasons such as an emergency  situation at home or if they become seriously sick or injured in theater.  According to medical officials in theater, when these gaps occur, Army  commanders have used two approaches to fill these gaps: backfilling and  cross-leveling.
Backfilling involves the identification and deployment of medical  personnel into theater from the United States or elsewhere who were  not originally scheduled to deploy overseas at that time, according to  medical officials in theater. For example, a dentist assigned to a  brigade combat team in southern Iraq was evacuated out of theater for  medical reasons. Given the backlog of needed dental work,  commanders expressed concern about losing a dentist. In response,  Army Forces Command initiated an effort to identify another dentist  not in Iraq who was eligible to deploy to fill this need. DOD officials  told us that selecting and deploying an active component medical  provider to backfill a position typically takes about 45 days.
Cross-leveling involves the temporary relocation of personnel from one  unit in theater to another, according to DOD officials. Medical officials  in theater told us that cross-leveling is often used as an interim  measure to minimize risk when a gap in medical personnel coverage  occurs. For example, an operating room nurse assigned to a forward  surgical team in Iraq had an unexpected medical situation and was  evacuated out of theater. It was critical that this personnel requirement  be filled in a timely manner, given that the forward surgical team was  staffed with only one operating room nurse. Theater officials requested  a replacement from U.S. Army Forces Command and U.S. Army  Reserve Command, but the individual identified as a replacement could  not deploy for at least 30 days. Recognizing the high priority need for   a forward surgical team to have an operating room nurse, Task Force   1st Medical Brigade identified an operating room nurse that it could  borrow from another unit in theater until the replacement arrived.  After the replacement nurse arrived in theater, the operating room  nurse on loan returned to the unit the individual came from.
Personnel gaps that occur in theater cannot always be prevented and  when gaps do occur, theater commanders assess the risk associated with  the gap and decide on an appropriate course of action, according to  officials with Task Force 1st Medical Brigade. Cross-leveling in particular  requires the assessment of risk associated with the personnel gap and the  gap that would be created by the relocation of a medical provider from  another unit. According to theater commanders we spoke with,   cross-leveling, while temporary, is not an ideal solution and can present  risk to medical operations in theater, especially when conducted on a  recurring basis. We recognize that risk cannot be eliminated; it can only be  managed. Army officials told us that they are willing to accept some risks  in order to mitigate other risks they believe are higher.
According to medical officials, when medical personnel gaps in an Army  reserve component medical unit occur, it can be challenging to fill the gap  before the start of the next 90-day rotation, given it can take around   120 to 180 days to identify, notify, and then mobilize an Army reservist to  fill an unfilled requirement by which time the next expected 90-day  medical provider has already arrived. The Army’s 90-day rotation policy— while intended to ease the financial burden of deploying reserve medical  personnel and help retain them—has presented some challenges for the  Army in quickly filling these gaps when a medical provider is not able to  deploy. For example, the 9l5th Forward Surgical Team—an Army reserve  medical unit—was authorized to deploy to Iraq in September 2009 with  three general surgeons, according to theater medical officials. Instead, it  deployed with only one surgeon for the first 90-day rotation, despite  efforts to identify two other deployable general surgeons. The Army  Reserve identified a doctor to fill one of the two vacancies; however this  individual could not deploy due to an inability to be credentialed as a  general surgeon. The Army Reserve then identified another surgeon for  deployment, but this individual had educational requirements issues, and  yet a third identified surgeon resigned. By the time the Army Reserve was  able to identify a surgeon who could deploy, the 9l5th Forward Surgical  Team had been in Iraq for a month out of its first 90-day rotation. Further,  the Army was unable to identify the third authorized surgeon for the   9l5th Forward Surgical Team before the end of that 90-day rotation given  another identified surgeon scheduled for deployment resigned, and the  replacement surgeon turned out to be nondeployable for medical reasons.  In fact, the 9l5th Forward Surgical Team did not have one out of its  authorized three general surgeons for the first three 90-day rotations— approximately 270 days. Moreover, the 915th Forward Surgical Team was  expected to operate as two smaller units at two separate locations in  southern Iraq, but it was unable to provide surgical capabilities in both  locations as expected without three authorized general surgeons. As a  result of the personnel gaps, Task Force 1st Medical Brigade temporarily  relocated medical personnel already in theater from other medical units   to the 9l5th Forward Surgical Team so it could meet its mission.
Although we found examples of the 915th Forward Surgical Team not  having all of its medical personnel before the end of each 90-day rotation,  Army data show the magnitude of these unfilled gaps or late arrivals for  the reserve components ranged from about 3 percent to 7 percent from  January 2008 to July 2010. Specifically, Army data showed that about   4 percent of mobilized Army reserve component 90-day medical rotators  (21 medical providers out of 594) did not deploy to theater or arrive in  theater on time for 2008. In 2009, that figure reached 7 percent (38 medical  providers out of 519) and through the first 6 months of 2010, this figure  was over 3 percent (8 medical providers out of 236). Unfilled reserve  component personnel requirements can have serious consequences  depending on the needed medical specialty. Therefore, medical  commanders in theater typically cross-level to fill short-term temporary  personnel gaps, although medical officials in Iraq we spoke with said  cross-leveling is a less than ideal approach to fill these medical personnel  gaps.
section_title: Conclusions
paragraphs: DOD has continued to assess its need for medical personnel in theater  based on the requirements of the mission and a variety of medical data   and has made adjustments to meet specific theater needs to achieve the  goal of providing advanced life-saving care quickly. DOD has noted that,  increasingly, deployed civilians also face dangerous circumstances in  ongoing contingency operations. While DOD has stated that deployed  civilians will receive emergency care whenever needed, the extent of  routine medical care available to DOD deployed civilians is unclear due to  inconsistent guidance. Inconsistent guidance could potentially impact the  medical personnel requirements planning process if medical officials in  theater are uncertain about deployed DOD civilian employees’ access to  routine medical care. While we did not learn of any deployed DOD  civilians being turned away for medical care in theater during the time   of our audit, DOD could still benefit by assessing the implications the  inconsistencies in guidance could have if there were a sizeable increase in  the number of DOD deployed civilians in theater.
Conducting counterinsurgency operations in often uncertain, dangerous  environments such as Iraq and Afghanistan, Army theater commanders  have reconfigured the composition of field hospitals and forward surgical  teams by breaking them down into smaller stand-alone units to better  position them to give the severely wounded or injured, such as the  casualties of blast-type injuries, the advanced emergency medical care  needed to save lives. By being in more geographical areas, these critical  life-saving medical units are better able to achieve their goal of providing  advanced emergency medical care within 60 minutes of injury to increase  survival rates. Acknowledging the current practice of splitting medical  units, the medical brigade that provided oversight over medical units in  Iraq reported that one of its top issues was advocating for updates to the  doctrine and organizational redesign of these split units that govern its use  and personnel allocation. By leveraging lessons learned collected from this  practice, especially the needed number and mix of medical personnel, the  Army could benefit from integrating these lessons systematically into  Army doctrine and the design of these medical units. Updating doctrine  and organizational design of these split medical units used in theater could  help to assure that these units will be resourced with the needed number  and mix of medical personnel to continue providing critical life-saving  capabilities for counterinsurgency operations in other theaters and in the  future.
section_title: Recommendations for Executive Action
paragraphs: To better understand the extent to which deployed DOD civilian  employees have access to needed medical care, as appropriate, we  recommend that the Secretary of Defense direct the Combatant  Commander of U.S. Central Command to clarify the level of care that  deployed DOD civilian employees can expect in theater, including their  eligibility for routine care.
To enhance medical units’ preparedness to conduct current and future  operations given the changing use of combat support hospitals and  forward surgical teams in Iraq and Afghanistan, we recommend that the  Secretary of the Army direct the Army Medical Department to update its  doctrine and the organization of medical units concerning their size,  composition, and use.
section_title: Agency Comments and Our Evaluation
paragraphs: In written comments provided in response to a draft of this report, DOD  generally concurred with our findings and recommendations. DOD fully  concurred with our first recommendation that the department clarify the  level of care that deployed DOD civilian employees can expect in theater.  DOD partially agreed with our second recommendation that the Army  Medical Department update its doctrine and the organization of medical  units concerning their size, composition, and use. DOD noted that there is  an unquestionable need to formally update doctrinal publications. DOD  also noted that the Army is constantly reviewing and assessing medical  capability, the use of those capabilities and the organization of medical  units, and updating doctrine to evolving staffing requirements. As an  example, DOD mentioned in its official response that a recent review of  medical capability indicated the need for additional medical personnel,  and the Army responded with guidance to increase the number of enlisted  health care specialists assigned to Army Brigade Combat Teams. The  department also noted that the Army continues to capture lessons learned  and input from commanders to ensure use of medical personnel meets  requirements. We recognize that the Army continues to capture lessons  learned and input from the commanders, and we noted in our report that  the Army Medical Department Center and School has updated its forward  surgical team field manual although updates to this field manual did not  specifically note changes in the number and mix of medical specialists that  make up a forward surgical team if the team is providing advanced  emergency care as a stand-alone unit. Thus, we still believe the Army  would benefit by fully updating the organization of medical units  concerning their size, composition and use, as applicable, to incorporate  current practices of splitting and reconfiguring deployed medical units in  theater. DOD also provided technical comments that we incorporated as  appropriate.
We are sending copies of this report to the Secretary of Defense, the  Secretary of the Army, and appropriate DOD organizations. In addition,  this report will be available at no charge on GAO’s Web site at  http://www.gao.gov. If you or your staffs have any questions about this  report, please contact me at (202) 512-3604 or by e-mail at  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 major contributions to the report are listed in  appendix IV.
section_title: Appendix I: Scope and Methodology
paragraphs: We examined the Department of Defense’s (DOD) efforts to identify and  fill its military medical personnel requirements in support of operations in  Iraq and Afghanistan. Specifically, we evaluated the extent to which   (1) DOD has assessed its need for military medical personnel in Iraq and  Afghanistan, (2) the Army has adapted the composition and use of its  medical units to provide advanced medical care, and (3) the Army fills  medical personnel gaps that arise in theater. During our evaluation, we  contacted DOD and service officials, including officials from United States  Forces-Iraq and United States Forces-Afghanistan; U.S. Central Command;  U.S. Joint Forces Command; Joint Staff; Office of Secretary of Defense for  Health Affairs; Offices of the Surgeons General for the Army, the Navy,  and the Air Force; and U.S. Marine Corps Headquarters.
For the first objective—to evaluate the extent to which DOD has assessed  its need for military medical personnel in Iraq and Afghanistan to support  ongoing operations—we analyzed DOD and service policies and processes  that govern the determination of medical personnel requirements,  including service doctrine, DOD guidance, and current theater-level  guidance regarding medical care in Iraq and Afghanistan. Specifically, we  compared a current DOD directive regarding medical care for DOD civilian  employees and theater-level guidance regarding medical care for U.S.  federal civilians, including DOD civilian employees, and noted how they  differed. To augment our analysis, we interviewed officials, including  representatives from the theater medical task forces and Surgeons’ offices  in Iraq and Afghanistan about how they assess their military medical  personnel needs in Iraq and Afghanistan and possible effects of differences  in guidance that govern medical care in theater.
For the second objective—to evaluate the extent to which the Army has  adapted the composition and use of its medical units to provide advanced  medical care in Iraq and Afghanistan—we reviewed reports from the  medical task forces in theater, Army documentation of the composition of  medical units in Iraq and Afghanistan, theater-level publications regarding  medical care in Iraq and Afghanistan, Army medical doctrine, and Army  field manuals for medical units. We interviewed officials, including  officials with the medical task forces and Surgeons’ offices in Iraq and  Afghanistan about the current use and composition of medical units in  theater, and the extent to which they are captured within official Army  documentation of doctrine and the organization of medical units. In  addition, we interviewed representatives from the Army Medical  Department Center and School, Directorate of Combat and Doctrine  Development about the relevance of doctrine and the organization of  medical units and the role lessons learned in Iraq and Afghanistan might  play in any plans to update doctrine and the organization of medical units  in the future.
For the third objective—evaluate the extent to which the Army fills  medical personnel gaps that arise in Iraq and Afghanistan—we reviewed  the approaches used by Army theater medical commanders to meet  medical personnel requirements when gaps in needed personnel coverage  occurred and interviewed officials with the theater-level medical task  forces and Surgeons’ offices in Iraq and Afghanistan regarding reasons  why unexpected medical personnel needs arose and the approaches used  to address those needs in theater. When possible, we obtained and  reviewed supporting documentation, and interviewed other officials  involved in these efforts, including officials with the U.S. Army Forces  Command, to fill unexpected medical personnel needs in theater. We also  reviewed policies and guidance for meeting medical personnel needs that  arise in theater for both the active and reserve components, specifically  the Army’s 90-day deployment policy for reservists applicable to  physicians, dentists, and nurse anesthetists. To determine the extent to  which the Army’s reserve component medical units deployed their  authorized medical personnel in 2008, 2009, and through the first 6 months  of 2010 to Iraq and Afghanistan, we reviewed Army’s deployment data on  late deployments of medical providers from the reserve components. We  assessed the reliability of the data by interviewing the agency official  responsible for manually collecting and summarizing the data. We  determined that the data were sufficiently reliable for the purposes of this  report.
Additionally, to better understand how military medical personnel  requirements are met, we obtained information on DOD’s Global Force  Management process and how the services identify medical units and  personnel to fill these requirements. We interviewed officials with the  Joint Staff, U.S. Joint Forces Command, and the military services’ force  providers to include U.S. Army Forces Command, U.S. Fleet Forces  Command, U.S. Air Combat Command, and U.S. Marine Forces Command,  as well as officials with the Army Medical Command, the Navy Bureau of  Medicine and Surgery, and the Air Force Personnel Center about their  processes for filling in-theater military medical personnel requirements.  For a more comprehensive listing of the organizations and offices we  contacted, see table 1.
We conducted this performance audit from August 2009 through January  2011 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: The Global Force Management Process and Service Processes to Identify and Select Medical Personnel to Fill Requirements for Deployment to Iraq and Afghanistan
paragraphs: The Department of Defense (DOD) uses its Global Force Management  process to meet its requirements, including those for medical personnel  and units. For ongoing operations, this process periodically examines  requirements for rotational forces as well as emerging requirements as  they arise. In addition, the services each use unique yet similar processes  to identify and select medical units and personnel to fill requirements for  Iraq and Afghanistan.
subsections: section_title: DOD’s Global Force Management Process
paragraphs: DOD designed the Global Force Management process to provide insight  into the global availability of U.S. military forces. For the rotational force  management process, requirements are identified 2 years in advance. The  rotational force management process is facilitated through Global Force  Management Boards, which are typically held on a quarterly basis. The  Global Force Management Board brings together general officers from  interested parties—Office of the Secretary of Defense, the Joint Staff, the  combatant commanders, the services, and the joint force providers—to  specifically lay out known requirements, review and endorse sourcing  recommendations and associated risk and risk mitigation options, and  then to prioritize and meet the requirements as appropriate. The product  of these Global Force Management Boards is the Global Force  Management Allocation Plan, a document that is approved by the  Secretary of Defense, which authorizes force allocations and deployment  of forces in support of combatant commander rotational requirements. In  both Iraq and Afghanistan, medical personnel and unit requirements are  included in the Global Force Management Allocation Plan, which provides  an approach for U.S. Central Command, the services, and the services’  force providers to manage the sourcing of rotational requirements,  including requirements for medical personnel and units, such as the Balad  Theater Hospital in Iraq or a combat support hospital in Afghanistan.
For requirements, including medical personnel and units, that are not  known in advance, DOD used the emergent force management process  extensively to meet requirements through requests for forces. Generally,  the parties involved in this process have separate, sequential roles in the  process. Requests for forces are generated by combatant commanders and  submitted to the Joint Staff for validation, and then to the joint and  service force providers to identify potential sourcing solutions to fill  requirements before being transmitted to the Secretary of Defense for  approval. In sourcing requests through the emergent process,  requirements are prioritized according to a force allocation decision  model. While emergent requirements are considered within the model’s  general framework, each request for forces is individually evaluated as it   is received, meaning that officials focus on whether or not forces are ready  and available to fill the request rather than trying to determine the relative  priority of the request, as is done at the Global Force Management Boards  for rotational requirements. As part of providing and evaluating potential  solutions for the request for forces, the services’ force providers often  conduct risk assessments to provide information on the availability and  readiness of both active and reserve forces. These risk assessments  include violations of the services’ rotation policies regarding the required  time at home for servicemembers and the impact to current missions and  operations, such as the staffing of U.S. military treatment facilities in the  case of medical personnel, if a service is selected to meet the requirement.  In addition, each of the services maintains a list of specialties that are in  high demand relative to available personnel. All of the services identified  critical care nurse, physician assistant, psychiatry, and clinical psychology  as high-demand specialties.
section_title: Service Processes to Identify and Select Medical Personnel to Fill Requirements
paragraphs: The services use unique yet similar processes to identify and select  medical units and personnel to fill requirements for Iraq and Afghanistan.  Once the Secretary of Defense designates a service to meet an emergent or  rotational requirement, the service’s force provider then begins the  process of filling the requirement with personnel. While the procedures  and systems used by each service to select the appropriate medical  personnel vary, the services’ processes for filling requirements all result in  a unit and its personnel deploying to an operational theater to carry out a  mission. The identification of individual medical personnel to fill the  requirements is important because medical personnel across the services  typically are assigned to fixed military treatment facilities caring for active  duty personnel, their dependents, and retirees. However, in wartime, each  service’s medical personnel processes allow for the deployment of medical  personnel from fixed military treatment facilities to support contingency  operations, such as Iraq and Afghanistan, while considering potential  impacts on the medical mission of the fixed military treatment facilities.   In addition, the processes attempt to distribute the burden of deployments  within and across medical specialties (e.g., orthopedic surgeons, critical  care nurses, and psychiatrists), to comply with service guidelines, such as  required time at home for servicemembers, to maintain a healthy inventory  of medical specialists.
section_title: Appendix III: Comments from the Department of Defense
section_title: Appendix IV: GAO Contacts and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: In addition to the contact above, Laura Talbott, Assistant Director; John  Bumgarner; Susan Ditto; K. Nicole Harms; Stephanie Santoso; Adam  Smith; Angela Watson; Erik Wilkins-McKee; Michael Willems; and  Elizabeth Wood made major contributions to this report.